ing a person who only watches him for a few minutes to believe that he is in the presence of a case of acute mania; but if the case is watched for a few hours or days, the deception becomes apparent. No muscular endurance, and no tenacity of purpose, will enable a sane man to keep up the resemblance of acute mania: nature soon becomes exhausted, and the would-be patient rests, and at length sleeps. The constant agitation, accompanied by symptoms of febrile disturbance, by rapid pulse, foul tongue, dry and harsh, or pallid, clammy skin, and the long-continued sleeplessness of acute mania, cannot be successfully imitated. The state of the skin alone will frequently be enough to unmask the pretender. If this is found to be healthy in feeling, and sweating from the exertion of voluntary excitement and effort, it will afford good grounds for suspicion. If after this the patient is found to sleep soundly and composedly, there will be little doubt that the suspicion is correct. Chronic mania may be imitated, and if this should be done by an accurate observer of its phenomena, who also happens to be an excellent mimic, it cannot be denied that the imitation may deceive the most skilful alienist. It is remarkable that two of the most perfect pictures of insanity presented to us in the plays of Shakspeare, are instances of feigned madness-namely, the madness of Hamlet, assumed to escape the machinations of his uncle; and that of Edgar, in Lear, assumed to escape the persecutions of his brother. These consummate representations of the phenomena of insanity are so perfect, that in their perusal we are insensibly led to forget they are feigned. In both instances, however, the deception was practised by educated gentlemen; and on the authority of the great dramatic psychologist, it may perhaps be accepted that the phenomena of insanity may be feigned by a skilful actor like Hamlet, so perfectly that no flaw can be detected in the representation. Fortunately for the credit of psychologists, insanity is rarely feigned except by ignorant and vulgar persons, who are quite unable to construct and to act out a consistent system of disordered mind. It must be remembered that all the functions of every case of insanity form a consistent whole, which it requires as much intelligence to conceive and represent, as it does to conceive and represent any dramatic character." (p. 336.)

Some remarks of Dr. Snell on this subject are quoted. He observes:

"Common people have not the slightest rational idea of insanity. They believe that all mental manifestations are completely altered in it, and that an insane person knows nothing— he ceases to read, to write, and to reckon, and that all his conditions and relations are completely reversed. Hence it happens that all uninformed people find it difficult to acknowledge actual insanity."

But it is not only "common," "uninformed," and "uneducated" people who find it difficult to recognise and acknowledge actual insanity. Some, in consequence of prepossessions of which they cannot divest themselves, are unable to understand how a person can be insane who talks rationally upon any subject; others are willing to give such latitude to eccentricity, to extreme religious opinions, belief, and practices, and to what are called the liberties of the subject-in more senses than one-that it is impossible to convince them that certain faculties of the mind may be disturbed, and insanity exist, while other faculties maintain their normal condition, and the patient is enabled to conduct himself with propriety, and to manifest great intelligence and reasoning power. The well-educated and well-informed classes fall into the same error, and it is shared by a large number of medical men of experience in other departments of medicine, who have comparatively little opportunity to study the subject of mental disease. There are also many who are as unwilling as others are unable to recognise in the persons of their relatives a malady whose existence may have an important bearing upon their own future. And again, it is not probable that, as a rule, insane persons would acknowledge that they were unable to take care of themselves, although there are many exceptions to this rule. The consequence of all this is, that many cases are allowed to become confirmed; the opportunity to arrest the disease, which perhaps only occurs in the early stage, is lost in discussing doubts and scruples, and in determining the true nature of the case; and then come the unavailing regrets that no efficient steps were taken to save the unfortunate sufferer when there was yet a chance of restoring his reason. The idea of controlling the actions and conduct of another, however unreasonable, is often thought so grave a matter that patients who are only suffering from the premonitory symptoms of insanity-which are not recognised as such-are allowed to dissipate their property and ruin their families before any check is interposed to save

them from the effects of their own helplessness. In ordinary illness, or in cases of injury from accident, we at once adopt proper treatment and restrictions, if need be; why should disease of that exquisitely delicate organ, the brain, be allowed to make fatal progress before we resort to any treatment worthy of the name? To be of any value it must be prompt, discreet, and resolute. There is no class of cases which so much requires that the authority of the physician should be supported by the friends of the patient, who should yield him implicit confidence and submit absolutely to his judgment. A firm front being at once presented to the disease, saves a great deal of irritation, and improves the chances of cure.

