mind, and that it is double and multiple. Subordinate doctrines of phrenology must also be incorporated with such a system of mental philosophy as the practitioner desires; but we fear phrenology itself—as a system-is irretrievably damaged by its friends. On the one hand, the presuming empiricism which has been grafted upon it, chiefly by its illiterate cultivators, repels the thoughtful and cautious inquirer; on the other, the avowed materialism of another section of phrenologists has shocked those religious convictions. which are deeply seated in man's nature, and are based upon the grandest doctrine of theology-the immortality of the soul. Nor is it possible for the impartial inquirer, rigorously divesting himself of all theological prepossessions (if such they may be termed,) to avoid the conclusion, that the naked materialism which declares mind has no existence, is alike opposed to the conclusions of inductive inquiry and of common sense. The decline of phrenology may be, we think, dated from June, 1842, when Dr. Engledue delivered, at Exeter Hall, the introductory address, to a general meeting of the Phrenological Association. In that address Dr. Engledue proposed to substitute the word cerebration for mind, which he declared to be non-existent. All the leading phrenologists strenuously repudiated this doctrine, and a large number withdrew from the association. These steps did not, however, arrest the evil consequences anticipated from Dr. Engledue's avowal, but perhaps rather hurried them on, for phrenology became more and more popular in connexion with zoism, phreno-mesmerism, &c., and more and more abhorrent to the inductive philosopher, the metaphysician, and the physiologist.

The imperfections of mental philosophy and of cerebral physiology which we have indicated, are eminently of a nature to puzzle the practitioner. Both sciences develop great truths, and yet they seem to be antagonistic; the truths are thus neutralized, and a practical application is impossible.

So long as, in metaphysical inquiries, the existence of the material organ is practically ignored, so long will the state of that material organ be practically ignored also, in those forms of chronic disease of the cerebrum involving the judgment and the morals. Furious mania, dementia, and idiotcy, are easily connected, both theoretically and practically, with cerebral disease, by both metaphysician and practitioner. It is "rational" insanity which is referred with the greatest difficulty to structural disorder, and most easily comprehended as a disease of the mind distinct from organization.

These imperfections undoubtedly constitute the reason why the treatment of the insane has been so contradictory and empirical. It cannot be denied, however, that modern neurology (including cerebral physiology), has very considerably advanced the treatment of mental disorder. For a long series of ages mental philosophy had undivided sway; for an equally long series of years the insane were the victims of cruelties innumerable; and not the insane only, but all that large class of persons of aberrant or weak intellect to whom the mysterious has irresistible charms. In every past age, all kinds of enthusiasts (now left harmlessly to their vagaries), were very commonly the subjects of violence and persecution. As to these, cerebral physiology has indirectly done much. Were it not for the general enlightenment it has afforded, the spirit-rappers, magnetizers, electrobiologists, and the rest, might experience something more serious from the world than a smile at their busy credulity.

Another important consideration arising out of the hypotheses as to the nature of insanity, is the question of its curability. Dr. Winslow very happily shows the importance of a sound theory in this respect. He remarks:

"No right estimate can be entertained of the importance of these investigations unless we apply to the study of the diseases of the brain, and the cure of its disorders, the same enlarged and general principles which guide us in the investigation and treatment of the affections of other organic structures. An error of some magnitude has been committed by those who consider insanity to be a special, uniform, specific, and peculiar malady, justifying us in placing those so afflicted out of the ordinary nosological scale and sphere of medical practice. Again, it is necessary that we should, before being able to appreciate the effect of medical treatment, entertain just and enlightened views as to the CURABILITY OF INSANITY. I now speak from a somewhat enlarged experience, from much anxious consideration of the matter, and I have no hesitation in affirming that, if brought within the sphere of medical treatment in the earlier stages, or even within a few months of the attack, insanity, unless the result of severe physical injury to the head, or connected with a peculiar conformation of chest and cranium, and an hereditary diathesis, is as easily curable as any other form of bodily disease

for the treatment of which we apply the resources of our art. Can there be a more lamentable error, or a more dangerous, false, or unhappy doctrine than that urged by those who maintain that the disordered affections of the mind are not amenable to the recognised principles of medical science? . . . . The existence of so vast an amount of incurable insanity within the wards of our national and private asylums, is a fact pregnant with important truths. In the history of these unhappy persons-these lost and ruined minds—we read, in many cases, recorded the sad, melancholy, and lamentable results of either a total neglect of all efficient curative treatment at a period when it might have arrested the onward advance of the cerebral mischief, and maintained reason upon her seat; or of the use of injudicious and unjustifiable measures of treatment under mistaken notions of the nature and pathology of the disease. My experience irresistibly leads to the conclusion that we have often in our power the means of curing insanity, even after it has been of some years' duration, if we obtain a thorough appreciation of the physical and mental aspects of the case, and perseveringly and continuously apply remedial measures for its removal." (pp. 59-61.)

