Mental Disease, Mental Derangement, or Mental Alienation, comprises two great and distinct classes of morbid affections of the mind,—the one, the result of disease attacking a person of sound mind, is called Insanity or Lunacy; the other, the result of original or congenital conditions of the individual, is called Idiocy, or, in its lesser degrees, Imbecility.

All modern physiologists are agreed in regarding the brain as the organ of the mind; it may therefore be stated, that these diseases result from affections of the brain,—the one class (insanity) resulting from diseases of a brain originally healthy; the other (idiocy) arising from original defects in the brain, such as imperfect development, or congenital disease of that organ.

Many attempts have been made to define insanity and idiocy; but as the varieties of the mental diseases classed under those general terms are so numerous, and their distinctions in some instances so great; and in others so minute, it may be questioned whether it is possible to define either so as to make the definition of any practical value. Accordingly, most definitions will be found to be either so general and comprehensive as to include sane persons, or so circumscribed as to exclude many who are of unsound mind. Those definitions which will bear criticism will be found to be too general to be of practical use, and to amount to little more than is conveyed in the terms mental derangement or unsoundness. A brief review of the subject will make this apparent, and serve to show in what manner insanity and idiocy can be best described and defined for all legal and practical purposes.

The celebrated Locke incidentally remarked that "madmen do not appear to have lost the faculty of reasoning; but having joined together some ideas very wrongly, they mistake them for truths, and they err, as men do that argue right from wrong principles." Idiots, on the other hand, do not labour under delusions, or mistake mere ideas for truths, but they reason imperfectly. It has accordingly been said that the insane reason rightly from false premises, and idiots reason falsely from right premises. It was the fashion to consider this a definition of insanity and idiocy. But it is obviously no definition at all, as it would include all careless observers among the insane, and consign all illogical reasoners to the category of idiots. Almost all attempts at a definition of insanity, both by medical writers and legal authorities, have been founded on the same idea which occurred to Locke,—namely, that in every case of insanity there was some delusion, and that delusion was, in fact, an essential feature of insanity. This continues to be generally believed even at the present day, and has been laid down in our courts of law authoritatively from the bench. Proceeding upon this assumption, Dr Cullen defined insanity to consist in erroneous or false judgment; and Dr Haslam, to obviate the objection to this as a definition, that some people also make errors in judgment as to facts, added to the definition the impossibility of convincing the insane that this false judgment, error, or delusion, was a delusion. Dr Pritchard rendered the definition more precise in his work on "Nervous Disorders," by defining insanity to consist in the conceptions of the mind being mistaken for realities.

More recent authorities have introduced another element into their definitions of insanity,—namely, the loss of self-control—of moral liberty. Thus, M. Morel, one of the latest French writers on insanity, defines it as "une affection cérébrale idiopathique ou sympathique élevant à l'individu lésé à la fois dans ses fonctions physiologiques et psychologiques, l'exercice de sa liberté morale, et constituant dès lors chez lui une depravation maladive dans ses actes, ses tendances, et ses sentiments ainsi qu'un trouble général ou partiel dans ses idées" ("Etudes Cliniques," Morel, p. 214). And Mr Noble, the author of the latest systematic work on insanity published in this country, defines it to consist in "chronic disorder of the brain inducing perversion of ideas prejudicial to, or destructive of, the freedom of the will."

The impairment or loss of the power by which we regulate our actions, or the succession of our thoughts, or our judgment regarding external objects or conceptions of the mind, is certainly the most essential peculiarity of insanity; but this seems to be something different from the loss of moral liberty, or the destruction of the freedom of the will. Further, all these definitions seem to assume that there must be some perversion of the understanding—some delusion in insanity. This is by no means the case. Nothing is now more fully demonstrated in relation to the insane than this, that there are many cases in which there are no delusions, erroneous impressions, or false judgments, but in which a morbid and ungovernable passion, emotion, or impulse, constitutes the disease. The late Dr Abercrombie was nearer the truth when he described insanity to consist in the undue (morbid?) exercise of one or more powers or faculties of the mind; and idiocy (including dementia) in the deficient exercise or power of the mental faculties. The one consists in a loss of balance; the other in a loss of power,—terms, however, too general for the purposes of a definition.

Assuming that insanity is a disease of the brain, and making provision for cases in which there are no delusions,—cases of what is called moral insanity,—the following definition appears to be as precise as any that can be arrived at,—namely, that it is a chronic cerebral affection, in which emotions, passions, or desires are excited by disease (not by motives), or in which conceptions are mistaken for acts of perception or memory.

This definition distinguishes two classes or general forms of insanity,—one in which the emotions, passions, or desires alone are affected, constituting cases of moral insanity. There may be a general perversion of the emotions and passions without delusions, or a morbid excitement of one particular emotion or passion. In the one case the disease is called mania, or general madness; in the other, monomania or partial insanity.

In the same way the second part of the definition includes those cases in which there may be a general perturbation of the ideas or understanding, general excitement, and incoherent raving on a variety of subjects, referable, therefore, again to mania or general insanity; and also cases in which there is a perversion only in particular trains of thought, or in reference to one object, and referable therefore to monomania or partial insanity. The various forms of insanity are thus arranged in two great classes,—moral and intelligential, or emotional and notional; and in either of these classes it may be either general (mania) or partial (monomania).

The loss of self-control, and of the power of directing the thoughts or correcting the judgment by an act of volition, is an important feature of insanity, and probably constitutes the proximate psychological cause of the mental condition of the insane. As was remarked by Dugald Stewart, the insane are very much like persons asleep, by whom the objects of reverie, and the conceptions which pass through their minds, are believed at the time to have a real existence, because they cannot correct their judgment regarding them by voluntarily referring to the objects by which they are surrounded, as persons do when awake. Thus, in dreams all the persons we see are really believed to be actually before us; the events which are apparently taking place fill us with pleasure or terror according to their character, because they are believed to be realities. Is it not so with the insane? Is it not the suspension of some power of volition, self-direction, or judgment, which makes the insane the sport of their passions and desires, and gives rise in them to the belief in the extraordinary delusions which fill them with ecstasy, terror, or despair?

Insanity can only be defined in very general terms as a congenital mental deficiency. The degrees of this deficiency are infinitely varied, from the total absence of anything like human thought or reason up to the smallest amount of imbecility which distinguishes a naturally weak-minded person from one of sound mind.

The history of some sciences and arts may with propriety be consigned to oblivion as the cumbrous record of ignorance and error; but the history of this department of study is that of the development of the human mind,—of man himself,—and is therefore deserving of study. The philosophy of mind, and by consequence that of mental diseases and their treatment, has, moreover, by no means attained even at the present day such precision as to render the opinions of previous authors uninteresting or superfluous. (Feuchtersleben, Principles of Medical Psychology, p. 23.) A brief historical sketch of the subject may therefore be both instructive and interesting.

The most ancient historical records prove that insanity was recognised in the earliest times. The Israelites were threatened with "madness, and blindness, and astonishment of heart for their transgressions" (Deut. xxviii. 28). David feigned madness before Achish the King of Gath (1 Sam. xxii. 13); and what is more curious, he alleviated the fits of madness to which Saul was subject by his skilful playing on the harp. The influence of music, and of those distractions so much lauded in the present day for the treatment of the insane, appears to have been also well understood by the priests of ancient Egypt. There the temples of Saturn were resorted to by crowds of melancholics. "Whatever gifts of nature or productions of art were calculated to impress the imagination were there united to the solemnities of a splendid and imposing superstition. Games and recreations were instituted in the temples. The most voluptuous productions of the painter and the statuary were exposed to public view. Groves and gardens surrounded those holy retreats, and invited the distracted devotee to refreshing and salubrious exercise. Gaily-decorated boats sometimes transported him to breathe amidst rural concerts the purer breezes of the Nile. In short, all his time was taken up by some pleasurable occupation, or rather by a system of diversified amusements, enhanced and sanctioned by superstition." (Nosographie Philosophique, Pinel, tom. ii. 28; Pinel On Insanity, by Dr. Davis, Introduction, p. xxii.)

From the hands of the priests the care of the disordered mind first passed into the domain of medicine with the philosophers of ancient Greece. Pythagoras is said to have employed music for the cure of mental diseases. The order of the day for his disciples exhibits a profound knowledge of the relations of body and mind, and constitutes a most complete system of mental dietetics. The early morning was divided between gentle exercise and reflection, music and study; then came conversation, followed by gymnastic exercises, and a simple and temperate diet; attention to public affairs succeeded, followed again by walking and cheerful conversation, and afterwards a cold bath and supper, with a sparing allowance of wine; and then reading, music, and reflection, concluded the day.

The formation of medical schools in Greece by the disciples of Pythagoras completed the transfer of the sick and insane from the trammels of superstition and priestcraft, consolidated medicine into an art, and, in the department of psychology at least, the philosophy of the Greeks elevated it to the rank of a science. The treatment of mental disorders by Asclepiades, as described by Celsius and Aurelianus, might almost be taken for an epitome of the modern method. "Music, love, and wine, employment exercising the memory and fixing the attention, were his principal remedies. He recommended that bodily restraint should be avoided as much as possible; and that none but the most dangerous should be confined by bonds. He was peculiar in advising that the lunatic patient should be engaged in the self-regulation of his mental powers." (Feuchtersleben, op. cit., p. 36.)

Of the opinions of Hippocrates, the father of medicine, on the subject of insanity, although contemporaneous with Asclepiades, we know less, but yet enough to satisfy us that he was a careful observer of the phenomena of that disease.

The philosophy and the arts of Greece spread to Rome, and the first special treatise on insanity is that of A. Corn. Celsius, which distinguishes several varieties of insanity and their appropriate treatment. Aretens of Cappadocia describes in graphic terms many additional varieties of the disease, with their causes and prognostics. He and Aurelian both laid the psychological treatment of Asclepiades. Lastly, Galen, with all his learning, appears to have added little to this department of medical observation and treatment.

Over the arts and sciences of Greece and Rome the errors and ignorance of the middle ages gradually crept, until they enveloped them in a vast cloud of worse than Egyptian darkness. The insane, if treated at all, were again consigned to the miracle-working artifices of priests, or else totally neglected. Idiots and imbeciles were permitted to wander about clotheless and houseless, the sport of the wanton and wicked thoughtlessness of children; the frantic and furious were chained in loathsome dungeons, and exhibited for money like wild beasts; the monomaniacs became, according to circumstances, the objects of superstitious horror or reverence; they were regarded as possessed with demons, and subjected either to priestly exorcisms, or cruelly destroyed as wizards and witches; at other times they were made the tools of the designing and ambitious, and, as inspired instruments of the Deity, became the leaders of revolutions and revolts. Vast epidemics of insanity spread over Europe at various periods of the dark ages; lycanthropy, vampirism, the Crusades, the dancing mania, the pilgrimage mania of children, St. Vitus' dance, and various other epidemics, followed each other in successive generations. The total neglect or cruel treatment of the insane continued, with little or no alleviation, down to the end of the last century in all the civilized countries of Europe. The revival of learning,—nay, even the reconstruction of medical science,—shed no ray of light upon the unhappy victims of this disease.