One of the principal divisions or chapters of the work before us is devoted to the pathology of insanity. The authors object to the distinction between organic diseases and those which are functional, on the ground that the further we advance in our knowledge of pathology, the more we discover changes which were previously not suspected to exist:

"For example, fatty degeneration of the heart and epithelial desquamation of the uriniferous ducts are structural diseases to us; a short time ago their phenomena were regarded as functional. Facts of this kind would of themselves be sufficient to create distrust in the theory of functional disease; but many accomplished physicians still maintain that abnormal vital phenomena may be, and are likely to be, occasioned by dynamic aberrations alone, and that such phenomena are correctly designated as functional disease. We cannot concur in this opinion. . . What is called force of every description is connected with, if not dependent on, changes in the atoms of matter. Force is the hypothetic agent which underlies the phenomena of material change; and to affirm that dynamic modifications of vital functions may exist without alterations of material organization, is to ignore the fundamental principles of philosophic physiology. All disease, therefore, in our opinion, is organic. Not only is this so with diseases which come under the common observation of the physician, without leaving traces of organic change-asthma, for instance, and angina and epilepsy-but mental and nervous diseases also of every kind and form. Not a thrill of sensation can occur-not a flashing thought or a passing feeling can take place-without changes in the living organism; much less can diseased sensation, thought, or feeling occur without such changes-changes which we are not able to detect, and which we may never be able to demonstrate, but which we are nevertheless certain of. For, whether we adopt the theory that the states and things which we call heat, electricity, vitality, &c., are distinct entities of what is called imponderable matter, or the far more probable theory, that they are only phenomena belonging to ordinary ponderable matter; an atom or a cell charged with electricity or heat, or in a state of chemical activity, is essentially in a different condition to a cell or an atom in chemical or electrical equilibrium with surrounding substances. On the lowest view of organic action, therefore, alterations of what are called dynamic force cannot exist without corresponding changes in material condition. If it is possible to suppose that the cells of a living structure in a state of disease can only differ from the cells of the same structure in a state of health by an alteration in their electric states, this will in itself constitute a material difference, capable of being readjusted by appropriate remedies. But there is no ground whatever for supposing that vital force and electrical force are the same, or that anomalous action of living bodies ever depends upon the mere distribution or activity of such force. The only force capable of explaining any of the phenomena of life is the chemical one, and this only in a state of constant activity and interminable change. In a state of health such change takes place within a range whose limits permit beneficial, and restrict injurious, action; in a state of disease the range of chemical change is widened or contracted, so that mischief results from excess of action, or the well-being of the organism is lost by deficient action. In either case the chemical composition of the cells cannot fail to be altered from the standard of health, and alteration of chemical composition is the real groundwork of organic disease, since it invariably interrupts the healthy portion of the part affected. Those abnormal states which depend upon an altered condition of the blood are not less strictly organic than all other diseases; for not only can no change take place in the composition of the blood without in some degree affecting all the parts which are nourished thereby, but this fluid is, strictly speaking, itself a living cellular organism, and every change which takes place therein is organic. It may seem superfluous that, after having expressed our opinion that the noblest functions of the healthy nervous system are invariably accompanied by organic changes therein, we should argue that such changes must exist when the functions are performed abnormally. It is true that the greater proposition, that function is always accompanied by organic change, includes the lesser proposition, that diseased function is so accompanied; but the latter has a difficulty to

contend with from which the former proposition is free-it has to oppose and subvert a longestablished erroneous theory."

Our space will not permit of our going into any discussion upon the various points raised in connexion with the pathology of insanity, but this part of the subject is very ably treated, and will abundantly repay attentive study. The author observes upon the remarkable fact, that serious diseases of vital organs will make fatal progress without manifesting the ordinary signs observed in sane persons suffering from similar maladies, and this fact suggests the necessity of a careful examination of all the important organs in insane persons of impaired health, even where there are no symptoms indicating particular disease.

