do not know how it is, but such picturesque cases of insane would-be murderers do not seem to occur now. The fewer precautions are taken, the less need there seems to be for them. When he died his head was found to have undergone great changes in shape, as compared with a cast taken twenty years before, and his brain was much atrophied.

I had a patient once, C. Z. A., æt. about 28, with a strong heredity towards mental disease, who had been working too hard at brain work that was uncongenial to him, and also had had a disappointment, and who had previously shown only a little mental confusion for a week, when suddenly, without warning, he made a homicidal attack on his brother when taking a walk, under the delusion that his brother wanted to do him harm. This was really the first distinct symptom of an attack of subacute mania. There were strong reasons why he should not be sent to an asylum, and I got a first-rate attendant for him, who kept him out in the open air, walking, fishing, etc., for ten hours a day. I put him on milk diet, with warm baths, Parrish's syrup, occasional draughts of bromide of potassium and chloral at night, and used occasional blisters to his head. He used often to attack his attendant from delusions about him, who, however, never lost his nerve, and was not afraid of him. He always apologized afterwards. Gradually the excitement passed off, and in about eight months he recovered. A certain mental irresolution and tendency to change was the last symptom to disappear, as is the case commonly in mental disease. A perfect power of volition, spontaneity, the power to originate, is, in fact, the highest mental faculty, and is the last to return and the most apt to be left impaired. I could scarcely have believed at one time that such a patient as C. Z. A. could possibly or safely be treated out of an asylum.

The second kind of maniacal homicidal attacks, viz., that from sheer excess of motor energy, is often seen both in acute and chronic cases. We had a young man, C. Z. B., in the asylum, who, when he first became insane, attacked a man on the street, and got his own eye knocked out, and for many years did little by night and day but groan and shout in crescendo movement, box the walls so that his hands and knuckles were hard as horns, swollen, and often cut. He would often attack patients and attendants and officials violently. He was wonderfully rational amidst all this, saying he could not help it, that the steam would out, and that he had no desire to hurt any one or any feeling of revenge against any one. I have now a lady who is subject to paroxysms of acute mania, during which she screams in an unearthly howl, tears her clothes, bites her own hands, and will take your hand into her mouth and bite it a little all round, without really hurting you, if you will allow her.

The third form, that, namely, resulting from a distinct morbid impulse to kill without conscious motive, I shall treat of more fully under impulsive insanity, the homicidal variety of which it is, with maniacal exaltation superadded.

The fourth, or merely delirious form, is not really very dangerous, because it is purposeless and aimless, and the violence is not coördinated. It seldom is seen except when delirious patients are unduly controlled. A physician or an attendant in an asylum generally walks up to a

PLATE VI.

CHART.

Showing the numbers per 1000 of Total admissions, and the Ages of 996 cases of Mania, 535 cases of Melancholia, and 104 cases of General Paralysis, making together 1635 cases of the 1778 Total cases admitted into the Royal Edinburgh

160

150

ADMISSIONS.

Asylum in Five years.

10-15 15-20 20-25 25-30 30-35 35-40 40-45 45-50 50-55 55-60 60-65 65-70 70-75 75-80 80-85 85-90 ACES

160

150

10-15 15-20 20-25 25-30 30-35 35-40 40-45 45-50 50-55 55-60 60-65 65-70 70-75 75-80 80-85 85-90

MANIA
MELANCHOLIA

GENERAL PARALYSIS

maniacal patient quite unconcernedly as to danger, thinking only of the symptoms present just as one would go in to see a case of pneumonia. PREVALENCE OF MANIA.-The relative prevalence of conditions of mental exaltation is brought out by the fact that out of twenty-three hundred and seventy-seven cases admitted into the Royal Edinburgh Asylum in the seven years, 1874-80, thirteen hundred and ten, or fiftyfive per cent., were classified as mania, while only seven hundred and twenty-nine, or thirty-six per cent., were cases of melancholia. The relative prevalence of the two conditions I have shown in Plate VI., which also shows the ages at which they prevail. Mental exaltation is there seen to prevail more at earlier ages than depression, and to occur most at two periods, viz., at the end of adolescence, and then about ten years afterwards.

