Reactions. The erethism of the psychomotor centers, constant in mania, gives rise to maniacal excitement the elements of which are imperative want of movement, abnormal rapidity of the reactions, and impulsive character of the acts.

Maniacal excitement always has a psychic origin (Wernicke); the acts, though impulsive, are dependent upon an appreciable cause and have a definite purpose.

This excitement often assumes the aspect of morbid activity which, lacking in logical sequence, remains unproductive when it does not become harmful. The maniac every instant leaves one task to begin another, or undertakes tasks for which he possesses neither the necessary aptitude nor the qualifications. A farmer, fifty years of age and scarcely able to read or write, wanted to undertake the study of Hebrew "to unite the Jews and the Protestants."

The maniac is strongly inclined to intrude into the affairs of others, causing, as might be expected, much trouble. He offers his advice and assistance to everybody. In the asylum he accompanies the physician on his rounds, makes diagnoses, and prescribes treatment. Often he tries to assist the nurses, who find it very difficult to moderate his zeal.

In the more marked degrees the excitement leads the patient to many eccentricities. He removes his clothing, replaces it; executes pirouettes and dangerous leaps; sings obscene songs; performs grimaces and contortions for the amusement of his spectators; and frequently annoys others in a thousand ways.

The conversation is animated, strewn with eccentric expressions, strange words and puns. The language may

be either profane and obscene or marked by a labored refinement. The tone may be jocose or solemn, accompanied by the gestures of a gamin or, on the contrary, by those of a commander or a preacher. There is often a veritable logorrhea.

The writing presents analogous characteristics. Volubility and prolixity are manifested by whole pages scribbled within a few minutes. The lines cross each other in every direction, the letters are large in size, and capitals and flourishes are abundant. Often there is maniacal graphorrhea, analogous to the maniacal logorrhoea referred to above.

The discourse is conducted at random: reflections upon questions of transcendental philosophy as well as upon those of dress or cooking; slander and intimate confidences, extravagant projects, and erotic proposals. The maniac conceals nothing.

Physical symptoms. -We find in mania the physical symptoms which, we have already seen, are associated with morbid euphoria: the general nutrition and the peripheral circulation are active, the pulse is full and rapid, respiration is deep and accelerated, the appetite is good, and the weight increases.

Sleep is diminished, occasionally altogether absent; but in spite of the insomnia the patient experiences no fatigue.

Often in women the menses are suspended, and their return announces the approach of recovery. When they persist through the attack their appearance is likely to provoke a recrudescence of excitement.

Delusional mania. - The fundamental symptoms are the same as those of simple mania. The excitement

may be more marked and the lucidity perhaps transitorily disturbed.

The delusions are usually mobile and consist in ideas of grandeur.

The most varied delusions follow each other, modified every instant by external impressions. The patient assumes all the titles mentioned to him: he is in turn pope, physician, and admiral. Occasionally the delusions are referred to the past and take the form of pseudoreminiscences: a shoemaker pretended to have directed an expedition to the North Pole.

The patient often transforms the surroundings in which he finds himself. A maniac called the head nurse of the service where he was treated the chief of his military station, and the physician the prince of Sagan.

The costume corresponds with the delusions: the patients clothe themselves in fantastic uniforms, cover their chests with decorations, comb their hair in the style of Bonaparte, etc.

Sometimes one delusion persists and remains fixed during the entire duration of the attack in the midst of more mobile accessory delusions: a modest business agent for several months proclaimed himself to be the President of France, and referred to the physicians and nurses as his "grand staff."

The maniac never has absolute faith in his delusions. His conviction is easily shaken. Often even he himself only half believes in the pompous titles that he gives himself; his delusions are a sort of pleasantry with which he amuses himself and with which he mystifies those about him.

Some ideas of persecution, mostly bearing upon the deprivation of liberty, may occur in addition to the ideas of grandeur. In some cases even hypochondriacal ideas may occur. The patient declares that he is afflicted with a grave disease, but that he will cure himself "by taking a trip to London" or by having an operation done by "the greatest specialists of Paris and America."

Hallucinations are rare and fleeting. On the other hand, illusions are frequent and lasting; they often assume the form of mistakes of identity: the patient is apt to believe himself surrounded by his acquaintances and by familiar objects.

In grave forms, during the excited paroxysms, the consciousness at times undergoes a certain degree of clouding and the period of illness leaves but a very vague impression, or none at all, upon the memory.

The following case is a good example of delusional mania.

Gabrielle L., fifty-two years old, housewife. Family history unknown. The patient has always been impressionable and lively; intelligence normal. She had five previous attacks of mania, the first at the age of nineteen; all terminated in recovery.

The present attack began with rambling speech, assaults upon others, and a tendency to alcoholic excesses; the patient, though usually temperate, began to drink to intoxication. She was taken

to the Clermont Asylum where Dr. Boîteaux issued the following certificate of lunacy: "Condition of acute mania with extreme disorder of ideation, speech, and conduct. Illusions of the senses. Obscene actions. Ideas of grandeur: owns millions, heavens and earth. Excited, difficult to control."

On February 25, 1904, one month after the patient's admission to the asylum, examination was as follows: Medium stature, strong constitution, slight obesity, skin flushed, voice loud, gestures lively, clothing disarranged, hair down over the shoulders. From the

beginning the patient showed extreme familiarity. She offered her arm to the physician, whom she took to be the husband of the head nurse, and laughingly asked the latter if she was not jealous. She was well oriented as to place; she knew that she was at the Insane Asylum at Clermont where she had already been five times before. Her orientation of time was somewhat inaccurate: she said the year was 1904, that it was the spring of the year, and gave the date as March 25 (actual date February 25, 1904); on being asked to think a while and make sure of the date, she said: “Why, of course it is March, a few days ago we had a holiday, that was Mid-Lent." (She was evidently referring to Shrove Tuesday.) Later other ideas appeared and it became impossible to prevail upon the patient to reflect properly before speaking. She had a certain realization of her condition: she said she felt odd, "at times driven to play all sorts of silly pranks." She was very obedient, and always started out with remarkable eagerness to carry out any order that might be given her. But her extremely mobile attention caused her to be each instant distracted from the object to be attained. She was asked to write a letter: "Why, certainly! To whom?" To whomever you wish. "Very well, to the President of the Republic? To the Minister of War? No, I shall write to my husband." Then she began to write: To Mr. L., Gardener in C. . . . Then turning again to the physician: "Because, you know, we have been living in C. . . for the past eighteen years. I have a house there. The hospital at C. . . . belongs to me. I know Sister Antoinette there. They wanted me to disguise myself as a Sister, but my husband wouldn't have it. He adores me, my husband does!" She was again asked to write, which she did, jabbering all the time and reading aloud everything she wrote. Every moment her attention kept getting distracted by the conversation of the persons in the room, although they spoke in a low voice and upon matters which did not concern the patient. They spoke, in fact, about another patient who helped the nurses with the service in the dining-room. "Good gracious!" exclaimed the patient, interrupting her writing and bursting out with laughter, "that woman is pretty stingy with her bread! One would think she was paying for it! It was I that gave her the money to buy it with!" When asked again to continue her letter she willingly resumed her writing. A minute later they spoke about another patient, and someone made the remark, "She does not sleep.” This started the patient again: "Who, I? I don't sleep? Why, I sleep like a dormouse!" It is to be noted that she wrote slowly,