During all this period, then, our subject can scarcely be said to have a history. At best it is but the history of scholastic disputations regarding the soul and the supposed humours of the body, or a history of the demonomaniacs of those times, the trials for witchcraft, and the wide-spread massacres which followed; or a history of the epidemics referred to, or of the neglect and cruelty with which the helpless idiots or furious maniacs of all countries were treated.

With the metaphysical speculations of Locke and Leibnitz, followed by those of Bonnet, Condillac, and the Scottish school of metaphysicians, appears to have originated the first impulse to the study of the subject from its purely psychological side. Added to this, came the doctrines of Stahl, which laid the basis for a psychological and practical view of it, which gradually acquired solidity and system from the researches into the anatomy of the brain and nervous system by Soemmerring, Reil, Meckel, and Gall. During all this period, however, to which we can only allude, no practical results followed as regarded the treatment of the insane. Public asylums, indeed, existed in most of the metropolitan cities of Europe; but the insane were more generally, if at all troublesome, confined in jails, where they were chained in the lowest dungeons, or made the butts and menials of the most debased criminals. Even in the public asylums, many of which were endowed by the munificence of philanthropists, the inmates were generally confined in low and damp cells, sometimes isolated in cages or chained to the floor or wall; if harmless, they were huddled together, without regard to their habits, in cells not fitted to contain one tithe of the number immured in them. The medical treatment consisted, perhaps, in an annual bleeding and a few emetics; while the lash was systematically used, justified, and even recommended, as it had been by such authorities as the celebrated Cullen. These unhappy victims of disease were exhibited to the public like wild beasts, and their passions irritated to gratify a morbid and vulgar curiosity. They were often killed by the ignorance and brutality of their keepers, sometimes during rough methods of forcing meat into them, sometimes by barbarous and violent beating.

Such was the state of the insane generally throughout Europe at the commencement of this century; such it continued to be in England so late as 1815, and in Ireland in 1817, as revealed by the inquiries of parliamentary commissions in those years respectively; such it doubtless was also in Scotland, as the report of the commission appointed in 1855, showing the neglected condition of the pauper insane even at the present day, abundantly testifies. Indeed it cannot be doubted that, in many countries of Europe the insane are little, if at all, better cared for even now, especially in rural and remote districts.

The greatest step in the amelioration of the condition of the insane originated in Paris with the illustrious Pinch, who immortalized his name by liberating all the inmates of the Bicetre from their chains in 1792. The success attending his philanthropic efforts speedily led to great changes in the treatment of the insane; and his distinguished successor Esquirol endeavoured to extend the same humane principles of treatment to all the asylums of France. One of the earliest institutions of this country to adopt the humane system of treatment was one belonging to the Society of Friends near York, called the Retreat, where, under the auspices of William Tuke, not only were chains, stripes, and cruelty abolished, but the most enlightened principles of moral treatment were adopted. The attention directed to the subject by the published account of the Retreat (1813) speedily led to the introduction of the law of kindness into some of our large public asylums. In the Lincoln Asylum mechanical restraint of every kind was abolished (1836). In the large asylum of Hanwell, Dr Conolly soon afterwards, in spite of many obstacles, succeeded in carrying out the principle of non-restraint with remarkable success; and he has continued to this day to advocate the complete abolition of all mechanical restraint in the treatment of the insane in public asylums, with a devotion and eloquence which has contributed very largely to the adoption of this principle throughout the county asylums of England. The reports of the parliamentary committee (1815, 1816) led to the appointment of a permanent lunacy commission in England, under the auspices of which a number of new county asylums were erected, and in these the principles of non-restraint, and the improved moral treatment of the insane, were carried out and developed.

Similar results gradually followed a parliamentary inquiry into the condition of the insane in Ireland (1817). In Scotland the philanthropic efforts of a few individuals led to the erection of several public or chartered asylums in the early part of the century; and in most of these (Edinburgh, Glasgow, Dundee, Dumfries) at an early period, (1840-42) not only was mechanical restraint almost entirely abolished, but a great variety of moral appliances were introduced, such as schools, lectures, concerts, dramatic representations, social entertainments, periodicals written, and in some instances printed, by the patients, excursions to the country, and numerous sources of healthy occupation. If Scotland is still behind the sister countries, in consequence of the want of a legal provision for her insane paupers, she may well be proud of what has been achieved by the spontaneous efforts of the benevolent, and of the admirable manner in which her public asylums have been conducted. In the multitude and variety of the moral appliances for the cure and alleviation of insanity in use in those institutions, she has been in advance of most of the public asylums of either England or Ireland. The hospitals for the insane which have been erected in the various states of the North American republic during the last twenty years, have also been organized and conducted upon the most approved and enlightened principles of modern science; in them everything that can minister to the mind diseased, by distracting it from morbid trains of thought,—the influences of literature, and science, and music, and recreation,—have been added to the salutary regimen and judicious medical treatment of well-arranged and well-regulated hospitals.

Accompanying and assisting in this onward movement we find valuable works on insanity appearing on the Continent and in this country, of which a list is appended to this article. An agent, not less important in the dissemination of all the improved methods of treating the insane, was found in the annual reports of the best public asylums; and of those deserving of especial notice may be enumerated the reports of the Retreat, of Lincoln Asylum, of Hanwell, of the Northampton, Lancaster, Gloucester, and Stafford asylums, and of the Scottish chartered asylums, particularly those of Edinburgh, Glasgow, Dundee, and Dumfries, in all of which the rapid progress of psychological medicine, in its humane and moral aspects, was early and most fully represented. The reports of the excellent county asylums more recently established in England, those of the American asylums, and, lastly, the valuable reports of the Commissioners on Lunacy, have all contributed largely to the spread of the new and improved methods of treatment. Another and important agent in this cause has been the establishment of journals specially devoted to medical psychology. The first of these appeared in Germany in 1806-1808; then followed Nasse's Journal (1818-1826); Friedrich's Magazine (1829-1838); and, lastly, Dameron and Fleming's Allgemeine Zeitschrift für Psychiatrie (1843). In France the Annales Medico-Psychologiques (1841); in America the American Journal of Insanity (1844); and in England Dr Winslow's Journal of Psychological Medicine (1848); and, lastly, the Asylum Journal (1853), successively appeared, and continue to be published.

Special attention to the care of idiots has been a matter of comparatively recent date. The establishment of schools for their education, and the development of their latent or imperfect faculties, first attained considerable success under M. Séguin at Paris. (Traitément Moral Hygiène et Éducation des Idiots, par Edouard Séguin, Paris, 1846.) Dr Gügenbuhl simultaneously (1840) established, under the auspices of the Swiss government, an institution for the cure of cretinism at Interlacken, on the Aabenberg, where, by commencing their treatment in infancy, it is said that those congenital diseases upon which this condition de- The interest excited by the philanthropic labours of this physician has led to inquiries into the condition of idiots in various countries. A commission of inquiry investigated the subject fully in Sardinia (Report de la Commission pour étudier le Crétinisme, Turin, 1848), where, as also in Austria, Prussia, Württemberg and Saxony, Bavaria and Baden, institutions for idiots have been established. A careful inquiry, under the direction of Dr Howe, was made into the number and condition of the idiot population in Massachusetts (U.S.), and a school was established there for their benefit. Lastly, in England, at Bath, and afterwards at Highgate near London (1847), and more lately at Dundee and Edinburgh (1853), medico-educational establishments for idiots have been instituted, and promise to confer great benefits upon this interesting and helpless portion of the human family.

In concluding this brief historical retrospect, we cannot refrain from expressing our surprise that the study of mental diseases has been deemed of so little interest or importance hitherto, as to form no part of the curriculum of medical education in this country. Although the large metropolitan asylums afford ample means of illustrating courses of instruction in psychological medicine, the study of the subject has never been required by our licensing medical or surgical boards or universities. Lectures on mental diseases, both systematic and practical, have indeed been delivered in many of the continental medical schools; and of late years, in some of the large asylums of London and in that of Edinburgh, clinical lectures have been given; but attendance upon such courses of instruction is voluntary, with the exceptional case of candidates for appointments in the H.E.I. Company's service, who have been required during the last four years to attend an asylum for the insane for three months. This neglect seems altogether unaccountable, when we reflect upon the many collateral sciences students of medicine are compelled to master, of comparatively little value to them in actual practice, and the many diseases, accidents, and operations, toxicological and analytical investigations, they are carefully and minutely schooled in, which it may never fall to their lot, in a long life, to see or practise; while insanity, which affects 1 in every 400 or 500 of the population, and which, in some of its stages or forms, they can hardly pass a week in medical practice without being consulted about,—often in circumstances requiring great judgment and skill,—is made no part of their medical education at all.

A variety of methods have been proposed for classifying the different forms of insanity. Without entering into a critical examination of these methods, it may be sufficient for the purposes and limits of this article to give what appears to be a comprehensive and convenient classification, and one as nearly as possible in conformity with the terms in common use among writers on insanity at the present time.

Insanity consists either in a general or partial exaltation or morbid excitement of the faculties, or an impairment of them to a greater or less extent; and we have accordingly three great divisions of the subject—Mania, Monomania, and Dementia, under each of which there fall to be arranged various modifications, subdivisions, and complications; and, lastly, we have Idiocy, consisting in a natural want of development of one or more or all of the mental faculties. The following table exhibits this classification, with the subordinate subdivisions referred to:

I. Mania.—General Derangement of the Faculties.

| Acute | Affecting the emotions and passions only—Moral Insanity. | |-------|----------------------------------------------------------| | Chronic | Affecting the intellectual faculties also, generally—Mania or Raving Madness. | | Periodic | Remittent |

II. Monomania.—Partial Derangement of the Faculties.

| Melancholia | Affecting the desires, emotions, or passions only, without delusion—Moral Insanity. | |-------------|-------------------------------------------------------------------------------------| | Suicidal Mania | Affecting the intellect or understanding, with delusions, illusions, or hallucinations—Intellectual or Notional Insanity. | | Homicidal Mania | Unseen Agency |

III. Dementia.—Obliteration of the Faculties.

| Stage | Forgetfulness—loss of memory—senile dementia. | |-------|------------------------------------------------| | 2d | Irrationality—loss of reason—marked incoherence. | | 3d | Incomprehension—instinctive stage—fatuous. | | 4th | Inappetency—loss of instinctive action—total fatuity. |

General Paralysis with Insanity.