It has alrea ly been abundantly proved how much may be done in cases of congenital idiotcy, hitherto considered to be hopelessly incurable; in analogous cases of so-called incurable cases of insanity, it will sooner or later be shown (we feel confident) that the resources of the medical art have been under-estimated.

It being considered to be an established proposition, that insanity is nothing else than a cerebral disease, we have to inquire what is its nature and seat? Every man who has reflected on the phenomena of his own mind-not as a metaphysician only, but as an observing physiologist-must have noted daily what a varied number of physical or corporeal influences change the action of his mind. As to some of the changes thus induced, he can clearly see, also, that if they were more intense and more prolonged-that is to say, different only in extent and duration, they would constitute insanity. But they are evanescent, enduring only for the shortest period, and quickly ending in normal, healthy activity of the cerebrum. Some forms of insanity are, indeed, nothing else than transient, momentary states of this kind prolonged during a sufficiently lengthened period, so as to influence the actions of the individual to a degree which renders him no longer a free and responsible agent. Such attacks are, however, so evanescent, that it is obvious no important change in the material organ has occurred. Not so, however, with the persistent forms. As to these, we think Dr. Winslow's views are reasonable, and in accordance with experience. He believes them

"To be the result of a specific morbid action of the hemispherical ganglia, ranging from irritation, passive and active congestion, up to positive and unmistakeable inflammatory action. This state of the brain may be confined to one or two of the six layers composing the hemispherical ganglia; but all the layers are generally more or less implicated, in conjunction with the tubular fibres passing from the hemispheres through the vesicular neurine. This specific inflammation, from its incipient to the more advanced stage, is often associated with great vital and nervous depression." (p. 61.)

Conjoined with this condition of the hemispherical ganglia, there may be general congestion or inflammatory action of the brain or its membranes; all those manifest structural changes in these tissues found after death, are, without exception, in Dr. Winslow's opinion, "the results or sequela of that specific inflammatory condition of the hemispherical ganglia" which he indicates. That this is true of a very large proportion of cases will be generally allowed. There are some forms of insanity, however, which can hardly be classed with them-namely, those in which there are simply fixed erroneous ideas. We have in the "electro-biologized" a transient, in fanatics and enthusiasts a permanent, form of this kind of cerebral change. In these, it would appear, as if the usual healthy action of the cerebrum quoad the erroneous ideas, had been just so much changed as to fix them in such a way, that whenever the succession of ideas passing through the mind brought these within the chain, they were presented to the consciousness, and not the ideas which would normally have risen, had the cerebral tissue been free to act. It is apparent that a very minute pathological change in the cerebrum need only be assumed in these cases of fixed ideas, and this being granted, it would be difficult to assign it to inflammatory action, or even congestion.

The principles of medical treatment laid down by Dr. Winslow, flow from the pathological premises. There is no uniform method of treatment. In proportion as the

symptoms approach to those of phrenitis or meningitis, in other words, in proportion as they indicate active inflammatory action, general and local blood-letting is advisable. Local bleeding is not to be confined to the seat of the disease, for it not unfrequently happens that it may be adopted with reference to a distant viscus. Leeches to the vulva and thighs are beneficial in cases concurrent with the menstrual period; to the sphincter ani, in those obviously connected with suppressed hæmorrhoids. In some instances Dr. Winslow has applied leeches to the Schneiderian membrane, particularly in those cases occurring in early life, and in persons of plethoric constitution and of sanguine temperament. He has known illusions of hearing or of vision which had embittered the patient's life, removed by leeching behind the ears, or over the superciliary ridges. Dr. Winslow also speaks in warm terms as to the great utility, in acute mania, of prolonged hot baths, according to the method of Dr. Brierre de Boismont, of Paris. The patients remain from eight to fifteen hours in warm baths, at 82° to 86° Fahr., whilst a current of water at 60° is continually poured over the head. The method is inadmissible in intermittent mania, and in insanity beginning with great mental derangement, or associated with epilepsy or general paralysis.

