may be safely stated that all idiotic or imbecile children have a far better chance of amelioration in asylums devoted to them than by any amount of care and teaching lavished upon them at home. In the class of idiots just spoken of imperfect de The general conformation of the idiot is often very imperfect; he is sometimes deformed, but more frequently the frame is merely awkwardly put together and he is generally of short stature. Only about onefourth of all idiots have heads smaller than common. Many cases are on record in which the cranial measure-velopment of the intellectual faculties is the prominent ments exceed the average. It is the irregularity of development of the bones of the skull, especially at the base, which marks the condition. Cases, however, often present themselves in which the skull is perfect in form and size. In such the mischief has begun in the brain matter. The palate is very often highly arched, in some cleft; hare-lip is not uncommon; in fact congenital defect or malformation of other organs than the brain is more commonly met with amongst idiots than in the general community. Of the special senses, hearing is most frequently absent. Sight is good, although co-ordination may be defective. Many are mute. On account of the mental dulness it is difficult to determine whether the senses of touch, taste, and smell suffer impairment; but the impression is that their acuteness is below the average. It is needless to attempt a description of the mental phenomena of idiots, which range between utter want of intelligence and mere weakness of intellect. feature, so prominent that it masks the arrest of potentiality of development of the moral sense, the absence of which, even if noticed, is regarded as relatively unimportant; but, in conducting the practical study of congenital idiots, a class presents itself in which the moral sense is wanting or deficient, whilst the intellectual powers are apparently up to the average. It is the custom of writers on the subject to speak of "intellectual" and "moral" idiots. The terms are convenient for clinical purposes, but the two conditions cannot be disassociated, and the terms therefore severally only imply a specially marked deprivation of intellect or moral sense in a given case. The everyday observer has no difficulty in recognizing as a fact that deficiency in receptive capacity is evidence of imperfect cerebral development; but it is not so patent to him that the perception of right and wrong can be compromised through the same cause, or to comprehend that loss of moral sense may result from disease. The same The term Imbecility has been conventionally em- difficulty does not present itself to the pathologist; for, ployed to indicate the less profound degrees of idiocy, in the case of a child born under circumstances adverse but in point of fact no distinct line of demarcation can to brain development, and in whom no process of edube drawn; the application of either term to a given cation can develop an appreciation of what is right or case depends more on the opinion of the observer than wrong, although the intellectual faculties appear to be on the condition of the observed. As the scale of im- but slightly blunted or not blunted at all, he cannot beciles ascends it is found that the condition is evi- avoid connecting the psychical peculiarity with the denced not so much by low obtuseness as by irregu- pathological evidence. The world is apt enough to larity of intellectual development. This serves to mark refer any fault in intellectual development, manifested the difference between the extreme stupidity of the by imperfect receptivity, to a definite physical cause, lowest of the healthy and the highest form of the mor- and is willing to base opinion on comparatively slight bidly deprived type. The two conditions do not merge data; but it is not so ready to accept the theory of a gradually one into the other. Extreme stupidity and pathological implication of the intellectual attributes sottishness mark many cases of idiocy, but only in the concerned in the perception of the difference between lowest types, where no dubiety of opinion can exist as right and wrong. Were, however, two cases pitted to their nature, and in a manner which can never be one against another-the first, one of so-called intelmistaken for the dulness of the man who is less tal- lectual, the second, one of so-called moral idiocyented than the average of mankind. Where in theory it would be found that, except as regards the psythe morbid (morbid in the sense of deprivation) and chical manifestations, the cases might be identical. the healthy types might be supposed to approach each In both there might be a family history of tendency to other, in practice we find that, in fact, no debatable degeneration of the nervous system, a peculiar cranial ground exists. The uniformity of dulness of the former conformation, a history of nervous symptoms during stands in marked opposition to the irregularity of men- infancy, and of a series of indications of mental incatal conformation