Epilepsy with Insanity.

IV. Idiocy.—Non-Development of the Faculties.

| Imbecility | | |-----------| | | Idiocy | | | Cretinism | |

L.—Mania.

The most striking features of acute mania are the exaltations of the emotions, or, as it is commonly termed, the excitement of the patient, the incoherence of his ideas, the restlessness and agitation of his movements and gestures, and the volubility and energy of his language. The invasion of mania is sometimes sudden, and the disease is at once developed by an outburst of violence or excitement. Most frequently, however, it is preceded by some premonitory symptoms, of which the most frequent is the want of sleep; so constant indeed is this harbinger, that a distinguished American writer (Dr Brigham) regarded it as the cause of insanity. This sleeplessness is generally accompanied by loss of appetite and derangement of the digestive functions. The patient often complains of headache, confusion, and fear of going mad. He displays irritability of temper and impatience of contradiction or interference. He is unusually active, and full of new projects and ideas. His settled habits become altered; he neglects duties heretofore punctually discharged, or becomes suddenly an attentive observer of duties before neglected. Not unfrequently he uses stimulants to excess, although before temperate in his habits. His affections are altered or perverted; he dislikes his nearest friends, and views all their acts with suspicion and distrust. After these symptoms have gradually manifested and developed themselves during a period of a few days or weeks, he ultimately loses the power of self-control, and his conduct becomes violent, or his ideas and conversation incoherent, or both. In the former case he destroys his clothing, strips himself naked, dresses his naked body fantastically with strips of his blankets, besmears himself with filth, talks incessantly and vociferously, walks up and down, or flings his arms, or tumbles his person about without ceasing. His conversation is characterized by wit, or violence, or obscenity. All these symptoms may exist without any delusions or any incoherence of thought; but on the contrary the individual may display great acuteness, intelligence, and wit, combined with any conceivable amount of excitement, activity, obscenity, and destructiveness. Such a variety of mania belongs, then, properly to that kind of madness called moral insanity; the emotions and passions being in a general state of exaltation or excitement beyond the powers of self-control, but without delusions affecting the intellect. Most frequently, however, in a mania, the ideas succeed each other without any apparent order, and the patient... raves or talks incoherently. Or some delusion seizes his imagination, and, according to the nature of it, he is affected with extravagant anger, joy, or terror. He is surrounded by foes on whom he seeks to vent his rage; or he is about to be married; or has become heir to enormous riches and to titles of high rank; or he imagines he is a divine being endowed with supernatural powers, and he calls down vengeance on all who oppose him; or he fancies he is surrounded by objects of fear, by fire, and blood, and demons, and he cries out with the utmost terror at the objects of his disordered vision. There may thus, in those cases where the intellect is affected, be only excessive activity of thought, producing rambling and incoherent conversation; or there may be delusions—the belief in the creations of the imagination; or there may be illusions—the belief that sounds or objects are other than they really are; or, lastly, hallucinations, or the actual perception, by the diseased organs of sense, of objects, of persons, and things, and sounds, which have no real existence.

The most essential and characteristic feature of acute mania appears to be the loss of self-control,—1. Over the voluntary acts, resulting in violent and excessive restlessness, walking to and fro, wild, extravagant, bizarre gestures, attitudes, and gesticulations. 2. Loss of control over the feelings, emotions, and passions, which are sudden, impulsive, violent, and varied in intensity and character. 3. Loss of control over the ideas, which appear to succeed each other without any order or law of succession, following neither the laws of association nor those of volition, and being therefore rambling and incoherent. The maniac cannot fix his attention; he hardly sees or recognises external objects; he is carried away by ideal terrors, and is the sport of his own diseased imagination. He confounds time and space, and persons and things, and himself, and is lost in an endless whirl of delirium. There is a total overthrow of the moral sense, the loss of all affection, of all regard to religion, or probity, or decency; even the commonest instincts of nature disappear in the total overthrow of all that is human and natural.

During all this time, however, the patient retains a certain consciousness of self; he may, at least for a moment, be brought to fix his attention and answer a question. After his recovery he may even be able to tell all that passed through his mind, all the delusions and hallucinations that haunted him, the attentions he received, the words addressed to him, and the feelings which influenced him in all his actions.

The countenance is remarkably altered in maniacs; it becomes dark and contracted; the eyes are brilliant, injected, and haggard, and expressive of suspicion,—wandering, but watchful; the sense of hearing is often rendered very acute; the tongue is dry and foul, and the patient is devoured by thirst; the appetite is at one time voracious, and at another seems lost; the skin is dry and greasy, and exhales a disagreeable odour; the cold and fatigue, to which they appear (only) to be insensible, affects them equally with other persons, and they sink exhausted under their own violence and incessant activity, or may die of pneumonia, or other diseases if unnecessarily exposed to cold. The pulse is generally small, weak, and frequent; and the excretions diminished or irregular.

The habits of maniacs are very offensive. None are more constant than the tendency to go naked, to tear all articles of clothing, bedding, and furniture, and to indulge in the most filthy and shameless practices and language.

The course of an attack of acute mania is very variable and uncertain; sometimes it is transient, and may not exceed twenty-four hours, or from three to five days. This, however, is rare. A remission frequently takes place within the first week, and after a brief tranquillity a fresh outbreak of excitement occurs. The average duration of cases of acute mania has been estimated at six weeks.

In some cases a frequent remission continues to take place, followed always, sooner or later, by recurrence of the Remittent excitement. These are called cases of remittent mania.

In other cases these remissions and aggravations occur Periodic at regular intervals of time,—every month, every two, three, mania, or six months, or every year; and these constitute periodic mania.

Again, the maniacal excitement continues with more or less amelioration, but still presenting some of the more characteristic features of mania, such as noise, violence, and destructiveness, for many months, or even years, and is then called chronic mania.

The curability of mania has been variously estimated at from 70 to 90 per cent. by different authorities. Although the most alarming and unmanageable, it is the most curable form of insanity.

The recovery is generally gradual, with occasional exacerbations: the patient sleeps, becomes stouter in person, gives up his destructive habits, becomes tidy in his dress, and slowly recovers, sometimes exhibiting a certain amount of reaction in a prolonged depression and want of confidence in himself. Sometimes, though rarely, the recovery is sudden; occasionally it is accompanied by some critical termination, as it has been termed, such as the reappearance of some suppressed discharge or eruption, or the formation of large boils.

If the patient does not recover, the disease passes into some other form,—either into chronic or partial insanity, or more frequently into dementia; or he may die from exhaustion or the supervention of some fatal disease.

Puerperal Mania differs little from the disease described, except in the fact that it is peculiar to females after parturition, and, strictly speaking, occurs within a month after delivery. It has been confounded with hysterical mania, with mania occurring during pregnancy, and with insanity developed after prolonged nursing. But in all these cases the disease more generally assumes some of the forms of partial insanity, and does not differ from such diseases arising from other causes. In puerperal insanity the homicidal impulse is not unfrequently developed; and unless the mother is watched, or the child removed, the offspring may be destroyed by its unconscious and delirious parent.

Delirium Tremens is another form of mania (mania d Delirium potis—brain fever), arising from the continued and intemperate use of stimulants. It may be termed a kind of alcoholic poisoning, arising from the accumulation of alcohol in the system. It has also been ascribed to the intemperate use of other narcotics, such as opium. The symptoms are in some respects peculiar. The delirium is generally one of alarm, of fear of robbers and murderers, and is accompanied commonly with hallucinations of vision, and with trembling of the limbs, copious sweating, and tendency to exhaustion. Its course is short, and it terminates either favourably or fatally within a few days; and in some cases, where the immediate danger and violent symptoms are recovered from, permanent lesions remain in some form of partial insanity.

II.—MONOMANIA

Was a term invented by Esquirol to designate cases of partial derangement; the ancient name, melancholia being inapplicable, in its modern signification, to those varieties where there was no depression of spirits. The term melancholia (lypemania) he reserved for cases where there was a true melancholy or depression, and monomana for other varieties of partial insanity. As all, however, are cases of partial derangement, all of them may be included under this general term, and we may consider therefore melancholia as one of the varieties of monomana. The general term monomania implies that the individual is deranged only on one subject, or in reference to one object, or in one particular train of thought or faculty of thinking, and that his intellect, judgment, and emotions are otherwise sound, at least when not exercised on the subject of his derangement. This, however, is not strictly speaking, true. There are exceptional cases in which persons have appeared to retain all their intelligence and reason, and every mental faculty, in a state of healthy exercise, except in reference to one point; but such cases are very rare, and it is doubted whether, upon a close acquaintance with such persons, we would not discover other points of insanity besides the one prominent and characteristic one. In almost all cases of so-called monomania there are other morbid indications besides the salient one,—morbid dislikes or suspicions, morbid vanity or irritability; sometimes other delusions, sometimes hallucinations of the senses. Still there is generally some one morbid impulse or delusion sufficiently prominent to form the principal and characteristic feature of the case, and to make the name of monomania applicable and convenient, and accurate enough for the general purposes of a classification.

It may be observed further, that almost all cases of partial insanity (monomania) may be referrible either to the category of moral insanity, when an emotion, passion, or desire is morbidly excited without any delusion; or they may be referrible to notional or intellectual insanity, when there are certain delusions. This distinction pervades most of the varieties, and will be illustrated immediately in describing the first variety of monomania.

Monomania is always preceded by some premonitory symptoms. Its invasion is seldom, like that of mania, sudden. It is emphatically a chronic affection, compared with mania, and produced generally by the continuous operation of some deleterious influences. In almost every case there exists a hereditary predisposition to insanity, and the attack is preceded by some derangement of the general health—in some cases it coincides with the development of scrofulous or pulmonary disease; in others it is the result of moral causes affecting the health, such as domestic anxieties, retired and secluded habits, reverses in fortune, disappointments in love or in business. The invasion of the malady is commonly preceded by sleeplessness, by altered habits,—the individual becoming irritable, suspicious, impatient of interference, doing odd things; the wife suspects her husband, or the husband his wife; he neglects his person or his food, or broods over some subject of vexation and anxiety. At length some manifest delusion or some overt act indicates that reason is upset. Some morbid propensity or appetite is developed, or some insane delusion is adopted, corresponding in some way with the previous character of the individual, the exciting cause of the disease, or the more prominent subject of interest for the time.

