of muscular or manual employment, for labor of this kind keeps the attention more or less fixed upon what is being done, the flow of ideas is checked and limited to a considerable degree, and the mind is prevented from concentrating itself upon illusions, hallucinations, and delusions. Moreover, muscular exercise is an outlet for superfluous energy; motor excitement is reduced by it; tissue metabolism is accelerated; and when the work is over, the organism gains all the more readily a certain composure of mind and repose of body. Out-of-door occupation is best-garden and field work for men, garden work for women; walking, bicycling, etc., for either sex. Among indoor employments we have ordinary housework, drawing, knitting, sewing, embroidery, carpentry, wood-carving, etc., all of which employ the muscles methodically. In certain cases mental occupation is useful, though it should be of the simplest kind. For instance, during my practice at the Hudson River State Hospital for the Insane, we found much value in the establishment of a regular country school, attended by patients of all ages. We had "spelling bees," copying lessons, reading aloud, blackboard exercises, geography, simple arithmetic, singing, and so on.

A very important point in the management of the insane is never to practise deception upon them in any way. Be absolutely truthful in every statement to them. Never remove a patient to an asylum under the impression that it is a hotel or sanatorium. It is better to state exactly what is going to be done, and then use force in the removal, if

necessary.

Hypnotism has been frequently practised upon the insane, in the effort to modify hallucinations or delusions, rarely with any definite success, occasionally with ill results, and generally with no effect what

ever.

There are a few conditions among the insane which require particular treatment or management. Among them are:

Suicidal Tendencies.-Suicidal patients are among those who require constant watching and the removal of every means of selfinjury. This is often difficult in treating such patients in their own homes. How difficult, it may be conjectured from the fact that, even in asylums, with all their safeguards, suicide is by no means infrequent. Thus, forty-eight patients in the asylums of the State of New York committed suicide between October 1, 1888, and September 30, 1896.

Suicidal patients are to be watched night and day, and kept in bed, and even put in restraint, if desperate. I have known a patient to strangle herself with a cord while lying in bed under the eye of a nurse. Another, broke a small piece from a china plate and tried to cut her wrists under the bedclothes, While suicide is most common among melancholiacs, patients with general paresis, paranoia, epileptic psychoses, and toxic delirium sometimes attempt it. The physician attending such patients should see to the guarding of windows and the removal of keys, hooks, scissors, weapons, drugs, strings, long pins, matches-in fact, of all instruments and means which he may suspect to be utilizable for a suicidal purpose.

Refusal of Food.-The acutely maniacal often can not be made to take sufficient nourishment, because they do not stop long enough in their ideomotor excitement to permit of eating. The watchful and persevering nurse can generally, by persistent effort, induce the patient to swallow a considerable quantity of liquid food (preferably in a metal or heavy china cup, because the patient frequently knocks the vessel from the hand of the nurse). Such patients can often be fed, as already stated, immediately after a hypodermatic injection of hyoscin or duboisin before the supervention of sleep.

Other patients refuse to eat because of delusions of poverty or poisoning, suicidal proclivity, or simply from absolute distaste.

Where ordinary means fail, the nasal tube should be resorted to,— one of large caliber with rubber funnel attached, and through this, once or twice daily, a mixture of a pint of milk, two or three raw eggs, a little meat-juice, and, if needed, brandy, may be introduced.

Before resort to this means nutritive enemata may be employed (three raw eggs, a half-pint of milk, a half-pint of water, and a little meat-juice).

I have been in the habit of delaying the use of the nasal or stomachtube to the last moment of safety, even for several days, rather than subject the patient to the excitement of its employment. It is only in rare instances that feeding is not effected in some other way before the use of the tube becomes imperative.

