life, and to practise system and order in their work. Reducing their ordinary lives to a routine is the safest thing for them if they can do it. Like leanness, want of system and method go with a tendency to melancholia, in my experience. They should not work, or think, or feel in big spurts. And as the crises of life-the climacteric, pregnancy, child-birth, and senility-approach, let special care be taken by them. Do not let them get to depend on soporifics for sleep. Nothing is more dangerous. An hour's natural sleep-"tired nature's sweet restorer"-is worth eight hours' drug-sleep. A country life, with much fresh air, is no doubt the best, if it is possible. Regular changes of scene, "breaks" in occupation, and long holidays, are of course most desirable for some people. Though travel and change are very often harmful to actual melancholic patients, yet, to many persons who merely have the temperament and the tendency, they are most effective in warding off attacks. I know several people who in that way keep well and moderately happy. The great thing to be avoided is too fatiguing travel-seeing too much in too short a time.

LECTURE IV.

STATES OF MENTAL EXALTATION-MANIA

(PSYCHLAMPSIA).

LIKE conditions of mental depression, states of mental exaltation, up to a certain degree, may be normal and physiological. This is especially apt to be the case in persons combining the sanguine temperament and the nervous diathesis. Everyone has met with the sort of person who is easily elated, has little power of controling the outward manifestations of exalted emotion, is quite carried away by joyous news or pleasurable feeling, so that he talks loud and fast, cannot sleep, cannot rest, acts in strange excited ways, and perhaps dances and singsall without cause that appears sufficient to produce these effects. Such conduct may be perfectly natural and physiological in any man, if the cause be sufficient; but, in the Teutonic races, at all events, such causes do not occur very often in the adult lifetime of an ordinary man. If such mental exaltation does occur in anyone on quite insufficient cause, or if it continues to manifest itself long after the cause has operated, we say that such a person is of an "excitable temperament." Many bodily diseases in persons of this constitution are apt to be accompanied, and are often much complicated, by such brain excitement.

Mental exaltation is perfectly natural in childhood. It is, in fact, the physiological state of brain at that period. Hence, whenever the temperature of the brain rises from febrile disorders in children, we are apt to have delirious mental exaltation. But if a grown man exhibited the same symptoms of mental exaltation as a child, it would be accounted morbid, and he would be reckoned insane. In children of the constitution I have referred to, this is apt to become a most serious

complication. While a high temperature is apt to cause violent delirium in such children, it is in them, too, that reflex peripheral irritations, such as teething, worms, undigested or indigestible food in the stomach, cause convulsions. In adults of this constitution, a febrile catarrh, a mild attack of rheumatism, or gout, or inflammation may be most serious. matters, from the sleeplessness, nervous excitement, intensity of the pain, or the delirium present. All febrile affections act as a match to gunpowder in such a brain. The exaltation and delirium are usually contemporaneous with the beginning and acme of febrile attacks, while depression of mind follows the disease. I consider that the bodily temperature at which delirium begins in a child is a good index of its brain constitution and temperament. I have known a very nervous child always delirious if its temperature rose to 100°, while in most children this does not take place till it is 102° or over. Then, apart from increased temperature, such children are subject to gusts of unreasoning elevation, during which they are quite beside themselves, rushing about wildly, shouting, fighting, and breaking things, not really knowing what they are about, this coming at intervals like the "attacks" of a disease. Most sorts of bloodpoisons, many drugs, such as opium, henbane, Indian hemp, and alcohol, as well as an increase of body temperature, readily cause maniacal exaltation in the brains of which I am speaking; and I have seen such usually temporary exaltation not pass off, but become a prolonged attack of mania in several patients— one after a dose of cannabis indica, another after opium, and more than one after alcohol. All were, of course, strongly predisposed to insanity by heredity.

There is much less difficulty in drawing the line in most cases between sane, or even between merely delirious exaltation, and pathological insane exaltation, than between the conditions of sane and insane depression of mind, though many individual cases of difficulty are met with. The reasoning power-that of judging rightly, and comparing is affected sooner and more decidedly in mania, and the loss of control in action,

That

conduct, and muscular movements is also sooner seen. stage of loss of memory and consciousness where the personality is lost, and the former mental life and experiences have disappeared, where in fact the metaphysical ego has fled, and a false consciousness-an unreal ego-has taken its place, is far sooner reached in mania than in melancholia.

The name Mania is apt to be used both professionally and popularly in a loose way as synonymous with insanity, or even to indicate a mental craze or eccentricity that falls short of that. This is a very great pity, for we shall never in mental diseases make satisfactory progress till we get an accurate scientific nomenclature. The loose way in which the present terms are used is certainly an excuse for those who, like the late Professor Laycock, coined a new medico-psychological terminology altogether, to express morbid mental conditions. Nothing is more common

than to see in medical papers "suicidal mania," when "suicidal melancholia" was meant. It is necessary, therefore, to define the term. Mania might be defined as morbid mental exaltation or delirium, usually accompanied by insane delusions, always by a complete change in the habits and modes of life, mental and bodily, by a loss of the power of self-control, sometimes by unconsciousness, and loss of memory of past events, and almost always by outward muscular excitement, all those symptoms showing a diseased activity of the brain convolutions. We think of melancholia chiefly from the patient's subjective point of view, taking his affective change and his conscious mental pain chiefly into consideration, while we think of mania more from our own objective point of view, and picture the patient's talkativeness, his restlessness, and his manifest changes of personality and habits: just as in neuralgia we think of the patient's sensations, and in tetanus of the convulsions which we see for ourselves. The definition of mental exaltation, too, must not be taken as if it were the mere opposite of depression or of mental pain. Mental exaltation in its medico-psychological sense is not consciously felt mental pleasure. It may be that, but, as in most cases of acute mania at all events, we have the unconsciousness of former

mental acts as well as of present circumstances, this definition could not properly apply to these cases. I would therefore define morbid mental exaltation to be a morbidly increased production of mental acts by the brain with or without an increased sense of well-being or pleasure, but distinctly without a conscious sense of ill-being or mental pain. The word excitement used medico-psychologically refers always to outward visible muscular acts, such as restlessness, muscular resistance, acts of violence, shouting, facial expressions, contortion, or movements or expressions of the eyes, or to an intense desire towards such acts restrained by a strong exercise of self-control.

Most melancholic patients can tell us how they feel. They know there is something wrong with them, exaggerating their mental pain; while in most cases of mania the patients affirm they are quite well, probably better than they ever were in their lives, and we have to judge of their mental condition from their speech and actions, which become to us the symptoms of the disease.

If we look at a number of patients who are all classified as labouring under mania, we see at once that there is a very great difference indeed between different cases. Without going into pathology or causation at all, the outward manifestations show not only far greater intensity of morbid action in different instances, as is the case in all diseases, but a difference of type of symptoms, mental and bodily, which I shall endeavour to assort for clinical and practical purposes into varieties of the disease; it being understood that these varieties are not necessarily distinct diseases or pathological conditions, but merely groups of similar symptoms that may be combined with other groups, or may be different stages, in the same disease. The great advantages of classifying mania into those varieties are, that thereby a student is less confused in seeing patients so very different from each other, and more especially in the guide that is thus obtained in treating and managing patients. The varieties I propose to describe and illustrate by clinical cases are-