In mania there is a complete perversion of the character, dispositions, and habits; in monomania the perversion most commonly corresponds in some measure with the previous character, or temperament, or habits of the individual,—the delusion or morbid propensity which is adopted takes its character from the prevailing train of thought preceding the attack, or from the nature of the exciting cause of the disease.

Melancholia attacks chiefly persons of a bilious or melancholic temperament; monomania of self-esteem and pride, those of a sanguine temperament,—the temperament modifying the form of the disease. If the moral causes are of a depressing kind, the delusions and propensities developed assume a corresponding character, and the patient imagines he is ruined—that his soul is lost—that he is about to be executed or poisoned. If the immediate moral causes are of an exciting kind, the resulting insanity is of a more or less gay and elevated character; the patient imagines he has succeeded to large estates or titles, or that he is a person of great power or genius.

The nature of the delusions of the monomaniac is often determined by the more exciting public topics of the day, and their character bears the date of the times. Among the ancients the monomaniacs were prophets and prophetesses, hermaphrodites, or changed in sex, or converted into pigs, foxes, or wolves. In the middle ages the dark superstitions of the times produced many wizards and witches, demonomaniacs and vampires. In modern times it has been observed, that during the first Napoleon's time there were many Napoleons in the public asylums of France. There were many queens in our asylums, and many pretenders to the crown, when our present sovereign ascended the throne. Later years have seen many victims of electrical machines and electricity, of mesmerism, and lastly, of spirit-rapping, in our hospitals. Instead of furies and demons now pursuing the victims of morbid fears, as of old, it is now the fear of the law, of justice, of prison, of the police, or of being hanged.

Insanity in some of its forms is highly contagious; or rather the imitative faculty, or the strong sympathies existing between morbidly predisposed minds, is so great, that the publication of any revolting murder by a homicidal maniac, or the perpetration of some remarkable suicide, immediately produces a host of imitators. When H. Corneille committed child murder, Esquirol was consulted by many families of distinction, and of all ranks, whose daughters were seized with a similar morbid impulse. When a female committed suicide by leaping from the summit of the Monument, she had so many imitators that it was found necessary to guard the balcony at the top by a cage.

1. Melancholia.—The subjects of melancholia are generally of a spare habit of body, have dark hair and eyes, and a brown or sallow complexion. The expression of the countenance is fixed and immovable,—a tension of the features expressive of fear, grief, or despair; the eyes are fixed on the ground, or watching surrounding persons with sidelong and suspicious glances. The pulse is commonly slow and feeble, but hard and thrilling. The skin is dry and hot, with the exception of the hands and feet, which are bedewed with cold perspiration. The sleep is interrupted, short, irregular, and often agitated by dreams and sudden starts. The tongue is white and loaded, the breath offensive, and the bowels constipated. Melancholics are extremely sensitive to external impressions, alarmed by the slightest cause, irritable and impatient of interference. They convert everything into a new source of distress, and dwell without ceasing upon their misery, their fears, and their sufferings. Melancholia may exist as a variety of moral insanity, or insanity without delirium. There may be no false belief, no delusion, but a simple abstract gloom, deep and rooted melancholy, an inexplicable but hopeless feeling of wretchedness, a loathing of everything, even of life itself, and an anxious craving for death. The suicidal impulse in some such cases is remarkably strong, and attempts to commit self-destruction are made by every conceivable method, and with the utmost craft and deliberation. In most cases of melancholia, however, there exists some delusion, which seems to be the focus round which the feelings of gloom and horror concentrate. Such is the common belief in eternal perdition; that the person himself has been the cause of ruin and misery to his family; that he has brought judgments and punishment upon the whole human family; or that he has committed the unpardonable sin, and is already suffering the pains of lost souls.

2. Very closely allied to these cases of melancholia are Monomaniac those described as monomania of fear, in which the characteristic feature is a constant dread and apprehension of some coming evil,—a foreboding of misery,—a terror of being hurried away, of being poisoned, or executed, or burnt alive, or of some dreadful and unavoidable calamity.

Such delusions are sometimes not incompatible with the discharge of the ordinary duties of life. The celebrated Robert Brown, at the time when all the powers of his mind were in full exercise, believed that his soul was annihilated, and that instinct only, common to him and the brute creation, was left to him. Cowper the poet believed that he alone of all human beings was excluded from the vicarious merits of our Saviour's sufferings.

3. These two varieties of monomania are those most frequently accompanied by a disposition to commit suicide. Sometimes this impulse is a morbid impulse, unaccompanied by any delusion—a loathing of life, a craving for death, an irresistible impulse to commit self-destruction. This must be regarded as another form of moral insanity, and may be termed suicidal mania. Most frequently, however, this fatal propensity seems to originate in the dreadful delusions of the patient, in the despair arising from the conviction of being ruined or eternally lost, or in morbid apprehension of some approaching and horrible calamity.

Not unfrequently these, as well as other varieties of monomania, are associated with hallucinations of the senses; the persons affected hear voices threatening them with their approaching doom; or they see objects of terror, visions of departed friends, or of demons; or they taste poison in their food, or smell the sulphurous vapours of the bottomless pit, of which they believe they are already the hopeless inmates.

4. Allied to these forms of partial insanity are those cases which has been described as monomania of unseen agency. Founded, perhaps, upon some morbid sensations caused by flatulence or neuralgia, the unhappy victims of the disease believe that they are the sport of some mesmeric or electrical operations; that gases are injected into their system; that they are subjected to some strange influence during sleep; that persons at a distance control and act upon them, and even strike them; or that some person is actually in the inside of their body, and sways their feelings and actions according to his own will.

5. Very different, indeed, in their external manifestations and general deportment are the cases of monomania in which the sentiments of self-esteem, pride, veneration, and love of approbation, are morbidly exalted. The delusions under which such monomaniacs may labour are as varied and as numerous as the objects which stimulate to ambition. One may imagine himself endowed with exalted genius,—he is a poet, or philosopher; another, a distinguished musician or vocalist, although able to produce only the most dissonant sounds from his favourite instrument, or to scream in wretched discord with it; another believes he is a royal or divine personage, or a prophet, or endowed with supernatural powers, able to cure diseases, to regulate the fate of empires, or to command the sun; another believes that he has discovered some infallible cure for all human miseries, that he is about to convert all mankind and make them supremely happy; another, that he can direct the elements and give rain, sunshine, or storm; another is possessed of enormous wealth, and has paid off the national debt, and is about to build palaces and endow numerous institutions for the public good. There is, however, in such persons no loss of the idea of personal identity; they are still John Smith, or James Johnston, or Thomas Brown; and they are capable of acting with the utmost want of consistency of character,—performing the most menial acts, or working industriously at some trade or domestic duty.

In some cases a morbid vanity amounts to folly or madness without delusion; and indeed any of the sentiments, passions, or desires may be exalted into morbid action without delusion. In such cases the conduct of the individual may expose him to ridicule or pity, and he may be looked upon as a harmless, half-witted creature; but he may buffet his way through life, supported by his own self-importance, and escape the restraints which society imposes upon the morbid exercise of passions or propensities when they interfere with the comfort, happiness, or safety of others.

In other cases the overt acts of the individual may endanger his own personal safety, may lead to the profuse and foolish expenditure of his means, or may exceed the limits which society deems tolerable; and he then becomes the object of treatment or surveillance, or even of confinement. To a morbid and ridiculous vanity such persons very often unite other depraved and morbid propensities. Of these, the most frequent, perhaps, is the practice of lying, and the art of deceit. A propensity to steal and hoard every article that can be surreptitiously appropriated is not an uncommon symptom in cases of this kind of moral perversion. This propensity to steal sometimes exists as a distinct form of monomania, without any other very obvious departure from sanity in the general state of the mind or conduct. It has been called kleptomania. The propensity has sometimes Klepto been exhibited by persons in the better ranks of life, who mania had no motive to steal, but could not resist the incontrollable impulse to purloin on all occasions. It is generally, however, one of the symptoms only of other forms of insanity, and of none more frequently than of those cases of moral perversion just described.

The propensity to tear and destroy, which is so constant Pyro in mania, sometimes also, in a minor degree, accompanies mania. partial insanity; in other cases the propensity to set fire to things, described as a special variety of monomania, under the name of pyromania, is a characteristic feature, and in some instances, it is said, is the sole morbid impulse.

Of all the symptoms of insanity, those referrible to altered affections, perverted desires, and morbid propensities, are the most constant; and delusions ought rather to be regarded, like hallucinations of the senses, as the accidental concomitants than as the essential features of insanity. In a large proportion of the cases of partial insanity in particular, the grand and distinguishing feature of the disease is, that the conduct of the individual is irrational or insane.—different from what it used to be, or from that of other people; or that his tastes, affections, habits, and propensities are changed, and no longer regulated, as they were wont to be, or as others regulate them, by a due regard to personal welfare and the settled opinions of society. He does things which very often his own reason and conscience revolt at,—things which he deplores and cannot help doing.

Such moral perversion is not unfrequently met with in young persons, and is sometimes associated with some natural peculiarities of character, such as inability to acquire certain elements of education, disregard to personal cleanliness, or the pride, natural to all children, of being well dressed. At an earlier or later period of youth, sometimes about the age of puberty, this moral perversion is developed. The person becomes irascible, passionate, vindictive, and dangerous; often violent without provocation; sometimes destructive of clothing or furniture; sometimes mischievous and cruel; at other times disposed to wander from home, without object or plan.

In persons who have passed the age of puberty this Satyrilis disease sometimes affects the sexual desires or propensities, and is indicated by gross obscenity of language, by licentious and lascivious looks, and acts of the most disgusting kind. This disease, if not a symptom only of other forms of insanity, is called satyriasis in the male, and nymphomaniac in the female. It is sometimes a symptom of some serious organic disease of the brain.

In other cases, and these not a few, in this country, the incontrollable impulses of the patient lead him into habits of inordinate drinking; and persons exhibiting those con- Mental Diseases.

stitutional peculiarities described, not unfrequently display great violence when under the influence of intoxicating liquors—becoming furious and dangerous.

In many of the cases of the kind of moral insanity which are referred to, the principal, and, indeed, in some the sole feature, is an incontrollable craving for stimulants, and the indulgence in them to an extent ruinous to health, and happiness, and every hope in life. It is difficult to distinguish this disease from mere drunkenness; but it is unquestionable that there is a diseased condition of the nervous system, whether constitutional or the result of habit, or partly both, in which the individual drinks without any self-control, in which he cannot control himself; and is therefore a proper object for control, protection, and treatment on the part of others.