The class of sedatives, or in other words agents, modifying directly the condition of the cerebral tissue, constitute very valuable remedies. In recent acute cases they are generally admissible; it is in the various chronic forms of melancholia they are most useful. Dr. Winslow observes,

"In suicidal insanity, when local cerebral congestion is absent, and the general health and secretions are in good condition, the meconite and hydrochlorate of morphia often act like a charm, if uninterruptedly and perseveringly given until the nervous system is completely under their influence. I could cite the particulars of numerous cases of this form of insanity radically cured by the occasional local abstraction of blood from the head, the administration of alteratives, the warm bath, and sedatives. In the exhibition of this powerful curative agent, our success will often depend upon a ready adaptation of the form of sedative to the description of case in which it may be deemed admissible, and a judicious admixture of various kinds of sedatives. I do not think we pay sufficient attention to this fact. I have often seen an apparently incurable and unmanageable case yield to a combination of sedatives, which had resisted the operation of any one or two when given separately." (p. 75.)

Dr. Winslow specifies the sedatives, and the combinations with other remedial agents, which he has found useful in certain forms of insanity.

We pass over numerous practical remarks, to note specially endermic medication in insanity-a plan offering numerous advantages, but little practised. Dr. Winslow states on this point:

"In some chronic forms of insanity, in dementia, and persistent monomania, connected, as it was supposed, with morbid thickening of the dura mater, and with interstitial infiltration of the membrane, as well as with exudations upon its surface, I have occasionally had the head shaved, and have perseveringly rubbed over the scalp a strong ointment of the iodide of potassium combined with strychnine. In other instances I have kept the head painted with the mixture of iodine. I have seen marked benefit from this mode of treatment. When the mental symptoms are supposed to be associated with effusions of serum, I have ordered the iodine to be applied externally, at the same time exhibiting minute doses of calomel, or mercury-with-chalk, to slightly affect the system: this, conjoined with occcasional tonics, diuretics, and stimuli to support the vital powers, is occasionally productive of considerable benefit, in cases apparently placed quite beyond the reach of improvement or cure." (p. 78.)

We have seen a solution of iodide of potassium constantly applied to the shaven scalp followed by improvement in the mental state. A cap lined with gutta percha muslin suffices to keep the scalp constantly moist. Cases of dementia, the consequence of strumous irritation or inflammatory action, are those in which endermic medication will yield the most satisfactory results.

Dr. Winslow concludes this lecture with some important remarks on the serious consequences which are resulting from the idea, that insanity is not amenable to medical

treatment.

"We see it," he observes, "influencing the conduct of county magistrates in the architec

A full account of this method may be found in the third number of the Journal of Psychological Medicine.

tural proportions, medical organization, and general arrangements of our great national asylums. We also perceive the consequences of the error operating in many of the private institutions for the treatment of the insane, thereby degrading them into places of detention, instead of conferring upon them the character of HOSPITALS FOR THE CURE OF THE INSANE.” (p. 80, 81.)

These remarks are apposite. It is very true, and a subject of very great congratulation that a manifest improvement in the treatment of the insane has been effected of late years. It cannot be denied, however, that there is a well-grounded fear that in the large asylums the curative treatment may degenerate into a simple hygienic plan. They are so under-officered, that the medical attendant cannot, from sheer impossibility (having only twenty-four hours in the day), give that minute attention to each individual case, which is often most essential to successful treatment. Then, again, it is necessary to the satisfactory management of these large establishments, that a system of government be strictly carried out; the inevitable tendency of this is to degenerate into routine, and routine practice (as is well known) is an insuperable bar to progress. If we add to these considerations another of not less importance-namely, the temptation to meet the wishes of economical magistrates and rate-payers, by making the labour of the inmates productive, we have sufficient grounds for expressing the opinion, that it is a great and good service to recal the practitioner's attention to the fundamental fact, that insanity is a disease of a viscus, and, like other diseases of the viscera, is amenable to medicinal agents.