in the latter. Comparatively speak- pacities during adolescence, differing only in this, that ing, there are few idiots or imbeciles who are uniformly in the first the prominent indication of mental weakdeprived of mental power; some may be utterly sot- ness was inability to add two and two together, in the. tish, living a mere vegetable existence, but every one second the prominent feature was incapacity to distinmust at least have heard of the quaint and crafty say-guish right from wrong. What complicates the quesings of manifest idiots indicating the presence of no mean power of applied observation. In institutions for the treatment of idiots and imbeciles, children are found not only able to read and write, but even capable of applying the simpler rules of arithmetic. A man may possess a very considerable meed of receptive faculty and yet be idiotic in respect of the power of application; he may be physically disabled from relation, and so be manifestly a deprived person, unfit to take a position in the world on the same platform as his fellows. Dr. Ireland subdivides idiots, for the purposes of education, into five grades,—the first comprising those who can neither speak nor understand speech, the second those who can understand a few easy words, the third those who can speak and can be taught to work, the fourth those who can be taught to read and write, and the fifth those who can read books for themselves. The treatment of idiocy and imbecility consists almost entirely of attention to hygiene, and the building up of the enfeebled constitution, along with endeavors to develop what small amount of faculty exists by patiently applied educational influences. The success which has attended this line of treatment in many of our public and private institutions has been very considerable. It tion of moral idiocy is, that many of its subjects can, when an abstract proposition is placed before them, answer according to the dictates of morality, which they may have learnt by memory. If asked whether it is right or wrong to lie or steal they will say it is wrong; still, when they themselves are detected in either offence, there is an evident non-recognition of its concrete nature. The question of moral idiocy will always be a moot one between the casuist and the pathologist; but, when the whole natural history of such cases is compared, there are points of differentiation between them and mere moral depravity which must appeal to even biased observers. Family history, individual peculiarities, the manifest imbecility of the acts committed, the general bizarre nature of the phenomena, remove such cases from the ordinary category of crime. Statistics. According to the census returns of 1871 the total number of persons described as Idiots and Imbeciles in England and Wales was 29,452, the equality of the sexes being remarkable-namely, 14,728 males and 14,724 females. Compared with the entire population, the ratio is one idiot Whether the returns are defective, owing to the natural or imbecile to 771 persons, or 13 per 10,000 persons living. sensitiveness of persons who would desire to conceal the occurrence of idiocy in their families, we have no means of knowing; but such a feeling is no doubt likely to exist | healthy climate, and may even be prevented by the among those who look upon mental infirmity as humil- gravid mother leaving a valley where it is rife for localiating, rather than as one of the many physical evils ities where cretinism is unknown. The physical and menwhich afflict humanity. According to Ireland, this num-tal symptoms of cretinism are so closely allied in essenber (29,452) is 25 per cent. below the mark. The following table shows the number of idiots according to official tials to those of congenital idiocy as not to demand a returns of the various countries; probably they are sub- separate description. The marked features of the disject to the same criticism as the census return for England. ease are its endemic nature and its intimate connection with goitre. See CRETINISM. Proportion 130 134 150 97 82 1,632 38 2,039 116 13,219 9,209 22,428 Bibliography.-Rapport de la Commission de S. M. le Roi de Sardaigne, pour étudier le Crétinisme, Turin, 1848; B. Niépce, Traité du Goître et du Crétinisme, Paris, 1851; Beobachtungen über den Crétinismus, published by the physicians of the hospital at Mariaberg, Tübingen, 1850, 1851, and 1852; Guggenbühl, Die Cretinen-Heilanstalt auf dem Abendberg, Bern and St. Gall, 1853; Virchow, Untersuchungen über die Entwickelung des Schädelgrundes im gesunden und krankhaften Zustande und über den Einfluss derselben auf Schädelform, Gesichtsbildung, und Gehirnbau (Berlin, 1857), and Gesammte Abhandlungen zur wissenschaftlichen Medicin (Frankfort, 1856); Saint Lager, Études sur les Causes du Crétinisme et du Goitre endémique, Paris, 1867, and Deuxième Série d'Études sur les Causes du Crétinisme, Lyon, 1868; Baillarger, Enquête sur le Goître et le Crétinisme, Paris, 1873; Max Parchappe, Études sur le Goître et le Crétinisme, edited and annotated by L. Lunier, Paris, 