Monomania. This disease has been termed dipsomania by some authorities, by others monomania. Both names are inelegant; it being neither a thirst, as the first implies, nor a thirst for wine exclusively, as the second signifies, but a craving for any kind of narcotic stimulants. It is more proper to regard it as one of the varieties of moral insanity, of which this craving for stimulants and insatiable use of them is one of the principal symptoms. It is perhaps in few instances the only symptom. The disease is generally hereditary, and it will be found that the father, mother, or some other near progenitor, has suffered from it. It is very generally associated with a total disregard to truth. Such persons, particularly females, are singularly mendacious. They will resort to every possible device to procure stimulants, to excuse their conduct, to deceive their friends; they generally utterly deny their habits, and display a fertility and ingenuity in deceiving themselves and others which is truly remarkable. This disregard of truth is very often associated also with a great deal of self-esteem and inordinate vanity. Such persons do not drink from the pleasures which the social board affords, but, on the contrary, in company will often preserve a certain amount of decorum. Neither do they drink for the pleasure which the wine gives them, for in the absence of their favourite beverage they will have recourse to any substitute. They labour under an uncontrollable craving, and drink because they cannot help it. No considerations of self-respect, no regard to domestic ties, to religion, to the certainty of ruin, shame, or even death, can prevent the individual drinking until he can drink no longer. He sees his impending ruin; deplores his fatal impulse, his inability to control his desires; and will assert with tears, that if hell were yawning on one side of him and a bottle of brandy standing at the other, he could not resist the impulse to drink, although the next moment he were to be precipitated into the gulf beside him. Such persons are now generally regarded as no longer responsible agents,—as insane,—and requiring, therefore, to be constrained and protected against themselves. Our asylums contain many such cases, although some degree of uncertainty prevails regarding the length of time they may be subjected to control; and the want of some legal enactments regarding them is much felt and complained of.

This disease sometimes assumes an acute form; and originating in some accidental cause, a constitutional change, or debilitating attack of disease, affects a person of temperate habits and predisposition; and in such cases is, with proper care, generally recovered from. Sometimes it assumes a periodical form; and persons have been known, distinguished as merchants or men of professional or literary reputation, who have been subject for many years to periodical attacks of insane drinking. But the most hopeless form is when the disease is chronic,—when it has been slowly engrafted upon a constitution hereditarily predisposed to it by systematic indulgence in intemperate habits. Several of our most attractive authors, men of singular and varied genius, have gradually sunk under this disease. One of the most noted of recent illustrations of this state is perhaps afforded by Edgar Poe, the American poet, whose whole life evinced that he laboured under moral insanity. Poor Charles Lamb, who played cribbage to amuse his demented father, and periodically conveyed his weeping sister to an asylum, was, by his own confession, for many years of his life, while he was writing to an adoring circle of readers, but a melancholy wreck, passing one-half of his time in the most wretched distress, and the other half in miserable imbecility.

One of the most constant and salient features of insanity Monomania is the suspicion which forms a prominent symptom in a vast number of cases of all kinds. It is common both to mania clon. and monomania. Even when the mind is carried away by a torrent of emotion or passion this is observed very generally as a marked trait among other symptoms. The patient watches every movement of his friends or medical attendant; suspects they are plotting against him; that he is supposed to be mad, and that some one is about to carry him off to an asylum; or suspects his food is drugged or poisoned. Not unfrequently one of the first indications of insanity is the idea entertained by the patient that every one he meets is looking specially at him; that the clergyman preached at him; that there is some plot of which he is the object. What is thus common to most varieties of insanity comes to be the principal feature in many cases of monomania: some suspicion regarding some person or subject occupies the mind and fills it with apprehension, while the faculties remain comparatively sound in reference to other subjects. Such cases have been designated monomania of suspicion.

This variety of monomania is not unfrequently associated with feelings of enmity and a desire of revenge against the perpetrator of the fancied injuries under which the patient suffers. In some cases the vindictive feeling is overpowering, and leads the patient to some dreadful deed of vengeance. These are the cases of insanity which are most dangerous to society. It was by such a monomaniac that the Hon. Spencer Perceval was shot in the lobby of the House; and from such another Mr Drummond met a similar fate, by being mistaken for Sir Robert Peel. (See the works of George Esquirol, Marc Prichard On Insanity; Simpson On Homicidal Insanity, &c., &c.)

The propensity to kill, although generally stimulated Homicidal into exercise by the belief in some imaginary wrongs, is mania, sometimes an abstract impulse without motive,—a morbid craving for blood,—an irresistible impulse to destroy. This constitutes another variety of moral insanity, and one which has been generally repudiated in our courts of law as a defence for homicidal acts. That this homicidal mania is a real disease, in which the patient is carried away by the incontrollable impulse of a morbid propensity, is established by a large array of cases. The most noted illustrations of this morbid state are those horrible tragedies so frequently recorded in the newspapers of a father or mother deliberately destroying their own offspring. Very often this homicidal impulse is accompanied by a strong effort to restrain it, or to save the victim of it by some timely warning. Such persons have begged to be restrained, to prevent them committing murder; or have called out to their friends to save themselves by flight, before they expended their last effort at self-control.

Religious madness, as it was called, at one time occupied Monomania a large space in works on insanity. It may with greater of superstitious propriety be called monomania of superstition. The subjects of it are generally profoundly ignorant of true religion. They are inspired by fanatical excitement or superstitious fears. One regards himself as a divine personage,—as the Saviour again incarnate,—and is prepared to be immolated for the sins of the world. Another is inspired with the prophetic spirit, and denounces curses upon all around as the worst of sinners. Another is the woman described in the Revelations, who is to give birth to a man-child. Or, again, we find others possessed with demons,—Satan himself,—accursed of God and man: the demonomania of former ages.

Such are the most frequent forms of partial insanity, arranged conventionally, and perhaps accurately enough for practical purposes. But there are innumerable cases which it is impossible to reduce to any classification, where the patient is insane in reference to one particular fact, and not in a faculty or train of thinking. Of such cases are those where persons have imagined themselves cocks, grains of wheat, pumps, pairs of shoes, a half-crown, made of glass or of gold; where men have believed themselves pregnant, and women have believed themselves men; and innumerable other fancies, which might be mentioned were it not that they are as numerous and varied as the fancies which the human imagination can conceive.

III—DEMENTIA

Dementia. Consists in impairment or obliteration of the mental faculties,—in a diminished activity of the mental operation, either general or partial. In mania and monomania there is an excessive activity of some feelings, or emotions, or faculties,—a disturbance of the equilibrium of the mind: in dementia there is a mental asthenia, an impaired action, a moral atrophy. This impaired activity may vary from the smallest appreciable weakness to the total loss of all indications of thought, consciousness, or volition,—to complete fatuity.

Dementia is most frequently the sequel of other diseases. It is the most frequent termination of mania or monomania when not recovered from, or may follow apoplexy or repeated attacks of epilepsy; although it is not unfrequently the original and sole form of an attack of mental derangement.

In demented persons external objects are generally viewed with little or no interest, and they appear to be imperfectly appreciated. Hence, perhaps, the impaired power of reasoning, or comparing, or perceiving the relations of things; hence, too, probably the loss of memory, which is a principal feature of dementia. The objects or events around being observed with little or no attention, make no impression on the mind, and are immediately forgotten. Such persons often retain a lively recollection of the events of their childhood, and of everything connected with their history up to the period of their insanity, and yet are totally forgetful of all recent events so much so, as very often not to remember that they have seen their husband, wife, or children, although visited by them only a few moments before.

In most cases of dementia, along with this impaired memory there is a marked incoherence. The ideas appear to pass through the mind as in dreams or in reverie, without any effort to direct them in a particular channel, without any apparent connection or sequence, such as takes place in the active operations of a healthy mind. Very often such persons repeat words or sentences without attaching any meaning to them; they talk as if they were thinking aloud, or rather as if they were not thinking at all, but merely repeating by rote a series of old forms of speech, or words associated together by their sound rather than their sense.

The activity of the emotions and passions is altogether destroyed, except when, as occasionally happens, a brief paroxysm of excitement lightens up the drear monotony of their stupor. In general they have no desires, no aversions, no hatreds, no affections; they are docile and passive; they have no will of their own; they spontaneously determine no act; they passively obey the will of others; receive the visits of their friends without pleasure, and part from them without regret; they are insensible to all the griefs and pleasures which affect others; at times they laugh at some passing thought, and at others cry, as children laugh or cry in their sleep according as their dreams are pleasant or painful.

Their movements are peculiar: some will walk up and down incessantly; others will dance for hours together, performing some monotonous movement continually repeated. Others, again, will sit for days, weeks, months, or even years, in the same corner, crouched up in the same attitude. Some will repeat incessantly the same words or the same phrase night and day; others will preserve a uniform and unbroken silence. Some clothe themselves in a ridiculous way, and, if permitted, will adorn their persons with a variety of absurd ornaments.

The face is generally pale; the eyes watery; the looks wandering, or fixed on vacancy; the countenance destitute of expression; the body lean and emaciated, or at other times loaded with fat.

The functions of organic life are performed with regularity; the sleep is commonly profound, and the appetite voracious.

Dementia is a rare disease in young persons, unless when complicated with epilepsy, and is most frequently either the termination of other forms of insanity or the accompaniment of advancing age. The varieties may be conveniently referred to different stages or degrees; and in the table of classification we have given the four degrees distinguished by Dr Prichard; namely, 1. That of forgetfulness, or loss of memory; 2. That of incoherence, or loss of the power of reasoning; 3. Incomprehension; and 4. Inappetence, or total fatuity.

Dementia is less curable than most of the varieties of insanity already described. Occurring in young persons, arising from removable causes of a debilitating kind, and occasionally when the result of mania, it may be removed by proper treatment; but a majority of the cases of this kind of mental derangement are very hopeless.

The duration and termination of uncured cases of dementia are very variable. When it is connected with serious diseases of the brain or of other organs, such as the lungs, it may terminate fatally within a short period, but if not so complicated, the patients may prolong their existence to nearly the average term of human life.

GENERAL PARALYSIS OF THE INSANE.—The insane are General more liable than others probably to paralytic attacks; but paralysis, the disease called general paralysis is one of a special character, and may be viewed either as a variety of insanity complicated with a peculiar affection of the motor powers, or as this affection of the motor powers complicated with insanity. The disease was first described by Esquirol and other French alienistes, but is now generally known, at least in all large asylums, in this country.

