and in three instances I have satisfied myself by microscopic examination, that death was occasioned by this change.

The

Disease of the Lungs occurs in the insane in all its varieties. It is frequently latent from the absence of congh, and the patient's absorption of mind preventing complaint. absence of cough in serious pulmonary disease is very peculiar. In dementia it arises partly from torpor of the excito motory system, partly from loss of attention, from the same cause in fact as the frequent dirty habits of the insane. In mania it arises from the attention being intensely preoccupied by the vivid ideas and delusions which absorb the mind. I have seen many patients in advanced stages of phthisis who never were heard to cough so long as they were under the influence of maniacal excitement. When this underwent a temporary diminution, they were greatly troubled with cough, which was again arrested by the recurrence of excitement. The continuance of colliquative diarrhoea and perspiration, and of emaciation, proved that there was no halt in the progress of the lung disease, as the absence of cough has led authors erroneously to suppose. The torpor of the nervous system in dementia leads to another peculiarity in the lung and some other bodily diseases of the insane, namely, the absence of irritative or symptomatic fever; and hence it happens, that in a demented person whose strength is unimpaired, and whose constitution is tolerably good, diseases will obtain a degree of development, with symptoms so few or obscure as to be incredible to the general physician. It is on this account that the numerous sloughing sores to which general paralytics are liable, produce so little suffering or constitutional irritation. I have known the stomach disorganised by cancer without the patient complaining of any pain until a few days before death, when perforation took place. The only case of carditis I ever saw, occurred in an insane person who complained of no pain, and in whome heart disease was only suspected twenty-four hours before death in consequence of failure of the pulse. This peculiarity in the intercurrent diseases of the insane should teach the physician to observe with watchful anxiety every physical indication from which he can derive knowledge of the attack of disease, before it is so advanced as to be beyond control. Pulmonary gangrene is more common among the insane than the sane, but not to the same extent here as at Vienna, where it contributes largely to asylum mortality. Diseases of the Stomach bear to insanity a relation of the highest importance. In acute melancholia attended by refusal of food, its mucous membrane is frequently found to be in

flamed and softened, or ulcerated, and it often requires all the skill of the most experienced physician to determine whether an inflammatory condition of the stomach is the cause or the result of the abstinence. Softening of the coats of the stomach is sometimes an effect or a concomitant of advanced cerebral degeneration. Whether the different forms of stomach disease classed under the term dyspepsia, are efficient causes in the production of insanity, by impeding the due nutrition of the body in general, and of the brain in particular, there are no reliable statistical data to determine. The probability is in the affirmative. This, however, is certain, that dyspepsia is common among the insane, and that its removal by therapeutic and dietetic agencies is an important and efficient means of promoting the cure of mental disease. There is nothing remarkable among the insane in the pathology of the small intestines; but the large gut suffers in chronic insanity frequent and extraordinary displacements, which I am quite at a loss to explain. The most common of these displacements is that of the transverse arch of the colon to the lower part of the abdomen, from whence it again ascends to take its proper position as the descending portion. But the most extraordinary anomaly I ever met with, was the formation of a cul de sac rising in the middle part of the rectum, and ascending in front of the other intestines until it reached the ensiform cartilage, the cul de sac being nearly two feet in length. Its walls were thicker than those of the colon, and it contained all the intestinal coats. The patient in whom it occurred had ascites, and prepartions were made for tapping; but percussion and palpation revealed the existence of something strange, and the operation was not performed. Had it been performed in the usual manner, the trocar would have passed into the rectum. My friend Dr. Parsey, of the Warwickshire County Asylum, assisted me in this case, and made the post-mortem examination.

The Liver is not more frequently congested or otherwise diseased in the bodies of the insane than in others. The old Greek theory, that madness depends upon black bile, has no foundation in pathological fact. The only noteworthy peculiarity in the liver which I have observed, has been an apparent loss of its structure occurring in melancholia and dementia of very long-standing, and in which great emaciation and prostration of vital power has long preceded death. In seven instances of this kind, I have found the liver shrunk and flabby, and its structure converted into an appearance closely resembling that of the healthy spleen. Dr. Budd describes

an analogous change occurring in persons not insane, but with acute and recognizable symptoms.

The Spleen is usually small in chronic insanity.

The Kidneys are remarkably free from disease in all the forms of insanity, and the changes which give rise to albuminous urine are especially rare in them. In the whole course of my practice I have never met with an instance of decided Bright's disease among the insane; and, upon inquiry in other asylums, I have found that the same observation has been made by others. The only case I ever saw was in the Rainhill Asylum, but the patient, an old drunkard, was not then insane. Prior to observation, we should have expected Bright's disease and insanity to have been frequently concomitant, on account of the common influence of intemperance in the production of the two disorders, or even that the former might be the occasion of insanity through the influence of its accompanying anemia, and the unsecreted urea upon the brain. Renal and vesical calculi are equally rare in the insane, I have not once met with either, and only once with prostatic calculi. In this case the bladder and kidneys had become diseased from irritation, communicated from the diseased prostrate.

