304 INSANITY particularly in the form of subcutaneous injec- tions. Constipation is to be relieved by laxa- tives and clysters. Other medicines, as bro- mide of potassium and digitalis, according to Blandford, are not worth the trouble of ad- ministering. Warm baths will be of great benefit, and the room should be kept warmer than usual. The patient wastes rapidly, and it is often impossible to give him enough food. Another form of melancholia of a chronic character often follows an attack of mania. It is attended with less mental excitement, re- sembling more a state of dementia, but recov- ery from it sometimes takes place. Mania. This is usually classified, in a general way, as acute and chronic, and Blandford adds a variety which he calls acute delirious mania. Mania, particularly where there is hereditary taint, may be brought on by grief, misfortune, or disappointment; but peculiar forms of it accompany epilepsy and general paralysis of the insane. Acute mania may come on sud- denly, or it may be preceded by melancholy lasting for some time. The symptoms of acute mania are by no means obscure ; there is almost always manifested extreme mischievousness, filthiness in person, and obscenity in language. One distinction between mania and melan- cholia is in the manner the mental state affects the acts. There may be delusions in mania, but they are of a more confused kind and the acts are more purposeless, while in melan- cholia there is the evidence of some plan. The conversation is more incoherent. Maniacs will heap abuse on all around them, and are in- clined to use violence. They commit self- abuse, and may become shameless in the ex- posure of the person. The bodily health often does not suffer greatly, and they seldom die unless their health is broken at the commence- ment of the attack, in which case they may wear themselves out. They eat heartily, but generally grow thin, although not very rapidly. There is want of sleep. Sometimes they will pass a good night, getting several hours of sleep, and then may go several days with only two or three hours' sleep, shouting, laughing, and singing. The tongue is often clean, and the bowels are not generally constipated ; hence maniacal cases do not yield to medical treat- ment as readily as some cases of melancho- lia. Chloral may be of benefit to procure sleep. The doses should be large, from 40 to 60 grains. Opiates are given by some and condemned by others. The prognosis, when acute mania is not complicated with other dis- ease, is on the whole favorable. Much, how- ever, will depend on the time which has elapsed since the commencement of the attack. If this has been long, recovery will be doubt- ful because of the changes which have taken place in the brain, a continued state of hyper- femia producing chronic thickening of the cerebral membranes and changes in the brain substance. The patient may recover, or die with a hyperaemic state of the brain, or gradu- ally sink into a state of hopeless chronic mania or dementia, or become melancholic. From this he may recover, and again become mania- cal. Acute delirious mania, as described by Dr. Blandford, differs from the preceding in being accompanied with more delirium and with more bodily disorder. The tongue is often coated, sometimes brown and dry, and as the patient becomes exhausted a typhoid condition ensues. The urine is scanty and high-colored, and the bowels rarely act without laxatives. The treatment consists in regulating the bodily functions, giving food freely, combined with plenty of drink, and also wine, and in the judicious use of hydrate of chloral. Opium should not be given, as it obstructs the secre- tions and is liable to increase the delirium. Kest is of the highest importance, and baths of warm water, in which mustard may be stirred, are of great benefit, the head to be kept cool during the operation. Purgatives at the outset of the attack may be of use, as aiding to arrest it. The termination is al- most always recovery or death, melancholia or dementia rarely following. Where an acute case of mania is neglected or badly treated, or is of a violent and persistent kind, it may pass into a chronic state in which there is either constant excitement of a less violent kind, or a fixed delusion. The patient gradually be- comes feebler in intellect, although his bodily health may improve, and with variable degrees of rapidity sinks into a state of dementia. General Paralysis of the Insane. The pecu- liar form of disease accompanied by insanity to which this name has been given is of the most formidable character, no instance of recovery in a well marked case having been recorded. The French physicians are entitled to the credit of having first recognized and described it. Esquirol was aware of the complications of in- sanity with paralysis, but did not recognize the whole as a distinct disease. Bayle in 1822 at- tributed the cause to chronic inflammation of the arachnoid, and named the disease arachni- tis chronique. M. Calmeil in 1826 gave a com- plete account of it, and for that reason he is often called its discoverer. It has received several names, as folie paralytique, paralysie generale progressive, and OeisterkranlcTieit mit Paralyse. In England and America it has usually been called general paralysis of the insane, or paralytic insanity, and lately it is often called simply " paresis." It is generally regarded as presenting three stages: 1, the period of incubation; 2, the acute maniacal period ; 3, the period of chronic mania, lapsing into dementia, with utter prostration of both mind and body. At the commencement of the disease an alteration in the manner of the pa- tient may be observed, similar to that which is noticed in other forms of insanity, although there are commonly other symptoms which are of importance in forming a diagnosis, such as excessive extravagance in the spending of money. A general paralytic is liable to com-