The characters of the mental disease which accompanies this affection are generally so peculiar and distinctive as to have acquired for it the name of Mania paralytica. The individual imagines that he is possessed of great wealth, and he is full of projects involving the expenditure of enormous sums of money; he believes that he is possessed also of titles and dignities of the most exalted kind; and, in short, all his delusions are of the most extravagant character (delire ambitieux). Conjoined with this there is generally a remarkably facile disposition, so that the patient is easily coaxed and managed. The mental disease is not always of this description; occasionally, but rarely, it presents the features of melancholia or monomania, and generally after a few months, when the violence of the first attack has subsided, it passes into dementia, which gradually increases and deepens until the fatal termination.

The peculiar general paralysis sometimes precedes the development of mental changes, but more frequently coincides with them, or is gradually developed after a maniacal attack. The first symptom is commonly a difficulty in articulating distinctly when speaking. The speech is "thick" or mumbling, like that of a person intoxicated. Next, although sometimes first, the powers of locomotion become impaired, and the person walks unsteadily, balancing himself with difficulty, like a drunk man. This loss of power, or rather of control over the muscular movements, gradually and slowly increases until the patient is unable to walk without assistance, cannot speak at all, and can scarcely swallow even liquids.

Patients labouring under this disease are generally subject to attacks of stupor or insensibility, with convulsions somewhat resembling epilepsy. Such attacks in some are frequent and severe, and in others are seldom or very slight.

The disease is regarded as incurable, and death generally takes place within one or two years. The fatal termination sometimes occurs during one of those epileptiform attacks to which the patients are subject; more frequently it is due to the development of other diseases, such as consumption or diarrhoea, or to the gradual exhaustion which accompanies the progress of the affection, accelerated not unfrequently by the formation of bed sores.

**Epilepsy with Insanity.**—Epilepsy, or the falling sickness, has been known from the earliest ages, and from the terrible character of the symptoms, it was ascribed by the ancients to demoniacal possession or to the anger of the gods. When it attacks young persons and continues to affect them, it appears to arrest the development of the brain, and to produce a permanent imbecility. Persons of mature years who are subject to frequent epileptic fits have a tendency gradually to become affected by some variety of insanity. Sometimes it assumes the form of mania, maniacal attacks supervening upon the occurrence of the epileptic fits. These maniacal attacks are of short duration, generally passing off in a day or two, but are very frequently characterized by extreme violence. Indeed, maniacal epileptics are the most dangerous of all insane persons; their fury is blind and impulsive, and no control or fear daunts them.

Epileptics are also subject to various forms of monomania, and not unfrequently suffer from hallucinations of the senses.

The most frequent effect, however, of continued epilepsy is the gradual impairment of the memory, of the sensibility, and intelligence, until the subjects of it fall into a complete state of dementia.

The tendency to dementia appears to bear a direct relation to the frequency and persistence of the epileptic fits.

Epilepsy with insanity is generally regarded as incurable, and the principal object in the treatment of the patients is to guard them against the dangers incident to the fits—to prevent them falling upon sharp corners, or into the fire; or dying of suffocation by turning over on their face upon the pillow during a fit; and to secure them and others from injury during the delirium or violence of the accompanying mental derangement. In the intervals between their paroxysms many of them are active and industrious, and make themselves useful and agreeable; and it seems well ascertained, that by judicious management, good diet, suitable occupation, and freedom from all causes of excitement or irritation, the frequency and violence of their attacks may be very much diminished.

**Pathology.**—The morbid appearances found in the bodies of those who have died insane are not such as to afford a satisfactory explanation of the symptoms of the disease. Changes indicative of a slow inflammatory action in the membranes of the brain are more or less frequent. Effusion of fluid beneath the membranes and into the ventricles or cavities of the brain is also a very frequent occurrence. These appearances are, however, very varied in their frequency and extent, and are sometimes found in the brains of persons who have not been insane. It is therefore inferred that they are the accidental concomitants of other morbid changes not yet recognised. Our ignorance of the minute anatomy of the healthy structure of the brain, and of those changes in its condition which accompany the exercise of its functions, make it probable that we are yet unable to appreciate by our means of observation those morbid changes which are the cause of mental disease. Some authorities have contended that insanity is a disease of the blood, and that the absence of pathological appearances in the brain, and the analogy between insanity and the effects of alcohol and other poisons which act upon the brain through the blood, afford strong presumptive evidence in support of this hypothesis. Others, again, have maintained that in those cases where no morbid changes have been found in the brain, the mental disease has been symptomatic of some other bodily affection, such as disease of the liver, bowels, or uterus. Lastly, in general paralysis of the insane the morbid changes generally found are more constant, such as thickening and opacity of the membranes of the brain, and effusion of serous fluid; and along with these, softening of the grey matter of the brain, and enlargement of the nucleated cells which enter into its composition. In not a few instances the white matter of the brain is increased in firmness and density. The large quantity of serous fluid found in the cavity of the cranium in many cases must be accompanied by a corresponding diminution of the size of the brain; and it appears also to be determined that the brain undergoes an increase in weight and in its specific gravity during the progress of the disease.

The predisposition to insanity, it is well known, is engendered by marriages between blood relations. The children of cousins-german are, according to common observation, peopled frequently of imbecile mind, idiots, or predisposed to insanity; and when intermarriages are confined within a predestined channel during successive generations, they lead to position, the production of a greatly deteriorated, scrofulous, imbecile, and insane family.

Besides marriages between blood relations, there are other causes affecting the parents which appear to have an influence in engendering a predisposition to insanity in the offspring. Of this kind are strong mental emotions, hysteria, insanity, over-exertion of the mental faculties, and bad health on the part of the mother, and, perhaps, more frequently than any other cause, excess in the use of wine or other stimulants. Guislain states that he has known a whole generation of lunatics born of a mother who was habitually intoxicated for a series of years, although neither she, her husband, nor any of their families, were predisposed to insanity. He has also known epileptic children born of drunken parents, neither of whom were epileptic or predisposed to disease of the brain.

It is believed that the children of parents advanced in life are more liable to insanity than others; and that any causes which may produce nervous debility on the part of one or both parents tends to produce imbecility or a predisposition to insanity in the offspring.

It may be observed that among the children of parents predisposed to insanity there are remarkable peculiarities; one perhaps is an idiot or imbecile, another is a great libertine or drunkard; one may be distinguished by genius of a particular sort, while another is extremely reserved and secluded in his habits; one is a poet, and another a religious enthusiast; in fine, there are peculiarities and eccentricities which distinguish one or more members of the family in which hereditary predisposition to insanity exists.

The hereditary predisposition is frequently developed at a particular age in successive members of the same family, and father and son, or mother and daughter, will become insane at the same period of life.

The predisposition also is generally to the same form of insanity in successive generations,—father, son, and grandson become maniacal or epileptic,—mother and daughter have puerperal mania,—a parent and a whole family of brothers and sisters die of delirium tremens; and of all facts of this kind, nothing is more remarkable or more constant (according to M. Falret) than the constancy with which the suicidal impulse is transmitted from parent to child. A grandfather, a father, and son, have been known to destroy themselves at the same ages and in the same manner.

In consequence of the dislike which exists among most families to admit that there is any insanity or scrofula in their blood, it is extremely difficult to arrive at correct conclusions as to the frequency of hereditary predisposition to this disease in those affected by it; and accordingly we find the hereditary tendency variously estimated by different writers: by Parchappe, e.g., it is estimated at 15, by Guislain at 25, by Webster at 33, by Thurnam at 34, by Esquirol at 45, by Jessen at 65, and by Holst at 69 per cent.

Lastly, M. Baillarger and Dr Browne deduce from their observations that the predisposition is more frequently transmitted through the maternal than through the paternal side of the family.

The predisposition to insanity appears to increase gradually with advancing age, being in infancy and childhood very small, and in extreme oldage, if we include senile dementia, very great. From an extended series of statistical records, it appears that insanity is most frequent between the ages of thirty and forty. Next in frequency is the decennial period between twenty and thirty; and then comes the period between forty and fifty. These results do not, of course, give the number of insane of each age relative to the entire number of the population alive at that age, but only the absolute numbers affected at each decennial period. Making allowance for the successively decreasing number of persons alive at each successive period of life, it may be stated that, with the exception of the first period named, insanity, including dementia and fatuity, becomes more and more frequent with advancing age.

Neither sex appears, on an extended view, to be more predisposed to insanity than the other. In some countries and in some districts the frequency of insanity in one sex is much greater than in the other; thus, in France the proportion of insane females to insane males is as 14 to 11, and in Paris as 3 to 2; on the other hand, in Great Britain and Ireland, and in Norway and America, the relation is reversed, the insane males being in the former as 13 to 12, in Norway as 6 to 5, and, taking the states of New York and Connecticut alone, as 2 to 1. These remarkable differences probably depend upon accidental circumstances, such as the greater frequency and poignancy of the exciting causes affecting the opposite sexes in these countries, than upon any greater predisposition to the disease in one sex as compared with another; for in collating the available statistics of all civilized countries, Esquirol arrived at the conclusion that the insane males were to the insane females in the ratio of thirty-seven to thirty-eight,—a very considerable difference taking into account the difference in the actual numbers of each sex in the population.

The influence of temperament appears rather to determine the form of insanity than to predispose to the disease in one temperament more than another. Persons of a melancholic temperament are more predisposed to melancholia than to other forms of insanity; the lymphatic temperament predisposes to dementia; and the sanguine temperament to acute mania, with great violence and excitement where the temperament is specially pronounced.

No cause predisposes more certainly to insanity than previous attacks of the disease, however occasioned. Exposure to the same influences which developed it before will almost certainly lead to its recurrence. The frequency of relapses, as shown by the statistics of asylums, is very great.

Defective education, over-stimulation of the intellect at an early age, the early indulgence in strong passions and sensual propensities, the neglect of the cultivation of the will, of habits of self-control and self-denial, particularly in mental constitutions naturally ill-balanced, conduce in the greatest degree to the development of a predisposition to mental disease.