The third lecture, "on Medico-Legal Evidence in cases of Insanity," comprises a practical statement of the cases in which medical evidence is required in courts of law; an examination of the legal dicta of the judges delegated by Parliament in 1843 to decide upon some fixed propositions as to the conditions under which a person is legally irresponsible, both theoretically and in relation to cases on record; and an analysis of the various terms used in courts. Dr. Winslow also gives practical instructions to the medical witness as to his conduct when giving evidence, and as to the manoeuvres of counsel, illustrations being drawn from his own experience. All these are of importance to be known; this lecture should therefore be carefully perused by every practitioner who is about to occupy, before a commission of lunacy or elsewhere, the position of a witness. The "safe rule" referred to in the subjoined paragraph is, we think, correctly characterized as the only safe rule; it is certainly the conclusion at which we arrived long ago, after a careful consideration of the question.

Having, I think, conclusively established that we have no uniform legal or medical test of insanity to which we can safely appeal in criminal cases, you will ask, have I any psychological criteria to suggest for the safe guidance of the profession?-can I propound any principles which will assist the medico-legal witness in arriving at a satisfactory result? In reply to these interrogatories, I allow that we have no infallible standard, no certain principles which would admit of general and indiscriminate application. The only safe rule upon which we can act, is that of comparing the mind of the alleged lunatic, at the period of his suspected insanity, with its prior natural and healthy manifestations; to consider the intellect in relation to itself, and to no artificial à priori test." (pp. 153, 154.)

Dr. Winslow quotes Dr. Combe's opinion to the same effect. We would suggest a further step in the inquiry-namely, to investigate how far the abnormal mental phenomena depend upon cerebral disease; for it is this which constitutes insanity; the morbid mental phenomena being only symptoms. This process will separate those cases in which the irregular mental action is congenital, but normal as to the individual, from those in which it is induced and abnormal as to the individual. In the former case, we have to investigate idiotcy, imbecility, or eccentricity; and these may be considered as removed from the domain of technical inquiry, to that of mere common sense, in which witnesses, counsel, judge, and jury are all equal.

Dr. Winslow finally calls attention to the important relations between the criminal and the insane mind, and, in illustration, quotes a remarkable table from No. 163 of the 'Quarterly Review.' It was not drawn up for the use to which Dr. Winslow applies it -namely, to establish "the painful fact, that there is in existence a large amount of crime connected by hereditary predisposition and descent with diseased mind." These

unfortunately constituted persons occupy, as to their mental state, a sort of neutral position between soundness and unsoundness of mind; not legally or medically insane, but yet weak in self-control from an over-mastering organization. To these, as well as to the legally insane, Dr. Winslow argues, some mercy should be shown, and in this opinion, all who are practically acquainted with the subject, will fully and approvingly concur. So important a step in legislation, however, can only be taken when public opinion is more enlightened, and when the profession itself is so much better informed in cerebral physiology as to gain the confidence of, and so guide, the bench and the bar.

T. Laycock.

REVIEW III.

Traité des Maladies du Sein et de la Région Mammaire. Par A. VELPEAU, Membre de l'Institut, &c.-Paris, 1854. pp. 717.

A Treatise of the Diseases of the Breast and of the Mammary Region. By A. VELPEAU, &c.

We are informed by the renowned Professor of La Charité, that this voluminous monograph is composed of materials collected during a public and private practice of thirty years. Nearly two thousand cases constitute its basis. From an experience of this magnitude we might be led to expect a considerable amount of novelty; and how these expectations are realized it will be the object of the following analysis of the work before us to exhibit.

The author disposes of the anatomical and physiological conditions of the mammary gland in less than twenty-one lines.

He arranges the affections of the mammary gland of the female in two principal categories.

"1. The diseases of benign nature, inflammatory and not inflammatory.

"2. The diseases of a malignant nature or cancerous."

Those of the first class are thus defined:

"By benign diseases I mean those which, left to themselves, do not fatally menace life, or of which cure is the natural termination. I divide this class into two groups, one of the different kinds of inflammation, the other of those diseases which, from the first, or in their course, are foreign to inflammatory action." (p. 2.)

The first chapter is devoted to the subject of the inflammatory diseases of the breast, and comprehends excoriations, fissures, eczema, various forms of erysipelas, congestion of the gland tissue with milk, and all the varieties of phlegmon. Of these various diseases, some attack the nipple or the areola, whilst others are confined to the lactiferous ducts. Many originate either in the gland alone, or in the cellulo-adipose tissue.

The first section of this chapter is devoted to the eczematous affections of the nipple and areola, to excoriations and fissures or chaps of the nipple, and to inflammation and abscess of these important parts of the organ.

The second section treats of inflammation of the breast, properly so called, of which the subjoined table represents certain divisions.