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or to any extent very dangerous, either to themselves or others. this matter, old opinions and prejudices, the fact that a few patients are dangerous, or that a dangerous stage occurs in some few cases, have given a wrong general impression, and done very much harm in the treatment of acute mania. But we are slowly getting over this, for now we endeavor to assume that any patient laboring under this disease is not dangerous till he is proved to be so, instead of the opposite old maxim, that he was to be regarded as dangerous till he proved himself to be safe, which had this unfortunate result, that the restraints and restrictions and supposed safeguards imposed on him so irritated him that, if he was not dangerous at first, he was probably made so by them. No safe outlet was provided for his morbid motor energy, so that, like all pent-up force finding no outlet, it became dangerous, and often killed the patients.

The motions and gesticulations of an acutely maniacal patient are often in an exact degree the muscular equivalents of the ideas and emotions passing through his brain, just as they are in the case of a savage or a born orator when he makes a speech about a subject which excites him. The most awkward of men often becomes easy in his motions when maniacal. The expression of the face is always changed, and also the appearance and expression of the eyes. Usually the man is so changed that he looks a different man. He is always "worn-looking," and this is more particularly the case in the female sex. There is no natural beauty of face that will continue during acute mania. Usually the face is flushed; the skin muddy and less delicate in tint and texture; the features unpleasant to look on. As might be expected, the infinitely delicate coördinations and fixations of the small muscular strands, that in the face mirror forth and express the mental and emotional states, are, in this disease, inharmonious, and express instead the incoördinated mental acts. The eyes are more especially characteristic. They usually glisten somewhat, as in fever; the eyelids are more widely dilated, so that the white is seen round the cornea; and their expression is that of excitement and turmoil.

The whole digestive tract is affected more or less. The secretions of the mouth and the saliva are altered in character, and, when inoculated, produce a septic or irritating influence. The sores resulting from a bite of such a patient, as I have often seen in attendants, are apt to be angry, the inflammation running up the lymphatics. The most recent investigations show the septic character of the saliva. The tongue is usually furred, and the breath foul. When the condition becomes delirious,, there is always a tendency to have a dry mouth and tongue, with sordes on the teeth. The appetite for food is usually paralyzed, though not always that for drink. The digestion is often vigorous enough, though not in the exhausted stage. I have found the stomach full of undigested food in patients who had died of exhaustion from acute mania. The bowels tend to be costive, though this is not always so. The temperature is usually from one to two degrees above the normal, especially the evening temperature. As we shall see, it runs far above this sometimes; but if it rise much above 100°, we look out for a febrile or inflammatory cause, or for general paralysis, or for organic disease. The skin is

usually clammy and ill-smelling, though sometimes harsh and dry. In women, the menstrual function is almost always interfered with, being usually stopped after the excitement has continued for a few weeks. The odor from a woman both menstruating and maniacal is most offensive. I find that out of the last fifty women admitted to the Asylum laboring under acute mania, three-fourths had irregular menstruation, and in most it ceased till they became convalescent or demented. The common sensibility is much diminished in such cases, patients not feeling pain acutely, some not feeling it at all. Injuries, cuts, boils, whitlows, and such painful affections are borne without any complaint of pain. With their feet inflamed, they will walk-with their hands in sores, they will use them freely.

The continuance of this condition is, of course, attended with rapid and great loss of body weight. I have known a patient lose a stone of flesh in a week, notwithstanding that he was getting plenty of food. But after losing any redundancy of fact, it commonly happens that the intensity of the disease diminishes, and the loss of weight is less rapid. It usually takes a considerable time, always provided a sufficient quantity of proper food is given, and proper treatment adopted, before extreme emaciation and weakness result. The more intense the attack, the shorter is usually its duration; in fact, a great prolongation of very acute delirious mania with a temperature of 100°, no sleep, and constant violent motor excitement are inconsistent with life. Few cases die in the first week of the attack; some do in the first fortnight, and some in the first month. In a somewhat subacute form, it is wonderful how long it may last, without producing fatal results, or even reducing the patient very much, if he eats enough-and enough may mean four times his usual amount of food-and is sufficiently in the fresh air, and is not restrained in his movements. In by far the majority of instances, such mechanical restraint as used to be employed in this country, and is still employed elsewhere, by strait-jackets, gloves, straps, etc., causes such a feeling of degradation, irritation, and resistiveness, that the good effect of any actual conservation of force by restraint is in my opinion far more than counterbalanced. The disease, if it does not kill, is more apt to run on into chronic mania and dementia. To restrain the mere outward muscular movements, while the motor energy is all the while being generated in the brain convolutions, is eminently unphysiological. Almost as well restrain the movements of the choreic or the convulsions of the tetanic patient by binding them tightly, and expect a good result. Our great efforts in the treatment of such cases now are to find suitable outlets for the morbid motor energy, to turn the restless, purposeless movements into natural channels, to get the patients to dig, and wheel barrows soon, and to walk long distances, instead of shouting and gesticulating. We find that this saps and exhausts the morbid energy and excitement, producing healthy exhaustion and sound sleep, vigorous digestion, and healthy excitation of the skin, the glands, and the excretory apparatus generally. This is the chief physiology and philosophy of the modern British non-restraint treatment of mental diseases. doubt there are exceptions to all rules. I have seen cases where restraint had to be applied to prevent the patient exhausting or hurting