INSANE DELUSIONS IN MANIA.-The most important thing to ascertain about delusions in mania is whether they are "fixed" or fleeting. A fixed delusion is usually the concentrated expression of a delusional condition of mind. I mean that it is seldom a patient. merely believes that a person works an electric battery to annoy him. Such a delusion is generally the expression of an organic or nervous sensation of discomfort or pain, which makes him have his natural suspicions heightened, he being morbid on other points. He will not trust any one. He is apt to think the air of his room or his food is poisoned. If the person whom he believes to be working this battery goes away, he will soon fix in his morbid imagination the same thing on another. A patient usually not only believes himself to be a king, but his whole state of mind is that of delusive grandeur. Such fixed delusional states, that last for more than a few weeks in mania, are unfavorable as to prognosis; but do not put down either a single delusive fancy that is repeated consistently a few hundred times, or a delusive condition that merely lasts a few weeks, as a fixed delusion. The fixity of a delusion depends on two things-the hold it has, whether it dominates the mental life, including other and natural mental acts; and the time it has existed. Fleeting delusions are most typically seen in that delirium where nothing that is said has any relation to facts, and where no fancy or untrue statement is ever repeated twice. In very many cases of mania a delusion persists for a few weeks or longer, and yet passes away, and should not be counted a fixed deluThere is no doubt that the less fixed and the more fleeting a delusion is, the better is the prognosis.

sion.

Delusions take most various forms in mania. One of the most common forms is mistaking the identity of persons, calling them by wrong names, and recognizing old friends in persons never seen before. Certain kinds of insanity, such as the puerperal form, is specially characterized by this sort of delusion.

INDICATIONS OF PROGNOSIS IN MANIA.-The following are in my experience favorable indications in prognosis: A sudden onset of the disease; a short duration; youth of the patient; no fixed delusions or delusional conditions; appetite for food not quite lost; no positive revulsion against or perversions of the food and drink appetites; no indication of enfeeblement of mind; no paralysis or paresis, or marked affection of the pupils; no epileptic tendency; no complete obliteration

or alteration of the natural expression of the face or eyes; the instincts of delicacy and cleanliness not quite lost; no unconsciousness to the calls of nature; the articulation not affected; the disease rising to an acme and then showing slow and steady signs of receding; no former attacks, or only one or two that have recovered.

The effect of a strong and direct hereditary predisposition is not, as is commonly believed, sufficient to lessen the chances of recovery, especially from the first attack. On the contrary, hereditary cases are often very curable, but relapses are more probable. A brain so predisposed is more readily upset by slight causes.

The following are unfavorable indications in prognosis: A gradual and slow onset, as if it were an evolution of an innate bad brain tendency— e.g., if a naturally suspicious man has gradually become insanely and delusionally suspicious, or a naturally vain man has become affected with insane delusions of grandeur; great length of duration of the attack, especially after twelve months' persistence of fixed delusions or delusional states; extreme and increasing exhaustion of the patient, in spite of proper treatment; paralysis of the trophic power, so that his body nutrition cannot be restored; persistent refusal of food, requiring forcible feeding; extreme failure of the cardiac action and circulation, so that the extremities are always blue and cold; persistent affections of the pupils, especiallly extreme contraction; persistently dirty habits; a tendency towards dementia; a tendency towards chronic mania; an utter and persistent deterioration in the facial expression, especially if it be towards vacuity; persistent and complete paralysis or perversion of the natural affection and tastes and appetites; many former attacks; convulsive, paretic, paralytic, or incoördinative symptoms; such perverted sensations as cause patients to pick the skin, pull out the hair, bite off the nails into the quick; a restoration of sleep and bodily nutrition, without in due time an improvement mentally; very persistent insane masturbation; a tendency for the exaltation to pass off, and fixed delusion to take its place; excitation of the limbs and subsultus tendinum; a "typhoid" condition. TERMINATION OF MANIA.-There may be said to be five usual terminations. 1. Complete recovery; this takes place in fifty-four per cent. of all the cases of mania. 2. Partial recovery; the patient becoming rational and fit for work, but where there is a change of character or affection, or there is an eccentricity, or slight mental weakness, or want of mental inhibition, or lack of fixity of purpose, or a partial paralysis of the social instincts, or some inability to get on with people, or a lack or lessening of some mental quality which the patient possessed before. This is unfortunately a by no means uncommon result of an attack of any kind of insanity, but more especially of an attack of mania. Such persons count, of course, among the recoveries, and are reckoned legally sane. It is quite impossible to find out how many such cases there are, but I fear that at least one-third of all those who "recover" exhibit some such mental change as compared with their former sane selves. I think it is of the utmost importance to have the cure completed therefore, if possible, by prolonged medical care, by getting the whole bodily state, in regard to nutrition and nourishment, up to the highest possible mark before a patient returns to work or subjects himself to the causes of a