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The physiognomy of mania has already been commented upon at sufficient length. The expression of wildness, distraction, or anger, is often varied with that of mischief, lasciviousness, or fear, and strong emotional excitement of some kind or other is rarely absent from the facial expression of the maniac.

The physical symptoms are by no means constant, and are of little value diagnostically; the face is pale or flushed, the skin dry and harsh, the bowels constipated, the pulse accelerated, the tongue bearing a whitish fur, the breath offensive, saliva increased and frequently spit out, the urine loaded with phosphates, &c. But any or all of these symptoms may be reversed, and any or all of them may and often do occur in numerous diseased conditions where there is no affection of the mental faculties. In the treatment of insanity all the signs of physical disturbance merit careful attention, but in the diagnosis their value is exceedingly small. Almost invariably in acute mania there is loss of sleep, a diagnostic symptom of the utmost value between the real and the feigned disorder. The acute maniac will often pass five or six days without any sleep, and five or six weeks with only three or four hours of sleep at intervals of several days. An impostor, feigning the violent form of madness, cannot refrain from deep and regular slumber, which falls upon him with the more certainty as he exhausts himself in his efforts of spurious fury. The impostor, moreover, cannot feign the physiognomical expression of acute mania, or at all events, he cannot maintain it for more than a few minutes. A man may imitate frantic gestures or shout gibberish without difficulty so long as his physical strength enables him, but he cannot maintain any look expressive of strong emotion unless he has practised the histrionic art with great care and success. The voice muscles, and those of the limbs, are constantly exercised in obedience to the will, but those of the countenance are the involuntary exponents of emotion. Conversation, properly so called, is always difficult, and often impossible with an acute maniac. In many cases the mind is so much occupied by delusive ideas, that only a few disconnected words can be elicited; more frequently, however, acute mania is accompanied by garrulity; this is especially the case when the exaggerated emotions are cheerful and expansive. This form of mania often exists without prevailing delusion, and the patient rambles on in his talk through a strange medley of boasts, promises and threats, oaths and obscene remarks, in a manner which renders it easy to understand why M. Falret supposes it possible that in this condition there is a spontaneous creation of ideas.

The restless and ever changing condition of the mind, expresses itself as strongly in action as in vociferation and wild words. The patient is always in movement, running, dancing, gesticulating, embracing, or fighting with those around him, displacing or sometimes breaking furniture, thumping with fists on the door of his room, and evincing in manifold ways the restless activity of the muscular system. It is probable that this impulse to action is not entirely dependent upon the condition of the brain. The nervous system generally, is in a state of excitement, causing an incontrollable desire to expend its energies in excessive muscular action. This restlesness, however, is not met with in all cases. In gay mania, in mania with fear and anxiety it is common; but in morose and sullen mania the patient will often retain one position for a considerable time. But even under such circumstances the clenching of teeth and hands, the half involuntary movement of the limbs, evidently restrained by the will, indicates strong impulse to action.

The condition of the mental faculties in acute mania presents the widest differences. In many instances no trace of delusion can be discovered in a patient who is vociferating, swearing, laughing, reproaching, in constant movement, and without sleep. All the observations and the remarks are sometimes found to have a certain kind of cleverness and shrewd appreciation of all that is taking place. The attention skips from object to object with choreic rapidity and abruptness, causing exaggerated and absurd emotional states, but in many instances not falsifying the judgment. In most instances, however, delusions and hallucinations exist, and the task of detecting them is not difficult, for in this form of disease the patient is so demonstrable that he usually dins his delusion into your ears.

Hallucinations appear to be more frequent in acute mania than delusions proper, and also more frequent than they are in any other form of insanity. Hallucinations of sight are very common. In acute mania, patients see the Deity, and angels, and devils, hear music and voices, believe their food to be human flesh or poison, and a hundred hallucinations of the same sort, far more frequently than in other forms of insanity.

Little address is required on the part of the physician to make himself acquainted with the intellectual and emotional perversions of these demonstrable patients, or to decide as to the existence of disease. The conditions with which it is possible that acute mania may be confounded, are drunken

The physiognomy of mania has already been commented upon at sufficient length. The expression of wildness, distraction, or anger, is often varied with that of mischief, lasciviousness, or fear, and strong emotional excitement of some kind or other is rarely absent from the facial expression of the maniac.