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himself, but they are amazingly few in a well-equipped asylum, with large grounds, a farm, good attendants, and plenty of them, and a padded room. Under those circumstances, not one case in ten thousand is found to need restraint. But it is quite different when we have to treat a patient in a private house, or with insufficient attendance. Then mechanical restraint may be quite unavoidable. It often happens that, at the commencement of a case, where the symptoms have developed rapidly into an acute form, you may think it advisable to give the patient a chance of its soon passing off, or arrangements cannot be at once made for removal to an asylum through the absence of those who can authorize it, or the relations of the patient may absolutely insist on his being treated out of an asylum. In all these circumstances, you have to do the best you can with the means at your disposal, carrying out to as great an extent as you can the principle of providing an outlet in the open air for the morbid motor energy that is being generated in the brain convolutions, but using, it may be, restraint to some extent.

Acute mania may in most cases be divided into three stages: the first that which I have described as simple mania; the second, that of ordinary acute mania; and the third, that of delirious mania, with a tendency to dry tongue, etc. The third, under proper treatment of the first two stages, does not occur in many of the patients.

As you can readily understand, from the delicate constitution of the gray brain-substance that highest evolution in nature of combined function and structure-and the infinite complexity of its balanced and interdependent functions, the continuance of such an abnormal storm as that which exists in acute mania is very apt to be followed by permanent and irretrievable damage. Such a storm, besides all the bodily symptoms and disturbances which I have described, is accompanied by intense congestion and over-action in the gray neurine and brain generally-the former usually seen in limited areas (see Plate III.), which tends soon to pass into structural changes. The cells soon get granular; there is a proliferation of the nuclei of the neuroglia; the lymphatic spaces and perivascular canals soon get over-dilated and blocked up with débris, and an enormous number of microscopic capillary extravasations take place in and around the convolutions in bad cases. Even the coverings of the brain are affected, the vessels getting thickened in their coats and tortuous, the fibrous matter of the pia mater getting hypertrophied, the arachnoid milky, the dura mater thickened or adherent to the bone, and even the bony case becoming dense and thickened.

All those things happen through prolongation of the acute symptoms. Therefore, it is of the last importance to shorten, if we can, the acute stage. Every week of this adds to the chances of the acutely excited state being followed by more or less permanent mental defect. Even the present risk to life is not so grave a risk as that; for which of us, if we had the choice, would not prefer, on the whole, death to a degradation from our mental and emotional eminence in creation to a state of permanent mindlessness, in which we would be dead to the love and hatred and to the joys and pains of life, oblivious of the past, and unconcerned for the future; stirred by no ambition; capable of no effort, and unmoved by any motive? For such is dementia. of which I am to speak

afterwards, that follows and results from mania. About sixty per cent. of the cases of acute mania recover, seven and a half per cent. die, and thirty-two and a half per cent. become demented, or pass into chronic mania. There is, perhaps, more opportunity for right treatment and management in acute mania than in any other kind of mental disease.