1874; Lombrosa, Rirista Clinica di Bologna, pt. 7, July, 1873, and pt. 11, November, 1873; 66 Ireland, Edinburgh Medical Journal for August and September, 1875, and On Idiocy and Imbecility, 1877. named is the standard work on idiocy. The relative frequency of congenital and acquired insanity in various countries is shown in the following table, taken from Koch's statistics of insanity in Würtemberg, which gives the number of idiots to 100 lunatics: 58 22 65 74 68 69 It is difficult to understand the wide divergence of these figures, except it be that in certain states, such as Prussia and Bavaria, dements have been taken along with aments, and in others cretins. This cannot, however, apply to the case of France, which is stated to have only 66 idiots to every 100 lunatics. In many districts of France cretinism is very common; it is practically unknown in England, where the proportion of idiots is stated as higher than in France; and it is rare in Prussia, which stands at 15 idiots to 100 lunatics. Manifestly imperfect as this table is, it shows how important an element idiocy is in social statistics; few are aware that the number of idiots and that of lunatics approach so nearly. ACQUIRED INSANITY. The last It is predicated in treating of Acquired Insanity that we have to deal with brains congenitally perfect, the exercise of whose functions has been normal until the incidence of disease. A full description of the tissues of the healthy brain will be found in the article ANATOMY (vol. i. pp. 763–773), a careful perusal of which will very materially assist the reader in following the present remarks on pathology. A short recapitulation of certain anatomical facts is, however, necessary. The purely nervous structures of the brain consist of very delicate fibres and cells, the latter occurring only in the gray matter. It is richly supplied Cretinism.-Crétin probably comes from Chrétien, with blood vessels, the supply being six times greater either from the idea that the person was innocent in to the gray matter than to the white. These tissues the sense in which that word is employed occasionally are supported and separated one from the other by a to imply a person who cannot sin, or from the religious connective tissue, or interstitial matter, the neuroglia; respect in which cretins were held. Cretinism is a the whole organ is enveloped in membranes which form of congenital insanity inasmuch as the cretino- separate it from the skull. By one system of independgenetic miasma acts before birth; it is endemic in ent fibres (the expansion system) communication is many mountainous countries, and is said to occur most maintained between the spinal cord, the central ganfrequently on magnesian limestone formations, but glia, and the cortical gray matter; by a second system never at an elevation above 3000 feet. Although all of fibres (the commissural), corresponding and identical cretins have not goitre, and all goitrous persons are not regions of the gray matter of the two opposite hemicretins, there is a very intimate relationship between spheres are united; and by a third system (the horithe two conditions. The districts in Europe in which zontal) communication is maintained between parts of it is most common are the departments of Hautes- the same hemisphere. The cells communicate one Pyrénées, Haute-Savoie, and Hautes-Alpes; Styria, with the other by means of processes or poles, fine Upper Austria, the province of Aosta, and Sardinia, projections from the body of the cell. The observaIt is found more sparsely in other parts of Europe, and tions of Cleland and Boll show that the apical proalso among the Himalayas and Andes. It occasion-cesses become connected with the fibres as they go to the ally presents itself in flat countries, -a remarkable in- periphery; the basal processes loop with the horizontal stance being the island of Niederwerth below Coblentz, fibres, and also, by means of their recurrent poles, with where out of 750 inhabitants there are 131 cretins (Dr. those of the expansion series. But it is of great importIreland). Notwithstanding the circumscribed area in ance to observe that we have no evidence of fibre comwhich this disease exists, affording, it might be sup- municating directly with fibre, or no certain proof that posed, data founded on the conditions of life common one series of fibres communicates directly with others; to their inhabitants for arriving at conclusions as to its in fact, all anatomical demonstration goes to prove the cause, nothing has been definitely determined. Cre- individuality and isolation of fibre, the processes of the tinism has occupied the attention of many eminent ob- cells being the connecting link. It is universally accepted servers, but the various theories they have advanced that the cerebral cells possess the vital property of genhave been in succession overturned. It has been sug-erating, receiving, and transmitting nervous influences, gested that the condition is due to the constant use of and that the fibres are the organs by means of which these