The exciting causes may be either moral or physical,—2. Exciting the former being those which affect the mind directly; the causes latter such as affect the body first, and through it the mind. It is believed that the moral causes are more frequent and efficient in the production of insanity than the physical. Of this it is believed the greater frequency of mental diseases among highly civilized communities than among barbarous or semi-barbarous nations, affords a strong proof. In uncivilized countries the habits are uniform,—there is the same invariable routine in the domestic history, in the manners, customs, and social institutions. In highly civilized states, on the other hand, where every department of life is full of competition, strife, and activity, the anxieties of living are innumerable; and there is a constant change of customs, of the position in life of individuals,—some rise to fortune, while others suddenly sink to ruin. The political and religious controversies which agitate the community; the arduous pursuits upon which numbers enter, stimulated by avarice or ambition; the race after fame; the jealousies and rivalries of parties; the intrigues of private life; domestic griefs and anxieties, caused by jealousy, misfortunes, and poverty,—are a few of the causes which may serve to account for the extreme prevalence of insanity in the European and North American states. In the tents of the Arabs, the huts of the Indians, and among the savages of Africa and the islands of the Pacific, insanity is said to be unknown. In Nubia and Abyssinia travellers failed to trace it. The insane in the asylums of Cairo and Constantinople are an insignificant portion of the population. In China we are assured it is very rare. The following table, constructed from various sources, shows its frequency in some of the more highly civilized states compared to the population:

| Country | Insane | |------------------|--------| | Italy | 4879 | | Rhineland Provinces | 1000 | | France | 1600 | | Westphalia | 846 | | Belgium | 316 | | United States | 721 | | England | 578 | | Denmark | 549 | | Scotland | 370 | | Norway | 329 | | Iceland | 311 |

It is difficult to account for the great frequency of insanity in the countries last mentioned, unless it be due to the scanty nature of the population, their miserable means of subsistence, and the greater frequency of intermarriages.

Pinel estimates the frequency of moral causes, compared with physical, in the production of insanity, as 464 to 219 causes.

The most frequent of all the moral causes are domestic griefs, anxieties, and reverses in fortune. Next in frequency are violent emotions and passions, disappointments in love, grief for the loss of relatives, and wounded ambition or pride.

It is inferred from statistical tables, that married persons are less liable to insanity than unmarried.

Religion was at one time supposed to be a frequent cause; and it might be inferred that a subject calculated to inspire, on the one hand, vivid emotions of happiness, or gloomy forebodings, terror, and despair on the other, would be likely to exercise an important influence on persons predisposed to mental disease, when their minds were absorbed with such feelings. Nevertheless, as a cause it is by no means frequent. Many of the cases ascribed to it are Mental Diseases.

due rather to ignorance and superstition; while most of the cases of religious despondency are due to other causes very often affecting the bodily health.

By far the most common in this country of the causes of a physical kind is intemperance. Next in frequency is general derangement of the health, particularly of such a kind as exercises a debilitating effect on the body and nervous system. The critical period in females, parturition, and uterine irregularities; blows on the head and diseases of the brain, epilepsy and advanced age, fever, intestinal worms, the suppression of an accustomed discharge or eruption, the metastasis of rheumatism or gout, and various vicious indulgences, are nearly in the order enumerated, among the most frequent of the other physical causes to which insanity has been ascribed.

Treatment. The medical treatment of the insane has undergone a great revolution during the present century. At one time large and repeated bleeding was much lauded in the treatment of mania. It is now almost entirely abandoned, and regarded as dangerous to life, or tending at best to convert the case into one of dementia. The general use of blisters and issues, of purgatives and emetics, and of specifics, once in high favour, has now also given place to the use of milder remedies and more rational principles of treatment. It would be out of place to enter into details in this article as to matters purely medical; but it may be stated in general terms that the warm bath, and especially prolonged warm baths with cold applied to the head, have been found of great advantage in allaying the excitement of mania; that the judicious use of opium in certain cases, for procuring sleep, has also been esteemed as a valuable remedy; and that the restoration of the general health by the use of appropriate means, and the removal of local diseases, when they exist, by treating them on the general principles of medical science, constitute nearly all the canons of medical treatment now recognised in regard to mental diseases. It is not now imagined that any particular medicine exerts a specific effect in the cure of insanity; and beyond the judicious and skilful treatment of the patient with a view to the cure of local bodily disease, and the restoration of the whole system to the standard of robust health, the great and important part of the management of the insane consists in what has been called the moral treatment.

The great principle upon which the moral treatment of mental diseases is founded is the distraction of the mind from morbid trains of thought or feeling, and its occupation in new and healthy channels. In carrying out this principle, the first and most important object is to remove the patient from the scene of his first attack, and from the presence of his friends. The objects which surround him suggest and preserve in activity the subjects of his excitement or delusion; the presence of friends exerts the same deleterious influence, and as they are commonly with the insane the special objects of dislike and suspicion, their presence irritates and aggravates the disease; while they commonly add to the injury they are thus unconsciously inflicting, the evil of deepening and strengthening all the morbid fancies of the sufferer by vain efforts to reason him into a belief of their absurdity. "Dr Willis," says Esquirol, "who acquired so great a celebrity by having assisted towards the happy termination of the first attack of madness experienced by George III., unfastened the king's apartments, dismissed his courtiers and domestics, and had him attended by strange servants."

The complete manner in which this change of scene and associations is effected by removal to an asylum, is one of the principal causes which renders early removal to such an establishment an efficient curative agent.

The patient requires to be surrounded by experienced attendants, allowed the greatest liberty, and treated with the utmost amount of kindness compatible with his own safety. All restraint should be avoided; the free use of his limbs, and abundant exercise in the open air, tend to carry off the superfluous energy and excitement of his malady.

A variety of means may be had recourse to, suited to the peculiarities of each case, for carrying out the first principle of treatment,—the healthy occupation of the mind. Of these, useful and rational occupation, particularly in the open air, holds the first rank. Walking, gardening, open-air games, travelling, angling, and other such like amusements, according to the rank, or taste, or disposition of the patient, are next to be preferred. In many cases music exercises a soothing and salutary influence. In others, drawing, and in-door games of all kinds, combined and varied with reading, sewing, knitting, embroidery, and other occupations suited to the peculiarities of the individual. In a large proportion of cases the regulated observance of religious exercises, and attendance upon divine service, contributes to the healthy moral influence of other agents. In fine, everything which can employ and interest a healthy mind, and which is apart in its character or by association from the morbid thoughts of the patient, ought to be brought into exercise for his recovery. These various agents, however, must be judiciously adapted to each case, and must be systematized and directed with prudence and skill, and a constant attention to the great object of establishing a healthy current of thought and feeling through the channel of regulated habits, occupation, and amusement.

These appliances for the treatment of mental diseases are best carried out in a well-managed asylum, where every thing is organized with a view to their development, and directed and superintended by a skilful and experienced physician. The treatment of the insane in private dwellings, even where the most lavish expenditure of money can be commanded, cannot in general secure the same advantages. The patients are exposed to the unkindness or neglect of mercenary and eye-serving attendants, who soon weary of duties which are both trying and onerous if not under the constant supervision of a controlling and directing power.

The arrangements and management of some of our best regulated asylums give at one view the best idea of the proper treatment of the various forms of insanity. These institutions, compared with those of former years, stand out in bold relief as monuments of the progress of the age; and to those whose ideas of insanity are associated with ferocity, danger, and all that is loathsome, they must appear to be among the wonders of modern times; so much has been effected in them by well-directed discipline and enlightened philanthropy in ameliorating the condition of the insane.

Such a house subserves a variety of ends: it is a place for the isolation and safety of the dangerous; it is a retreat and home for the hopeless and incurable; it is a great hygienic hospital for the restoration of the insane to physical and mental health; a house for moral and physical education; it is also a school for elementary, artistic, scientific, literary, and religious education; and an industrial establishment where the busy crafts of artisans and gardeners, and all the homely occupations which can employ the hands and heads of men and women, are called into systematic and daily activity.

The best institutions of this kind are erected on carefully selected sites commanding a wide prospect of cheerful and varied scenery. They are placed in sheltered positions, with a southern aspect, and are inclosed within an ample space of garden and farm. The beneficial influence of cheerful and picturesque scenery upon the minds of the insane is unquestionable; and the occupations afforded by a farm, by flower-gardens, pleasure-grounds, and conservatories, are of the very highest curative effect.

The buildings are constructed with taste and with a strict attention to the means of ventilation and comfort. Everything is avoided which can give the idea of a prison or of confinement; while the arrangements are such, at the same time, as to afford security to the inmates. The galleries are cheerful, spacious, and well lighted; and all the rooms and airing-grounds command an agreeable prospect. Workshops are provided for the industrious, and in these the carpenters, tailors, shoemakers, and other tradesmen, pursue with happiness their several occupations. The females are encouraged in habits of industry, and sew, knit, and embroider in their workrooms, or assist in the culinary department or the more laborious duties of the washing-house and laundry. The rooms and workshops are neatly furnished, and the walls are hung with drawings or paintings. Flowers and singing birds everywhere cheer the eye and the ear. Books, and periodicals, and newspapers, are liberally supplied, and perused with avidity. Each day is commenced with careful ablutions, followed by morning prayers. 'To a comfortable breakfast' succeed the various occupations of the day, when each one follows out the occupation prescribed for him, assisted and encouraged by the kind acts of his attendant, and stimulated to exertion by some trifling reward. Dinner is served with all the comfort and regularity of a private meal; and work is again resumed. At an early hour tea is followed by amusement of some kind; in the summer time by cricket, bowls, quoits, or some other open-air game; in the long evenings by a reading party, a lecture, a concert, or dance, some dramatic representation, or some in-door games suited to the taste and capacity of those engaged. Some are encouraged to prosecute a systematic course of reading or the study of some science; while others are induced to undertake some literary labours. All are as far as possible made to feel themselves happy and contented in the prosecution of some purpose, which carries their mind away from the subject of their disease, and which is adapted to their capacities, their natural tastes, or the peculiar phase of their malady.

This institution is, or should be, regulated and directed, throughout all the details of its management and daily routine, by a physician of the highest natural and professional ability. The qualifications for such an office are indeed of the rarest kind; but they are at the same time indispensable. He must unite the natural endowments of benevolence and firmness. He must be good and humane, and at the same time just and inflexible; courageous and calm; tempering firmness with serenity; and kindness with decision and impartiality. He must be possessed of a sound practical knowledge of human nature in all its phases, and that innate power or tact which enables one to govern others with ease, to acquire their confidence and esteem, and at the same time to command their ready obedience and respect. He must be acquainted with the usages of society among all ranks and among all the varieties of human character. He must be versed in polite literature, and must have a taste for the lighter accomplishments of civilized society, so as to be able to direct and give an impulse to the amenities of asylum life. He must have a general knowledge of business, of house architecture and engineering, of farming and gardening, botany and natural history, and of the various trades and manufactures, so as to qualify him for the superintendence of a large institution where operations in all these departments require to be directed and encouraged. Combined with these general qualifications, he must be skilled in his own profession in all its departments, so as to give the advantage of enlightened professional skill to the medical treatment of his patients.