The Reproductive Organs are frequently the seat of disease or abnormal function. Among male idiots and imbeciles, instances of deficient or excessive development of these organs are common; and the female population of every large asylum contains several instances of that masculine development of frame and constitution which indicates an abnormal formation of the sexual organs. There can be little doubt, from the number of such instances, that the androgynous character is frequently accompanied by mental imbecility.

Amenorrhoea is a frequent cause or consequence of, or concurrent phenomenon with mental disease, and its removal not unfrequently leads to recovery of sanity. Extreme congestion of the ovaries and uterus, with false corpora lutea in the former, I have found in two instances of young women who died during the excitement of acute nymphomania. Ovarian tumours are not uncommon; and at the present time I have two insane patients suffering from ovarian dropsy. One has been tapped several times to ward off the imminent danger of death from the upward pressure of the fluid on the stomach and lungs. The other, an epileptic, I, with the assistance of Dr. Parsey, tapped for the same reason nine years ago, drawing off five gallons of porter-coloured fluid, and, strange to say, the cyst has only refilled to a slight extent.

(To be continued.)

Does Civilization favour the Generation of Mental Disease? By DANIEL H. TUKE, M.D., Lecturer on Psychological Medicine at the York School of Medicine, and Visiting Medical Officer to the York Retreat.

This question may conveniently be regarded from two different points of view. Apart from the information to be derived from actual observation or statistical inquiry, it is manifestly very important also to inquire, whether the most frequent causes of insanity are to be found in greater force in civilized countries than in those which are not civilized.

There is no sufficient evidence to show that the brain, so long as it is not deprived of the ordinary range of exercise and stimulus which existence in the world necessarily pre-supposes and ensures, has any tendency, from the want of systematic cultivation, to become diseased, however true it may be that moderate use developes and strengthens it. On the contrary, from every analogy we should predicate that the healthy condition of this organ would be endangered in proportion to the amount of work, to which (beyond the limit. referred to) it is subjected. The mental faculties are the thinking man's tools, constantly in use, and often necessarily subject to very rough usage, but still oftener to unnecessary wear and tear-their employer not unfrequently totally unaware that in producing certain results he is using any tools whatever. If the above position be well founded, the inference would seem clear, that the liability to mental disease is greater (other things being equal,) in a civilized and thinking people, than in nomadic tribes, or in any race whose intellectual faculties are but little called into action. Knowledge brings The tree in the

with it its miseries as well as its blessings. Garden of Eden, which was 66 a tree to be desired to make one wise," was nevertheless the tree of the knowledge of evil, as well as of good. The tragical termination of the author of the "Old Red Sand-stone," speaks loudly in confirmation of this. The fatal effects of an overworked brain would not have occurred, had he not substituted head-work for manual labour." He has not wrought out his way," writes one who knew him well, "from the stonemason's quarry to so distinguished a position in science and literature, without a life of incessant and wearing mental toil. In fact, he had worked much too hard and constantly. And although a man of

sturdy physique, his brain was unable to stand the stress
of his will, and the strain of his perseverance." It is not
asserted, that the course of life which this gifted man pur-
sued did not add immensely, on the whole, to his happiness.
All that is here contended for is, that had he not pursued that
course, he would have been less likely to fall a victim to the
particular disease of insanity. Civilization, with its attendant
knowledge and education, creates social conditions, and offers
prizes dependent solely upon intense intellectual competition,
unparalleled in any former age, and of course unknown among
barbarous nations, which of necessity involve risks (to employ
no stronger term,) which otherwise would not have existed.
"Oh, sons of Earth! attempt ye still to rise,

By mountains piled on mountains, to the skies?
Heaven still with laughter the vain toil surveys,
And buries madmen in the heaps they raise.'

It may seem opposed to the importance which is here attached to overtasking the brain, that among the causes of insanity, as tabulated in our asylum reports, excess of study forms an insignificant item. Thus, in 472 cases in which the cause was traced by Esquirol, in 13 only is it referred to excess of study. But even if this proportion be generally true, it is not to be forgotten that there are circumstances almost necessarily associated with it (excessive study,) which are recognised by all as frequently productive of mental disease. Loss of sleep, by which the nutrition of the cerebral tissue is necessarily interfered with, is one of the most important of these. The health is, moreover, injured by the various attendants on sedentary employments, and it cannot be expected that the brain should escape without a certain amount of injury. Besides, in many an over-stimulated child, or over-worked student, there may be only sown the seeds of future mental disease. Other circumstances may cause the seed to germinate, and be regarded as the cause, instead of merely the occasion.

From these and other considerations, it is evident that excess of study may lay the foundation of many of those cases of insanity in which statistics recognise only loss of rest, and numberless other secondary causes.

It is sometimes remarked, in opposition to the view which is here taken, that our asylums are peopled with inferior, rather than highly intellectual, minds. But this circumstance (if true,) does not really militate against such a view, inasmuch as it is obvious that excess of study will be very likely to derange the former class, and leave the latter comparatively