In a discussion on the treatment of insanity, which forms the concluding chapter, the value of the various remedies which have at different times found special favour is considered. Tartrate of antimony and opium maintain their reputation as the most important, and the precautions and conditions to be observed in their employment are carefully pointed out. Of not less importance than the medical is the moral treatment of insanity, and on this subject Dr. Bucknill makes some very sound remarks. He says:

"In works which treat upon the moral treatment of insanity, it has been customary to prescribe rules for the guidance of the demeanour and behaviour towards the insane. From the excess of firmness which is demanded by some, one would think it needful that an alienist physician should have 'an eye like Mars, to threaten and command;' as if his chief functions were not unlike those of the worthy Mr. Van Amburgh. The universal gentleness and indulgence which others advocate would lead to an opposite extreme scarcely less adverse to the true interests of the patients. The truth, as usual, lies between; and the physician who aims at success in the moral treatment of the insane, must be ready to be all things to all men, if by any means he might save some.' He must, nevertheless, have a good backbone to his character, a strong will of his own, and with all his inflictions be able to adhere, with singleness of purpose and tenacious veracity, to the opinions he has, on sound and sufficient reasons, formed of his patient, and the treatment needful to be pursued towards him. With selfreliance for a foundation to his character, it requires widely different manifestation to repress excitement, to stimulate inertia, to check the vicious, to comfort the depressed, to direct the erring, to support the weak, to supplant every variety of erroneous opinion, to resist every kind of perverted feeling, and to check every form of pernicious conduct."

The work concludes with an appendix of cases, and is illustrated by a series of portraits of the different types of insanity, of great interest. We commend it to our readers in the full assurance that they will derive pleasure and profit from its attentive perusal, and that it will prove to them a sound and safe guide through some of the greatest difficulties which beset our path when our advice is sought, and we are called upon to deal with the most severe affliction which can befall the family of man.

REVIEW VI.

Clinical Lectures on the Principles and Practice of Medicine. By JOHN HUGHES BENNETT, M.D., F.R.S.E., Professor of the Institutes of Medicine, and Senior Professor of Clinical Medicine, in the University of Edinburgh, &c. &c. Second Edition, with 468 Wood-cuts.-Edinburgh, 1858. pp. 951.

EVERY member of our profession must admit that in these modern days a new spirit has come over the face of medicine; that a great change, a positive revolu tion, has been passing into the practice of the art. If we look into the sanctu aries of our knowledge-into the classical authorities of the day-we find therein

a strange want of accord between the theory of disease which is expounded and the practice which is enforced. The practice is for the most part novel-the practice of to-day; the theory is still impregnated with the dust of dogmatic and traditional authority, and still leavens the practice, and hampers and clogs its progress to a better state.

When we seek for the cause which has brought about these changes, we find it in the advancements made in Pathology, Diagnosis, and Clinical Medicine. The modern study of medicine has forced us to conclusions which are diametrically opposed, in many important particulars, to the doctrines of our early days; it has enabled us to strip experience of that false covering which has so long obscured the truth; to separate a true from a false experience, and a true theory from a false theory. Who can honestly search into the history of medicine and not confess that this vaunted experience has been as pregnant a source of error as ever theory has been, in misguiding the healing hand of the physician? The reason why this is so is obvious enough. The facts about which experience is exercised are most difficult of right appreciation. Disease is not a simple, but a very long and complicated process, and of this process we can seize only a few, and it may be the last, links in the series of antecedents and sequents which form it; and thus it is that we are apt to mark down as the effects of our remedies, results which have no relation to them. The fact observed may be true; but the consequence deduced from it is erroneous. The error consists in ascribing it to some especial antecedent to which in reality it has no reference. And thus has arisen that overwhelming mistake which has for so many ages obscured, and which still so fatally obscures, the practice of medicine-viz., that we arrogate to ourselves and ascribe to the power of our art, much of what belongs alone to the curative beneficent force of Nature.

What, then, is to rescue medicine from these errors, and give to it a firm and permanent basis? We answer unhesitatingly, a proper appreciation of the value of the facts which modern science has placed at our disposal. By these facts alone can we arrive at a true experience. We must have the courage to cast aside the false goddess which men have so vainly worshipped, and which they still so fondly cling to. We must abide by that true knowledge which is the offspring of an honest scepticism and a rational faith, enlightened by science. It is cruel and humiliating to the pride of Medicine to acknowledge that from the days of Hippocrates to our own it has put its faith in, and has practised the most grievous errors; but the cruelty and humiliation must be submitted to if truth demand the sacrifice. Tradition and the great authorities of other days are to be highly respected, but they must not be permitted to outweigh the facts which the discoveries of this day have brought to light. With all due deference to the men of old, we cannot close our eyes to their shortcomings, where our clearer vision shows us that they were wrong.