snow water, or to the presence of sulphate of iron or influences are received and communicated. In the words of lime in water, but none of these theories admit of of Herman, "in a part of the central organs (the coruniversal application. That the disease is due to some tical cells) certain material processes are accompanied geological or climatic cause appears certain from the in an inexplicable manner with wholly undefinable phefact. stated by Baillarger, that it disappears from a nomena which characterize what we term consciousness," family in one or two generations after removal to a The term mind may be applied to the combination of 66 all the actual and possible states of consciousness of the organism. We have a right to presuppose that in the brain, as in other organs of the body, the normal exercise of function is dependent on a perfect maintenance of the anatomical relations of the component structures, and conversely that morbid conditions of these structures must affect the whole economy more or less seriously" (Bucknill and Tuke). In studying brain pathology it must be kept in view that the brain cannot, like the lungs, liver, and kidneys, cast any of its functions on other organs; it must do its own work, rid itself of its effete matter, and of the products of injury or disease, and provide within itself for the resumption of functions the exercise of which has become impaired from whatever cause. Solutions of continuity, preventing perfect maintenance of the component cerebral tissues, may arise from-(1) idiopathic causes, i. e., causes originating primarily in the brain; (2) traumatic causes (injury to the head); (3) the effects of other neuroses (morbid nerve conditions); (4) adventitious products (tumors, etc.); (5) morbid conditions of the general system secondarily implicating the brain; (6) evolutional conditions of the system concurrently affecting the brain; (7) toxic agents (poisons). In the case of insanity the results of morbid action are confined to the convolutions of the superior surface of the brain, and to the upper part of its lateral aspects; for the most part its base and inferior lateral aspects and the cerebellum are unaffected. It is true that in old standing cases the central ganglia present lesions, but these are for the most part secondary, and are due to the action of disease in the superior convolutions. 1. Idiopathic changes occur from disease affecting the tissues, the cause of which it may be impossible to trace, as, for instance, acute inflammation, which, however, is not a frequent cause of insanity. Diffused subacute inflammation is held to be a much more fruitful cause, producing increase (sclerosis) of the neuroglia, degeneration of the cells, destruction (atrophy) and displacement of fibres, and aneurism, distortion, and obliteration of vessels. A large and important class of causes of idiopathic morbid action is due to over-excitation of the brain. The causes of over-excitation of the brain functions are those which, in most works on insanity, are spoken of as "moral" (grief, anxiety, domestic complications, disappointment, terror, sorrow or joy, religious or political excitement, the exercise of the mental faculties by study unduly prolonged or conducted under adverse circumstances) in contradistinction to "physical" causes, -a distinction which implies some material difference in their method of operation. To the most superficial observer, the deformed head of the idiot, and the paralysis of mind and body which follows on the rupture of a cerebral vessel, are coarsely material conditions; but when mental aberration follows on mental excitement, men are prone to regard it more as a derangement of function than as an evidence of deterioration of brain structure. If, however, we give due weight to the results of physiological research, the matter is not quite so obscure. Arguing from the analogies of other organs and from direct observation, there is reason to believe that when the brain functions are being actively exerted there is a dilatation of the vessels and an increased blood supply (hyperæmia) to its superior and lateral surfaces. This functional hyperæmia is caused by the direct action of the cerebral cells, which, along with the sympathetic system of nerves, exercise control over the muscular coats of the arteries, the immediate regulators of blood supply to any given part. Control over muscular tissue implies, of course, control in two directions, dilatation and contraction. Functional hyperæmia is in every respect a healthy condition, one necessary for the provision of temporary nutriment during temporary action, ceasing with the withdrawal of stimulus, when the calibre of the vessels is reduced to its original dimensions through the contracting influence of the cells. But if the exeitement is unduly prolonged a new result appears; the cells themselves become exhausted, and therefore, even if the stimulus is withdrawn, they are unable to assert their ordinary control over the arterial muscular coats in the direction of contraction, so that the