The physical symptoms are by no means constant, and are of little value diagnostically; the face is pale or flushed, the skin dry and harsh, the bowels constipated, the pulse accelerated, the tongue bearing a whitish fur, the breath offensive, saliva increased and frequently spit out, the urine loaded with phosphates, &c. But any or all of these symptoms may be reversed, and any or all of them may and often do occur in numerous diseased conditions where there is no affection of the mental faculties. In the treatment of insanity all the signs of physical disturbance merit careful attention, but in the diagnosis their value is exceedingly small. Almost invariably in acute mania there is loss of sleep, a diagnostic symptom of the utmost value between the real and the feigned disorder. The acute maniac will often pass five or six days without any sleep, and five or six weeks with only three or four hours of sleep at intervals of several days. An impostor, feigning the violent form of madness, cannot refrain from deep and regular slumber, which falls upon him with the more certainty as he exhausts himself in his efforts of spurious fury. The impostor, moreover, cannot feign the physiognomical expression of acute mania, or at all events, he cannot maintain it for more than a few minutes. A man may imitate frantic gestures or shout gibberish without difficulty so long as his physical strength enables him, but he cannot maintain any look expressive of strong emotion unless he has practised the histrionic art with great care and success. The voice muscles, and those of the limbs, are constantly exercised in obedience to the will, but those of the countenance are the involuntary exponents of emotion. Conversation, properly so called, is always difficult, and often impossible with an acute maniac. In many cases the mind is so much occupied by delusive ideas, that only a few disconnected words can be elicited; more frequently, however, acute mania is accompanied by garrulity; this is especially the case when the exaggerated emotions are cheerful and expansive. This form of mania often exists without prevailing delusion, and the patient rambles on in his talk through a strange medley of boasts, promises and threats, oaths and obscene remarks, in a manner which renders it easy to understand why M. Falret supposes it possible that in this condition there is a spontaneous creation of ideas.

The restless and ever changing condition of the mind, expresses itself as strongly in action as in vociferation and wild words. The patient is always in movement, running, dancing, gesticulating, embracing, or fighting with those around him, displacing or sometimes breaking furniture, thumping with fists on the door of his room, and evincing in manifold ways the restless activity of the muscular system. It is probable that this impulse to action is not entirely dependent upon the condition of the brain. The nervous system generally, is in a state of excitement, causing an incontrollable desire to expend its energies in excessive muscular action. This restlesness, however, is not met with in all cases. In gay mania, in mania with fear and anxiety it is common; but in morose and sullen mania the patient will often retain one position for a considerable time. But even under such circumstances the clenching of teeth and hands, the half involuntary movement of the limbs, evidently restrained by the will, indicates strong impulse to action.

The condition of the mental faculties in acute mania presents the widest differences. In many instances no trace of delusion can be discovered in a patient who is vociferating, swearing, laughing, reproaching, in constant movement, and without sleep. All the observations and the remarks are sometimes found to have a certain kind of cleverness and shrewd appreciation of all that is taking place. The attention skips from object to object with choreic rapidity and abruptness, causing exaggerated and absurd emotional states, but in many instances not falsifying the judgment. In most instances, however, delusions and hallucinations exist, and the task of detecting them is not difficult, for in this form of disease the patient is so demonstrable that he usually dins his delusion into your ears.

Hallucinations appear to be more frequent in acute mania than delusions proper, and also more frequent than they are in any other form of insanity. Hallucinations of sight are very common. In acute mania, patients see the Deity, and angels, and devils, hear music and voices, believe their food to be human flesh or poison, and a hundred hallucinations of the same sort, far more frequently than in other forms of insanity.

Little address is required on the part of the physician to make himself acquainted with the intellectual and emotional perversions of these demonstrable patients, or to decide as to the existence of disease. The conditions with which it is possible that acute mania may be confounded, are drunken

ness, delirium tremens, the delirium of fever, and inflammation of the brain and its membranes.

To distinguish acute mania from the ordinary cases of excitement from intoxicating liquors, it will be enough to observe, that the drunkard can be recalled to a sense of his position, that his excitement soon passes into drowsiness and tendency to coma, and that he has no real delusions or hallucinations. Frequently the stomach is deranged, and the intoxicating liquid can be smelt in the breath. The mental symptoms of ordinary drunkenness are mild and pale when contrasted with those of acute mania. But there is a form of drunkenness in which the distinction is difficult and not always possible. Persons who have suffered attacks of insanity, or of inflammation of the brain, or wounds of the head, are liable to a train of symptoms when they become intoxicated which are identical with acute mania. Drunkenness of this kind is not to be diagnosed from the disease under consideration, it is indeed the disease itself, so long as it lasts. The symptoms often, but not always, subside when the alcoholic stimulus has passed out of the system. The cause of the maniacal symptoms and their short duration, are the only indications that this condition is a dangerous variety of drunkenness.

Another variety of delirium from drink is only to be distinguished from mania proper by a knowledge of its cause. It is the delirium which sometimes comes on at the termination of a long debauch; when a man has been drunk for many successive days, a form of active delirium occasionally supervenes in which the symptoms resemble those of mania and not those of delirium tremens. This delirium is caused by excessive alcoholic stimulation, and not by the withdrawal of a stimulus as in delirium tremens. The countenance and conjunctiva are congested, the pulse is full, the skin is hot, and the delirium is loud and violent. There are no symptoms by which this form of delirium can be distinguished from acute mania.

The diagnosis between delirium tremens and acute mania can be made by observing in the former the peculiar muscular tremor, from which it derives its name, and the more remarkable and distinctive feature presented by the character of the illusions and hallucinations which are always fearful, and of a pursuing and persecuting character. Snakes are about the bed, robbers are breaking into the house, fiends are getting in at the window or down the chimney. Or if there is no decided hallucination of this kind, there is an anxious desire to do some particular thing, generally connected with the

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