Under the advantages of such an institution as we have described, and under the care of a physician with such qualifications as those enumerated, it cannot be doubted that an asylum affords the best prospect of recovery in curable insanity, and the best means of affording happiness and prolonged life in the incurable forms of this malady. That many of the best asylums of this and other countries possess all these means and appliances, and are conducted with consummate skill and benevolence, is not now a matter of doubt, but one of grateful reflection to every philanthropic mind.

It is a question of great interest, but of no little difficulty, at the present moment, to determine whether insanity is on insanity, the increase in this and other civilized states. The statistics of insanity, the gradual increase in the number of public and private asylums, and the rapidity with which they are filled as soon as erected, all seem to indicate a great increase in the numbers affected with mental disease. On the other hand, it is certain that statistical inquiries have in successive periods been conducted with much greater minuteness; that cases are now sent to asylums which formerly were allowed to go at large or were treated at home; that as the advantages of early seclusion in an asylum are becoming more widely known, and the prejudices against those institutions are dying out, friends more readily resort to them for the care or cure of their relatives, even under the slighter forms of insanity; and lastly, the legal enactments for the provision of pauper lunatics have gradually become more stringent, and few cases of idiocy, or epilepsy, or mania, are now permitted to wander at large. These causes have given an apparent increase to the number of those returned as insane; and it is impossible at present to determine whether there is actually any absolute increase in the ratio of the insane to the same portion of the population.

In England and Ireland no one can be sent to an asylum without an order from a relative, and the certificates of two medical men who have separately examined the patient, and who are required to state the grounds upon which they formed their opinion in their certificate. In the case of paupers the order of a justice of the peace is required. In Scotland the sheriff of the county grants a warrant for the removal of a patient to an asylum upon an application or petition from a relative or guardian, accompanied by the certificate of one or two medical men. If these rules are not attended to, the person sending and the person receiving a patient into an asylum are liable in heavy penalties.

The restriction of one's liberty by being placed in an asylum is a means of cure or safety, and does not in itself deprive the individual of his legal rights. He can only be deprived of these by a regular form of inquiry, whereby he is declared insane by a commission, or by the verdict of a jury.

The existence of insanity does not in itself disqualify for legal acts, or exonerate from responsibility for acts of violence or murder. Wills have been held to be good although executed by persons who were confessedly insane; but it was considered that their insanity, or the delusions under which they laboured, were not of such a kind as to interfere with their judgment in the disposition of their affairs. In the same manner persons have been held responsible for criminal acts about whose insanity there was no doubt, but it was deemed not to be of such a nature as to prevent them knowing right from wrong in the act which they committed. These subjects involve intricate and difficult medico-legal questions, and can only be briefly indicated here.

IV.—IDIOTY,

Or Idiotism, is a natural or congenital weakness of the mental idiosyncrasies, and varies in degree from slight impairment or imbecility, by gradual and insensible shades, down to absolute idiocy, or total absence of intelligence.

Idiocy depends upon some congenital disease of the brain, or the want of the due development of that organ. In the former case the head is often large and misshapen, and in the latter it is generally small, and also irregular in shape. The form of the head; the low, retreating, and contracted forehead; the flattening of the occipital region and the expression of the thick-lipped face; the figure, which is generally small and deformed—are all familiar, and are strongly indicative of the mental condition.

Idiocy exists to a very great extent in certain districts where goitre or bronchocele (an enlargement of a structure in the neck) is found to prevail. These districts are mostly the valleys at the foot of lofty mountains, where the air is stagnant and humid. This disease is called cretinism. It prevails to an enormous extent in some portions of Switzerland, Sardinia, and Austria. In the Canton du Valais 1 in every 25 inhabitants is a cretin, in the Canton de Vaud 1 in every 27, and in the Canton d'Uri 1 in every 83; in Judenburg in Austria there is 1 to every 53 of the population, and in Bruck 1 in every 74. In Upper Austria, along the banks of the Danube, whole families consist of cretins; and in some villages of from 4000 to 5000 inhabitants not one was found capable of bearing arms. In many other mountainous districts in Europe and other parts of the globe this endemic disease is found to exist.

The subjects of this affection exhibit idiocy in its most absolute and loathsome form. They are diminutive creatures with large bellies and misshapen limbs, heads of unusual form or size, blear and sunken eyes, flat noses, and large lips, the tongue protruding, the mouth open, and the saliva running from it. The skin is loose and yellow. The poor victims of this disease can neither see, hear, nor speak; they can scarcely creep from place to place, and are lost to all sense or intelligence beyond the bare instincts of animal life. This description refers to the worst class of cases. Many of them display a certain degree of intelligence; but although treated with extreme kindness, they are obstinate, mutinous, and incapable of gratitude. They seldom live beyond thirty years of age.

The causes of this disease have been sought for in the water which is drunk by the inhabitants of the affected districts, in the confined and humid atmosphere which they breathe, and in their filthy and crowded houses, their intermarriages, and their intemperate and lazy habits.

By Dr Guggenbühl and some other authorities this condition is considered to result from a disease analogous to rickets, and affecting also the cerebro-spinal system, and that by appropriate treatment adopted at an early age it may be cured. His treatment, combined with a gymnastic and educational training, has been successfully pursued for some years in his establishment at Interlachen.

We have already briefly alluded to the various institutions in this and other countries which have been recently organized for the care and improvement of idiots. It remains yet to be seen how far the mental faculties and moral emotions of this class of unfortunate can be developed and elevated by proper training and treatment; but the success which has already attended the philanthropic labours of those who have entered upon this path of benevolence is of the most gratifying and encouraging description.

The following is a condensed bibliography of the more important works on insanity, idiocy, and asylums:

- Celsius, lib. iii., c. 18; Aretaeus, Car. Celsius, lib. i., c. 5; Paulus Aegineta, lib. ii., c. 14; T. Bright, A Treatise of Melancholy, 1696; Burton, An Introduction Discours des Maladies Mentales, 1597; Burton, An Account of Madness, 1624; Harvey, Morbus Angelicus, &c., 1666; Batteux, Traité de Médecine, 1757; Le Roy, Remarks on Madness, 1757; Levy, De Melancholica, 1760; Perfect Methods of Cure in Insanity, 1778; Audry, Recherches sur la Manie, 1788; Arnold, On Insanity, 1782; Crichton, Inquiry into the Nature and Origin of Mental Derangement, 1798; Hallam, On Insanity, 1798; Hallam, On Madness, 1800; Hallam, Illustrations of Madness, 1810; Hallam, Considerations on the Moral Management of Insane Persons, 1817; Pinel, Traité sur l'Alimentation Mentale, 1801; Translation of it by D. Davis, 1806; Hoffmann, Untersuchungen über die Krankheiten Seelen, &c., 1803; Cox, Practical Observations on Insanity, 1804; Enfield, De Passionibus consideratis causae, &c., de l'Alimentation Mentale, 1805; Cowther, Practical Remarks on Insanity, 1807; Charrière, Deux Propos sur les Maladies, 1808; Hallaran's Inquiry, &c., 1810; Tuke, Dissertations on the Insane, York, 1813; Hill, On the Prevention and Cure of Insanity, 1814; Fodere, De Delirio, 1814; Heinroth, System der Geisteskrankheiten, 1818; Spurzheim, Observations on Insanity, 1818; Georget, De la Folie, 1820; Barrow's Inquiry, 1820; Barrow, Commentaries on Insanity, 1820; Falret, De l'Hypochondrie, &c., 1822; Prichard, On Nervous Diseases, 1822; Prichard, On Insanity, 1835; Willis, On Mental Diseases, 1835; Bayle, Traité des Maladies du Cerveau, 1820; Calmet, Du Trouble chez les Aliens, 1823; Guislain, Traité sur l'Alien Mentale, 1826; Guislain, Traité sur les Paranoïques, 1835; Do., 1852; Charlesworth, On the Treatment of Insanity, 1828; Hallay, General View, &c., of Lunatics and Asylums, 1830; Friedrich, Path. and Therap. der Psychischen Erkrankungen, 1830; Conolly, Observations on Insanity, 1847; Conolly, Treatment of Asylums, 1847; Conolly, Treatment of Insanity, 1850; Combe, On Mental Derangement, 1851; Seymour, On the Medical Treatment of Insanity, 1832; Uwins, Treatise on Disorders of the Brain, &c., 1833; Schlegel, Der Heimweh und der Selbstmord, 1835; Browne, Asylums as they were, are, and ought to be, 1837; Esquirol, Des Maladies Mentales, 1838; Ellis, On the Nature, &c., of Insanity, 1838; Mayo, Elements of the Pathology of the Human Mind, 1839; Hill, Total Abolition of Raving Insanity, 1840; Münchinger, Address on the Treatment of the Juane, &c., 1840; Wharton, The Institutions of Salerne, 1840; Lerois, Traité Moral de la Folie, 1840; Veillon, De l'Éducation chez les Enfans, 1843; Twinning, Account of Certain Cases, &c., 1843; Pinel, Traité de Pathologie Cérébrale, 1844; Wigan, Duality of the Mind, 1844; Thurnam, Statistics of Insanity, 1845; Turck, De la Nature et du Trait de la Folie, 1845; Moreau, Du Maladie et de l'Alimentation Mentale, 1845; Boismont, Du Délire Algie, 1845; Boismont, De l'Emploi des Bains Prolongés, 1848; Boismont, Des Remèdes, 1852; Boismont, Du Suicide, 1856; Sequin, Traité sur le Malade, &c., 1848; Rodrigues, De la Paralysie Générale, 1847; Morison, Lectures on Insanity, 1848; Goldstream, The Abandoned, 1848; H. Monro, On Insanity, 1848; Wharton, On Insanity, 1852; Morel, Traité des Maladies Mentales, 1854; Land, Chapters on Mental Physiology, 1852; Cumming, Notes on Asylums in Germany, 1852; Parchappe, Construction des Arènes d'Aliens, 1852; J. Falret, Recherches sur la Folie Paralytique, 1853; J. Falret, Lettres Cliniques de Médecine Mentale, 1854; Wharton, On Mental Unsoundness, 1855; Blackie, On Cretinism, 1855; Report on Insanity and Idiocy in Massachusetts, 1855; Noble, Psychological Medicine, 1856; Hölder, Lehrbuch der Gerichtlichen Psychologie, 1857; Bertrand, Traité du Suicide, 1857; Morel, Traité de la Dégénérescence, 1857.