increased blood supply continues although the stimulus which caused it has been removed. Instead of functional hyperemia we have a hyperæmia caused, not by functional excitement, but by exhaustion of the controlling organs. In a minor degree the results of this condition are matters of everyday observation; over-taxation of the brain functions, by study for instance, is very generally followed by sensations of fulness and aching of the head, loss of sleep, and general exhaustion,-a condition which is recovered from when the primary irritation is withdrawn, ie, when the arteries reacquire healthy tone. But if relief from the causes of irritation is not obtained, a sequence of events ensues tending to deterioration of tissue. In the first place, sleep, the condition necessary for rest and recuperation of the cells, becomes unattainable. Physiological research has shown that during sleep the supply of blood to the brain is diminished (anæmia), that anæmia is necessary for, and hyperemia is inimical to, its production. Further deterioration of cell activity follows on non-recuperation, and concomitant diminished control over the vessels tends to the establishment of morbid hyperæmia and more or less blood stagnation (stasis). It would be far beyond the compass of this article to follow out in detail the various pathological processes which ensue on paralysis of vasomotor action; two only need be alluded to-(1) the various changes which take place in the behavior of the constituents of the blood, producing congestion and greater or less obstruction to its normal distribution, and (2) the effects which congestion produces on the lymphatic system of the brain, the system by which effete matter is largely removed from it. It is now generally recognized that the lymphatics of the brain are perivascular, i.e., that they are tubes surrounding the arteries, patent under ordinary conditions; when, however, the arteries are distended, it is easy to comprehend that the lymphatic system becomes occluded by the artery filling up the space provided for it, and therefore that the removal of waste products becomes difficult or impossible. It is a pathological axiom that the structural integrity of a part is dependent on the maintenance of its vascular unity, in other words, on the regular supply and withdrawal of blood by its regular channels. This if impaired or destroyed is necessarily followed by histological changes and by disturbance of function. By this exposition of a probable sequence of pathological events it is desired to indicate that disturbance of function directly referable to over-excitation of the brain is not a mere functional derangement, not a mere morbid increase of a normal emotion, but that it is the manifestation of a pathological condition, that, in effect, so-called moral causes may be the producers of physical cerebral disease. This meets with support from the clinical observation that, with very rare exceptions, a considerable period of time elapses between the incidence of the moral cause and the first indication of mental alienation,- —an interval during which sleep has been absent in consequence of continued hyperæmia. Instances of melancholy or mania being suddenly produced by mental shock must be searched for in works of fiction. Sudden fright, more especially, is stated to produce immediate convulsion, epilepsy, and catalepsy, but not insanity; except in certain comparatively rare instances, in which it appears to induce with great rapidity a cataleptic mental state, presently to be spoken of as acute primary dementia. Overexercise of the intellectual function is not by any means such a prolific cause of brain disease as undue emotion. It is not work but worry that kills the brain. When both are combined the result is often rapid. On the removal or persistence of congestion depends connective tissue of the superior convolutions has been the issue of a case-recovery, or further and permanent demonstrated. solution of continuity. Unless relief is soon obtained, the changes in the cells are followed by lesions of other brain structures which are productive of important pathological conditions affecting the general system; these in their turn render recovery more difficult or impossible, or may even cause death. (For a full account of the various lesions found in the brains of the insane, consult Bucknill and Tuke, Manual of Psychological Medicine, 4th ed., cap. vi.; Fox's Pathological Anatomy of the Nervous Centres, London, 1874; J. Batty Tuke, "On the Morbid Histology of the Brain and Spinal Cord as observed in the insane," Brit. and For. Medico-Chirurgical Review, 1873-74.) 