The

What constitutes a sane theory and a sane experience in medicine? answer to this question is of every importance. A true theory is a conclusion which may be logically deduced from a consideration of scientific facts, which is founded on scientific facts, and is in none of its parts contradicted by them. A true experience in medicine is that which is the resultant of the observation of numerous fitting inquirers, who, after due investigation, arrive each at a like conclusion-the conclusion not being .contradicted by the observation of other equally capable observers.

By some such tests as these, it seems to us that we can alone arrive at a right appreciation of the meaning of theory and practice in medicine. The practice of our art is empirical; it is not guided by the rules of pure mathematical science. We can predicate nothing à priori of the effects of a remedy, and can only judge. thereof by the observation of what follows its administration. But, as we have seen, a right judgment in this matter is most difficult; and what has been the bane of past generations, and what is the bane of our own generation, is the drawing of firm convictions and hasty conclusions from the results of a too narrow

observation. The wide and uncontradicted assertion of a fact alone gives it the stamp of genuine value. Let us consider this by reference to a few examples. Is it not certain that there is somewhere a fallacy in the conclusion that mercury is the proper remedy for secondary syphilis, when we find that half the profession administer mercury for it, and half the profession regard salivation as a positive poison in this disease? Must not there be something wrong either in the observation which teaches us that without salivation there can be no hopeful cure for pericarditis, or in the observation which demonstrates that salivation so used is a very hurtful application? Can their observation be received as true who tell us that quinine infallibly cuts short continued fever, so long as the observation of others contradicts the assertion? We must assuredly act contrary to all rules of reason if we accept as a true cure any method of treatment which does not bear the test of experience, as above enjoined. Wherever serious discordance of opinion reigns concerning the influence of a remedy over disease, we may be sure that its real effect has yet to be proved. We admit, as an established fact, the influence of quinine over ague, of hydriodate of potass over periostitis, of the salts of potass over acute rheumatism, because there is no dissonance of opinion respecting the influence of the remedies over these diseases; and consequently facts thus obtained are the result of a true experience.

It may be, perhaps, a heavy trial for us to confess how many there are of our daily practical applications which will fail to bear this test of their real virtue; but until we draw a clear line of distinction between what is positively true and what is merely hypothetical in practice, we can never attain to a rational treatment of disease. Happy for us that we have begun at last to know our own ignorance, to learn the limits of our knowledge, and the extent of our powers. Science has given us at last something like a firm rock to rest our steps upon. Our knowledge may be very defective, but we now know that, as far as it goes, it is sure. We see how far we may reasonably trust it as a guide in the treatment of disease. The line between that which is demonstrated, and that which is hypothetical, is clearly and well defined. We may, indeed, have made but small advances towards a positive treatment of disease, through the light of this pathology; but in one sense the progress of our art is admirable. It is something, at all events, to have knocked away the props of ignorance and prejudice which have sustained the errors of old medicine. We have begun to ascertain the limits of our powers as curers of diseases-to learn what our art can and what it cannot do. We cease to arrogate to ourselves those kind offices which Nature, not our art, performs. These things our forefathers knew not, and could not have known, for the means of knowledge which has led us to these better things were closed to them. They thought that through their remedies they had a power over, and could control and destroy, diseases after a fashion which we know is impossible. We have learnt to guide the patient gently-tute et jucunde-to his cure through the via mala of disease. If we have gained nothing more than the being rid of the vicious theories which have hitherto directed, and of course viciously directed, the hand of the practitioner to his work, our gain is immense. Error was an essential and necessary associate of the practice of former days. It is not so now: our errors are voluntary errors, for which we are responsible. We can mark where our positive knowledge ends, and can estimate at their proper value the theories and the practices which we follow out in curing diseases. It is just this very knowledge of its falli bility-this philosophic estimate of its actual powers over disease-which distin guishes rational medicine from barren empiricism.

These are facts the truth of which has long been tacitly admitted by some of the philosophic minds of our profession, and which have now for the first time in Great Britain found a fitting exponent in Professor Bennett. Facts, and arguments in a consequent form, and data, were wanting to establish this new faith on an indispu table basis, to inaugurate this new practice. These facts and arguments are here supplied by Dr. Bennett in his 'Principles and Practice of Medicine.'

The appearance of this volume marks the period of a new epoch in the history of