The persistence of hallucinations and delusions in melancholia and paranoia is usually absent in mania. In this form of mental disturbance there is usually rapid change of delusions and hallucinations, ' often without apparent cause. The false sense-perceptions and ideas vary as rapidly as they sometimes do in dreams.
If unopposed in his irrational notions, the patient is usually in a cheerful, even happy frame of mind. Contradiction or opposition soon lead to irritability, and at times the patient may become so angry as to be uncontrollable. Under these circumstances maniacs may commit acts of violence, the patient's anger be ing entirely beyond his control. On the other hand, if the delusions are encour aged they "increase by what they feed on" and grow more persistent and in sistent.
In connection with the mental exalta tion there is often great restlessness. The patient may continue doing his usual work, but he does everything in a hurry. There is a more lively play of the facial expression. The patient frequently poses for effect. This is perhaps equally frequent in the two sexes, although more marked in women. Sexual desire is also enhanced, and, in advanced stages women are likely to exceed males in obscenity of speech and action. Masturbation is sometimes observed in mania, but much less frequently than in epileptic insanity. The open practice of the vice is compara tively rare.
In the more severe forms of mania all these manifestations are intensified. The rapid movements, the shouting and laughing, incoherence, obscenity, and profanity are greatly heightened in de gree.
Articles of clothing, bedding, furni ture, in short, anything that offers oppor tunity for tearing or breaking are liable to suffer destruction at the hands of the maniacal patient. He loses control over his sphincters, and wets and soils his bed and clothing, or defecates on the floor and then dabs his body or the walls of his room with his excreta. There seems to be anaesthesia in some cases; at all events slight injuries, that in the normal condition would give rise to complaints of pain, are either not felt or are thought unworthy of notice.
Fever is present in a considerable pro portion of cases of acute mania. It
should always lead to a careful physical examination to determine the presence of any local inflammatory condition. In two recent cases under notice the fever was due to considerable collections of pus. In one of these no pain was com plained of; and yet on examination a large perirectal abscess was discovered which discharged about ten ounces of pus when opened. Mere functional de rangement of the mind is not likely to cause appreciable elevation of tempera ture. There can nearly always be found some direct cause for the fever, either inflammatory or septic. The inflamma tion may be in the brain or its mem branes, in the abdominal viscera, the pelvis, the external ear, the integu mentary tisues, or the peripheral nerv ous system (neuritis). The septic infec tion may start from a wound, an abscess, or a diphtheritic patch, or it may be in the blood itself, as in various specific febrile conditions. Even when no phys ical cause can be discovered, fever is al ways a grave symptom, since, if it rises too high, exhaustion supervenes more rapidly.
The pulse in mania is usually full and regular. But when there is beginning exhaustion, as in those cases where the patient is constantly moving about, with insufficient food and sleep, the pulse is small and rapid. In these cases death from exhaustion is not infrequent.
An attack of mania may terminate in one of four different ways: (1) recovery; (2) death from exhaustion; (3) chronic mania; (4) consecutive dementia.
Diagnosis.—The diagnosis of the clin ical form of mental disturbance termed mania is sometimes rather difficult. As before stated, many forms of insanity have a maniacal stadium which may be, and often is, mistaken for a special dis ease. Hence prolonged observation, ex tended over days and sometimes weeks, is, at times, necessary to form a positive judgment. The greatest difficulty occurs in those cases due to septic or toxic causes which by many are not differentiated from true mania. In these cases the exaltation is often only apparent, the essential and characteristic manifesta tions being mental confusion or delirium.