2. The second class comprises all accidents and injuries affecting the brain, and is most conveniently termed traumatic. Violence to the head may produce fracture of the skull with or without depression, extravasation of blood in or on the brain, or concussion. There is no relation between the apparent extent of the injury and the results in insanity; extensive fractures of the frontal, lateral, and superior surfaces of the skull, even when complicated with rupture of the envelopes and loss of brain matter, are not, taken over all, more productive of insanity, if so much so, as the apparently less serious condition of concussion. The reason of this is not far to seek; by the open wound free egress is afforded for extravasated blood and the products of inflammation, whereas in concussion, which may also involve extravasation of blood in or on the brain, foreign substances have no means of escape, and so may set up morbid action of a grave nature. Occasionally insanity follows rapidly on the injury, but much more frequently weeks or even months elapse before development of mental symptoms amounting to insanity. During this period morbid action is proceeding on the inner surface of the skull, in the membranes, or in the brain itself. On the inner table of the skull bony growths may be in process of formation, subacute inflammation of the membranes may be going on, and from the same cause the brain may be undergoing progressive changes generally in the direction of sclerosis, Le, increase of connective tissue. 3. The nervous diseases in the train of which insanity occasionally follows are Epilepsy, Hysteria, and Locomotor Ataxy. In the case of Epilepsy the brain lesions are doubtless the result of the frequently asphyxiated condition of the patient and of the blood poisoning due to the retention of carbonic acid gas (see EPILEPSY). As might be expected, lesions of the arteries in the form of hypertrophy of their coats is frequently observed. The canals in the brain matter through which the vessels pass are very frequently found dilated to from two to six times their normal dimensions. If the richness of the blood supply to the gray matter is considered, this condition of dilatation must imply an immense loss of brain tissue; moreover, the cells are frequently found suffering degeneration. In dealing with the subject of Hysteria, we have, as stated in the article especially bearing on the subject HYSTERIA), to do with a disease which, although marked by very prominent symptoms, possesses no anatomical seat, and thus when the disease amounts to insanity we are equally in the dark as to the cerebral Conditions. The insanity following or accompanying hysteria is not a fatal one in its earlier stages, and there is no report extant of an autopsy on a recent case of this disease. Locomotor Ataxy is a disease of the spinal cord, sclerosis of its posterior columns (see ATAXY). It implicates other parts of the nervous ystem,-for instance, the optic tracts and nerves. Insanity occasionally is concurrent with, and probably, if not certainly, is produced by an extension of the sclerosis to the cerebral convolutions. This theory weets support from the fact that the mental symptoms sociated with locomotor ataxy resemble very closely those of general paralysis, in which hypertrophy of the 4. By the term adventitious products it is meant to indicate all forms of tumors of the brain, skull-cap, and membranes. Such foreign bodies have three distinct effects on the brain structure:-"1st, They create an irritation tending to ramollissement in the nerve substance, with which they are in contact from their first appearance. 2d, They cause pressure on distant parts, which in its turn causes an alteration of the structure and nutrition. 3d, They set up progressive disease and degeneration of certain parts of the nerve structure, the true nature of which is as yet not very well known; but it seems to be in some way directly connected with the essential nature and constitution of all sorts of nerve substance, whether cells or fibres. Its results pathologically are an increase of the connective tissue in the form of granules, and enlargement and thickening of the coats of the blood-vessels; but all these seem to be secondary changes" (Coulston, "On Tumors of the Brain," Journal of Mental Science, vol. xviii.). Apoplectic clots are practically tumors. 5. Morbid conditions of the general system secondarily implicating the brain. It is of great interest from an etiological point of view to note that insanity is seldom if ever the immediate result of diseases of individual organs, but that it is more or less intimately associated with those forms of disease which result from a general constitutional instability, such as tuberculosis, rheumatism, gout, and syphilis. There are many diseases painful in character and very depressing to the nervous system, such as stone, fistula (in fact all the so-called surgical diseases of the rectum and bladder), cancer of the uterus, etc., which might be presupposed to be probable causes of insanity, yet in point of fact are not inimical to mental health. They may be so indirectly, inasmuch as they prevent sleep, but even in this wise their effect is very slight. Nor does there appear sufficient reason to connect diseases of the heart, liver, kidneys, directly with insanity. Much stress has been laid on diseases of the uterus and ovaries, and more especially on tumors of these organs, being the primary factors in the production