Violence and Destructiveness.-Hypodermatic medication and hot wet-packs are indicated in periods of excitement with tendency to violence and destructiveness. It has already been intimated that active physical labor or exercise is a safety-valve for patients with proclivities of this kind. Isolation in an empty room with protected windows is sometimes resorted to in institutions, and abroad the padded room is a favorite place for patients whose violent jactitations may lead to serious injuries to himself. The padded room consists simply of a room lined as to walls and floor with cushions. Mechanical restraint is used in the last extremity, when chemical restraint and other means have failed. The camisole and safety-sheet are employed only in cases with desperate suicidal tendencies, proclivity to excessive masturbation, great violence and destructiveness, and where needed to keep in place surgical dressings, splints, etc. In asylums mechanical restraint has been nowadays almost entirely abandoned.

Masturbation.-Masturbation is more often the consequence and concomitant of insanity than its cause. It may be ameliorated occasionally by drugs like bromids, camphor, and lupulin. Cold baths and hard physical labor are more successful in combating this habit. In excessive masturbation, constant watching day and night or the use of mechanical restraint is necessary. The use of blistering fluids on the genital organs is only of temporary service. There are instances in which the habit is so fixed and so uncontrollable-for example, among some imbeciles that surgical interference would be quite justifiable (castration, clitoridectomy, ovariotomy, section of the pudic nerves, ligation of the vas deferens).

CHAPTER VI.

MANIA.

Definition.-Mania is a form of insanity characterized by emotional exaltation, acceleration of the flow of ideas, and motor agitation. It is probable that the elated mood and the hyperexcitation of intellectual processes are both primary and simultaneous in their development. The motor excitement results from the conversion of the swiftly flowing ideas into acts.

It

Etiology. There is no special etiology for mania-what has been said in the chapter on General Etiology has application to this form. may be said, however, that mania is ordinarily a disorder arising between the twelfth and twenty-fifth years; that it is more common in females than in males; that individuals of sanguine temperament are most liable; and that it is, upon the whole, rather an infrequent type of insanity. Hereditary taint is found in seventy-five per cent. and degenerative stigmata in twenty per cent. of cases. The percentage is larger for the periodical form.

Mental Symptoms.-An outbreak of mania is preceded by a period of depression lasting from a few days to a few weeks, sometimes as long as two months. This prodromal stage is characterized by a general feeling of malaise, vague uneasiness, and hypochondriacal complaints, accompanied often by headaches, cephalic paresthesias, constipation, loss of appetite, sleeplessness, and some loss of flesh.

When the true mental disorder begins to manifest itself, the sorrowful mood begins to give way to an exalted condition, which the patient looks upon as a state of renewed health and well-being. He takes a renewed interest in everything, and becomes unusually cheerful and talkative. The degree of increasing exaltation varies much in different cases. In mild cases the patient begins to surprise his intimates by his loquacity, facetious remarks, jocularity, and by his rather immoderate actions and undertakings. He enters upon many new schemes; makes innumerable calls upon friends and acquaintances; writes numberless letters; purchases unnecessary articles; and is inclined to excessive indulgence in tobacco, wine, and venery. There is considerable mobility or lability of the emotions, so that the elation may readily pass into conditions of anger or tears over trifles. In more severe types all of these symptoms are aggravated. A veritable chaos of ideas throngs through his mind, and the effects upon movement of this crowding series of ideas amount to a constant motor agitation. The patient laughs, declaims, sings, shouts, makes grimaces, dances, runs about, and becomes destructive and filthy, all inhibitory idea-associations ceasing to have any influence over the rioting torrent of thought. In still severer grades we have the picture of an acute delirium, boisterous incoherence, a motor agitation attaining to violent jactitation, and an actual and considerable increase of temperature.

The patient with mania is fundamentally optimistic and egotistic. Everything about him is rose-colored. He feels rejuvenated; rejoices in his health, strength, and vitality; is delighted with the vivacity of his ideas and the untrammeled virility of his intellectual processes. His general and special sensibilities are ordinarily unaffected; in only about one-fifth of the cases are illusions and hallucinations present, and these are almost always limited to vision. Occasionally there are illusions and hallucinations of taste and touch. Illusions of the special senses are more frequent than hallucinations. The manias of extreme youth or age and alcoholic mania are especially prone to manifest hallucinations. Mania marked by the presence of numerous illusions and hallucinations is often designated as hallucinatory mania.