GENERAL INDICATIONS FOR THE TREATMENT OF ACUTE MANIA.-In the beginning of the attack, and sometimes, when the patient is wealthy, all through it, we have to treat the case at home. Now, no doubt, the first thing to be done is to get proper trained attendants-one, two, three, or even four may be necessary for night and day work. Patient, sensible, experienced, cool and kindly men or women are what we want. Then proper arrangements must be made, a good suite of two large rooms on the ground floor of a house, with a garden, and not too near a public road, being required. Small breakable articles must be removed, but do not make the rooms quite desolate or unattractive looking. Fasten windows not to open more than five or six inches, and see that no knives or lethal weapons are too handy. But do not do all this demonstratively to attract the patient's attention. Next, you must look to the feeding with suitable nutriment very often; sometimes you can give it only little and often; sometimes in ordinary meals, with beef-tea and milk in between. Milk, eggs, beef-tea, ground beef, custards, strong soups, with plenty of vegetables, and porridge are the best, as often as the patient can be got to take them, and in as large quantity. Do not for a moment be afraid of a dirty tongue, and think it contraindicates food. Nothing could be a greater mistake, in acute mania at all events. The furred tongue is not from an overloaded alimentary canal, but results from perverted innervation of the digestive tract. Malt liquors, such as porter and ale, can be given freely with advantage-good wines, too, if they can be got. Even whiskey or brandy will act as a direct sedative to the excitement in some cases. Anstie taught us some good therapeutics, in his Stimulants and Narcotics, on this point. But alcohol, you will find, will sometimes flush and cause excitement. In that case, use it sparingly. I have seen a pint of beef-tea representing all that was soluble in a pound of beef-steak and a glass of whiskey reduce the temperature 2.30. To show the quantity of food that such patients can take and digest, I mention that at the asylum I am never satisfied except the bad cases get at least six eggs a day beaten up in liquid custards, in addition to their ordinary food, beef-tea, etc. I have known many patients take a dozen eggs a day for three months running. The constant motion and fresh air enable them to digest and assimilate all this. So long as a patient is losing weight, the physician should never be satisfied. When he becomes stationary, then one may begin to think that the disease is being overcome by nature and treatment. When he begins to gain in weight, and the temperature becomes normal, then convalescence or dementia has begun. The patient should be weighed every week during the acute stage.

a case.

Next to good food and nursing, fresh air is most essential in treating No patient must, on any account, or in any weather, except he is excessively run down indeed, be kept in bed or in the house. Herein is the essential difference between the treatment of this disease and that

of acute bodily complaints. I often keep patients out all day in the summer-time. When they are getting better, they all say that they feel better out than in. There is no soporific, no calmative, and no digestive like the fresh air. And the attendants must not restrain or interfere more than is necessary. There should be no nagging and small interferences, and no arguing, but a kindly, firm mode of dealing with a patient-coaxing, when coaxing will do, and firm insistance and force sufficient to overcome resistance when necessary. There is a certain kind of tact which some people have, and which may be partly acquired, but which is often a natural gift, and, when present, is of the greatest avail in overcoming resistance, persuading patients to take food, etc. Women have it more frequently than men, and women will often persuade male patients when their own sex fails. It does not do to let patients have too much of their own way. A happy mean between that and too much interference should be pursued. It is better to be honest, and not deceive patients into doing things. That often makes them lose confidence, and does harm afterwards. Medicine when given should, as a general rule, be given as medicine, and not be put in food surreptitiously. The safety of the patient and those about him must of course be provided for.

For the bowels it is sometimes necessary at first to use laxatives and enemata, and even strong purgatives, such as croton oil, but I try first such mild medicines as castor oil, Tamar Indien lozenge, liquorice powder, warm water enemata, etc. Do not insist on a stool every day; one every second or third day is quite enough. Depleting remedies of all sorts are in my opinion bad.

There is one remedy that I have seen do good in many cases, and in a few act like a charm, and that is, prolonged warm baths with cold to the head. The effect of this is to fill the capillaries all through the body, and to withdraw blood from the brain, to depress the heart's action,—and hence its danger,-to soothe the nervous irritation, and to produce sleep. I have the highest opinion of its efficacy, but unfortunately it is attended with danger in some cases. A man, whom I could not detect to have heart disease, once died in my hands, as it were, when I was sitting beside him, after being less than an hour in water at 103°. I know of two other cases where syncope and death resulted in the same way. I used to keep the water up to 110°, but I never do so now. I now prefer 99° as the proper temperature. But the effect with this is not so quick or so marked. Baillarger used to keep his patients steeping for days in water at 96° or 98°. I do not think, however, the treatment is so much in vogue now in Paris as it was twenty years ago. Showerbaths of a mild kind are sometimes useful when the mania threatens to become chronic, or when the earlier symptoms of dementia show themselves, and the patient is strong and can react after the bath. The great trouble is that patients are apt to look on the shower-bath in any form as a punishment, and so its use may have a bad moral effect on them.

In fact,

One difficulty in treatment is to use narcotics and hypnotics rightly. The greatest differences of opinion have existed, and do prevail at present, about them. What we want and have not yet got is a medicine that will cause really natural, restful, refreshing sleep. Then we want a medicine