of insanity. Skae laid down as a special form ovario- or utero-mania; and Wergt of Illnau has described the various morbid conditions of the female organs of generation found on post-mortem examination, and has connected with them mental symptoms. But authors on gynæcology make no mention of insanity being a sequela of uterine disease, except in so far as the mental depression which in most women follows on the knowledge that they are affected by serious, perhaps fatal, disease, and the pain and anxiety inseparable therefrom, may produce sleeplessness, and consequent melancholy; and there is no proof of such tumors exercising an extensive influence on causation by peripheral irritation. The fallacy has in the great majority of instances probably arisen from the observation often made in asylums that insanity arising from whatever cause is conditioned by the presence of uterine growths, and that delusions of a sexual character may arise from the sensations thereby produced. Of the very few instances on record in which a direct connection between uterine disease and insanity has been traced may be cited a case reported by Van der Kolk, in which deep melancholy and prolapsus uteri coexisted; the mental symptoms were at once relieved by the organ being restored to its normal position. Such cases are very rare. It is still a moot point whether a true tubercular or phthisical insanity exists; if it does, it certainly does not arise from tubercular deposits in the brain-a very rare condition in the insane. Those authorities who deny the existence of phthisical insanity hold that, although mental symptoms do frequently present themselves in cases of consumption, and although consumption is very frequent amongst the insane, the insanity is not directly dependent on the diathesis, but more probably results from the general lowering of the sys tem, and at most is only conditioned by the primary conditions. The development of phthisis during adodisease. In the case of rheumatism and gout there lescence, and of cancer amongst persons at the climacare strong reasons for believing that an actual transla- teric period, may be cited as instances. It may be freely tion (metastasis) of the materies morbi occasionally admitted that the nexus between the physiological and takes place from affected joints to the connective tissue the pathological position is, as regards certain of the of the brain and cord,-the evidence being choreic periods, obscure, and that it is dependent more on inmovements of the limbs (St. Vitus's Dance) accom- duction than on demonstration; but it may be pleaded panied by acute mental symptoms, both of which dis that it is not more obscure in respect of insanity than appear contemporaneously with the return of inflam- of other diseases. The pathological difficulty obtains matory swellings of the joints. Syphilis may act on mostly in the relation of the earlier evolutional periods, the brain by the production of tumors (which, how- puberty and adolescence, to insanity; in the others a ever, do not differ in their effects from those of other physiologico-pathological nexus may be traced; but in adventitious products), and by specific changes in the regard to the former there is nothing to take hold of coats of the arteries, which become thickened and even except the purely physiological process of development occluded. As a consequence the tissues in their neigh- of the sexual function, the expansion of the intellectual borhood suffer deterioration. powers, and rapid increase of the bulk of the body. Although in thoroughly stable subjects due provision is made for these evolutional processes, it is not difficult to conceive that in the nervously unstable a constrain laid on it. Other adjuvant influences may be at work tending to excite the system which will be spoken of The morbid condition of the general system which when the insanity occurring at these periods is described. most frequently implicates the brain is anæmia, not Between the adolescent and climacteric periods the conitself a disease, but the result of many diseases, such stitution of the nervous, as of the other systems, beas fever, and of such drains on the constitution as lac-comes established, and disturbance is not liable to occur, tation (suckling) and imperfect nourishment. The except from some accidental circumstance apart from operativeness of these drains may be assisted by over-evolution. In the most healthily constituted individuals work under unhealthy conditions. As a typical ex- the "change of life" expresses itself by some loss of ample may be cited the dress-maker, poorly paid, vigor. The nourishing (trophesial) function becomes poorly fed, working for many hours daily in an ill-less active, and either various degrees of wasting occur, ventilated room, and sleeping in an unhealthy garret. or there is a tendency towards restitution in bulk of The term anæmia is not used here to indicate a con- tissues by a less highly organized material. The most dition antithetical to hyperæmia-it does not imply important instance of the latter