The accelerated flow of ideas in mania is naturally most conspicuous in the speech of the patient, which varies from garrulity to logorrhea. In the milder degrees of loquacity we

are still able to follow the sequence of associations. The sentences are often bound together by the ordinary relationship and connections of ideas, but among which many latent ideas spring into consciousness and expression; and, again, the sounds of words spoken suggest others of similar sound, giving rise to rimes and assonances. Thus, the sight of the physician may suggest drugs, a certain apothecary, in a special street, in some familiar town; and the town may in turn give rise to another series. On the other hand, the physician's "How do you do?" may invoke a string of assonances (verbigeration) commingled with sentences expressing their associated ideas-shoe, two, new, grew, blue, crew, etc. But in the more striking grades the logorrhea is so pronounced that it is impossible to find clues to any association, whether of sound or idea. It becomes a chaos of words, consequent upon an actual dissociation of the ideas in the rushing stream of thought-a secondary incoherence. The entire loss of inhibitory control of ideas is especially shown in the absolute lack of modesty, in the tendency to the employment of vulgar and obscene words and expressions. This profanity and obscenity become all the more astonishing by contrast, when it is observed, as it often is, even in the most refined and cultured of women. The attention of the patient with mania is extraordinarily increased, so that the most insignificant trifle in his environment does not escape him. But this very increase of the power of attention, combined as it is with an unpausing stream of ideas, entails an absolute lack of concentration. His attention can not be held a moment. The patient's memory, too, seems preternaturally intense, and it is remarkable how,

after recovery, he may remember all the details of his delirious activity with great distinctness. Indeed, the patient, in the midst of the chaotic turmoil of his mind, often recognizes, as if he stood apart from and judged himself, the very madness of his fancies and acts. The judgment-associations are, in fact, normal.

The elated mood and rapid flow of ideas give rise to delusions of expansive character, mostly in regard to strength, beauty, and intellectual powers, but often also in relation to wealth, social position, etc. In severe cases there are the most marked delusions of grandeur, the patient affirming himself or herself to be a prince, president, king, queen, Christ, the bride of Christ, the mother of God, etc. A peculiarity of these affirmations is their transitory character, their impermanence. A patient will, in the same breath, call himself a millionaire, broker, and king, and in the next a minister of the gospel and railroad magnate. If sharply told by the physician to stop such nonsense, he will often say it was only a joke, or he had said such things for fun. This shows very well the latent consciousness of the patient of the true state of affairs.

The sexual instinct is morbidly exalted, giving rise in both sexes to immodesty and obscenity of speech and manner, and often to sexual excesses and masturbation.

The actions of patients with mania correspond in character to the degree of acceleration in the stream of ideas. When this is very great, turbulence, violence, and destructiveness are common, not with any homicidal or suicidal intent, because they are incapable of acts requiring any particular concentration of mind or reflection, but simply as the result of uncontrollable automatic impulsions.

Sleeplessness is characteristic of this condition. General sensibility appears to be benumbed, probably because of the want of concentration of thought. Patients seem insensible to changes of temperature and to severe pain. Such a state often masks the most serious disorders, like pneumonia or the pains of labor. I once made an autopsy upon a woman suffering from acute mania who died suddenly. She had been for days in the wildest uproar of mind and body. The cause of death was an acute peritonitis from rupture of a perforating duodenal ulcer. The peritonitis had evidently existed for several days, yet this painful affection had clearly had no effect upon the course of the mental and motor symptoms.

Some cases of mild maniacal character exhibit a peculiar tendency to logically explain and excuse their insane acts, and this type is often designated as reasoning mania.

As already stated, mania begins with a prodromal stage of depression. After the exalted stage has culminated and at the beginning of convalescence, a reactive stage of depression is presented, characterized by irritability, sensitiveness, and lacrymosity. This stage of depression may be so intense as to be an actual melancholia of simple nature or accompanied with stupor. In instances of this kind the possibility of the patient's having a circular form of insanity, instead of a simple mania, is to be considered.