tendency is fatty deany mechanical deprivation of blood supply; on the generation of muscle, to which the muscle of the artecontrary, the amount of blood, such as it is, is not re- rial system is very liable. In the mass of mankind duced in quantity. The temporary mechanical anæmia those changes assume no pathological importance: the which results from extreme cold produces its effects man or woman of middle life passes into advanced age rapidly, short delirium and profound sleep. But it is without serious constitutional disturbance; on the other qualitative anæmia, an impoverished state of the blood, hand, there may be a break down of the system due to which produces more or less permanent results on cere- climacteric disease of special organs, as, for instance, bral health. Inanition acts rapidly on the brain: in fatty degeneration of the heart. In all probability the the case of those cast away at sea on rafts or in boats insanity of the climacteric period may be referred to the general story is that of short delirious mania, sui- two pathological conditions: it may depend on struccide, or death from nervous exhaustion, before emaci- | tural changes in the brain due to fatty degeneration of ation (ie., before the reserve food of the system is its arteries and cells, or it may be a secondary result of consumed) takes place. So in cases where inanition is general systemic disturbance, due to cessation of menmore slowly produced, the nervous system is first de- struation in the female, and, possibly, to some analopressed. And here the position becomes somewhat gous modification of the sexual function in men. The complicated; for not only is, under such circumstances, senile period brings with it further reduction of formthe relative amount of the blood constituents different ative activity; all the tissues waste, and are liable to from the normal standard, but its corpuscular elements fatty and calcareous degeneration. Here again the change in quality; they acquire a degree of viscidity arteries of the brain are very generally implicated: athewhich tends to cause the red corpuscles to coalesce and roma in some degree is almost always present, but is hang together, and the white to lag and wander into by no means always followed by insanity. Whewell surrounding tissues; and further, this unphysiological retained his faculties to the last, notwithstanding that behavior of the corpuscles is apt to become aggravated his cerebral arteries were much diseased. Still this in regions whose nervous energy is depressed. Anaemia condition must be taken into account in studying the thus acts and reacts in procuring a condition of stasis. causation of senile insanity, as it necessarily implicates 6. The effects of evolutional periods concurrently the nutrition of the brain. It must assist in preventaffecting the brain: puberty, adolescence, utero-gesta- ing recuperation of the cells; it may in certain instances tion, the climacteric period, and old age. "Although diminish suddenly the blood supply to a particular from the time when the human being comes into the area; but the stronger probability is that senile menworld to the final cessation of his corporeal existence tal decay lies at the door of senile degeneration of the various functional operations of organic life are the cells. carried on with ceaseless activity, whilst those of ani- The various and profound modifications of the sysmal life are only suspended by the intervals of repose tem which attend the periods of utero-gestation, pregwhich are needed for the renovation of their organs, nancy, and child-bearing do not leave the nervous yet there are very marked differences, not only in the centres unaffected. Most women are liable to slight degree of their united activity but also in the relative changes of disposition and temper, morbid longings, degrees of energy which they severally manifest at differ- strange likes and dislikes during pregnancy, more espeent epochs" (Carpenter's Principles of Human Physicially during the earlier months; but these are univerology, chap. xviii.). These differences in degree imply physiological modifications of nutrition, and the observation of ages has caused it to be accepted as a fact in the etiology of disease that numerous and various degenerations occur contemporaneously with such modifications, more especially in the subjects of diathetic The pathological relation between sun-stroke (insolation) and brain disease has not been ascertained. A certain amount of brain congestion has been observed, but not invariably. The cerebral lesion is more prob-siderable risk is run by the brain in consequence of the ably due to the extreme depression of the whole nervous system; but the modus operandi is unknown. sally accepted as accompaniments of the condition not involving any doubt as to sanity. But there are various factors at work in the system during pregnancy which have grave influence on the nervous system, more especially in those hereditarily predisposed, and in those gravid for the first time. There is modification of |