invariable symptoms or characters which it is the business of a medical witness to display, in evidence, and of a medico-legal writer to describe. But a perusal of the evidence given at a few trials will surely satisfy those who entertain this notion, that each case must stand by itself. It is easy to classify homicidal lunatics, and say that in one instance the murderous act was committed from a motive-i. e. revenge or jealousy; in a second, from no motive but from irresistible impulse; in a third, from illusion or a delusive motive-i. e. mental delusion; in a fourth, from perverted moral feeling. This classification probably comprises all the varieties of homicidal insanity; but it does not help us to ascertain in a doubtful case, whether the act was or was not committed under any of these psychological conditions. It will enable us to classify those who are acquitted on the ground of insanity, but it entirely fails in giving us the power to distinguish the sane from the insane criminal.

"According to M. Esquirol, whose views, more or less modified, are adopted by all other writers on the medical jurisprudence of insanity, the facts hitherto observed indicate three degrees of homicidal monomania.

"1. In the first, the propensity to kill is connected with absurd motives or actual delusion. The individual would be at once pronounced insane by everybody. Cases of this description are not uncommon, and they create no difficulty whatever. The accused are rarely allowed even to plead to the charge.

"2. In the second class, the desire to kill is connected with no known motive. It is difficult to suppose that the individual had any real or imaginary motive for the deed. He appears to be led on by a blind impulse which he resists and ultimately overcomes. (Case by Mr. Daniell, antè, p. 670.)

"3. In the third class, the impulse to kill is sudden, instantaneous, unreflecting, and uncontrollable (plus forte que la volonté). The act of homicide is perpetrated without interest, without motive, and often on individuals who are most fondly loved by the perpetrator. (Maladies Mentales, ii. 834.)

"These three forms differ from each other only in degree;-the two first being strongly analogous to, but lighter modifications of the third. All the cases which came before M. Esquirol had three characters in common. An irritable constitution, great excitability, singularity, or eccentricity of character: and previously to the manifestation of the propensity, there was a gentle, kind, and affectionate disposition. As in other forms of insanity, there was some well-marked change of character in the mode of life. The period at which the disorder commenced and terminated could be easily defined, and the malady could be almost always referred to some moral or physical cause. In two cases it was traced to the result of puberty, and in four to the power of imitation. Attempts at suicide preceded or followed the attack: all wished to die, and some desired to be put to death like criminals. In none of the cases was there any motive for the act of homicide.

"M. Esquirol believes that there are well-marked distinctions between this state and that of the sane criminal. Among these he enumerates, 1st, the want of accomplices in homicidal monomania. 2d. The criminal has always a motive-the act of murder is only a means for gratifying some other more or less criminal passion; and it is almost always accompanied by some other wrongful act. The contrary exists in homicidal monomania. 3d. The victims of the criminal are those who oppose his desires or his wishes:-the victims of the monomaniac are among those who are either indifferent, or are the most dear to him. 4th. The criminal endeavours to conceal, and if taken, denies, the crime; if he confesses it, it is only with some reservation and when circumstances are too strong against him; but he commonly denies it to the last moment. It is the reverse with the monomaniac." (pp. 673-4.)

This section has also, we observe, an addition to it "on the Civil and Criminal Responsibility of the Deaf and Dumb."

ART. XV.

The Practice of Surgery. By JAMES MILLER, F.R.S.E., Professor of Surgery in the University of Edinburgh, Surgeon to the Royal Infirmary, &c. &c.-Edinburgh, 1846. 8vo. pp. 680.

We had occasion in a former Number of this Journal (April, 1845) to speak in deservedly high terms of Professor Miller's work on the Principles of Surgery, and we are happy to be able to pronounce an equally favorable judgment on the manner in which the present volume is executed.

The same reason which prevented our undertaking to give anything like a complete review of the preceding work, namely the extent of the field embraced by it, must be our plea for contenting ourselves with selecting portions here and there, as specimens of the manner in which the author has performed his task, rather than attempting a condensed survey of the whole.

The author has chosen the division of the body into regions as the groundwork of his arrangement, commencing with the injuries and diseases to which the head is liable, and passing successively to those of other parts of the body. This order is perhaps the most convenient. The objections that may fairly be made to it, viz. that analogous affections, such, for instance, as fractures and dislocations of the upper and lower extremities, are unduly separated from each other, will have less weight when we remember that the general principles of treatment have formed the subject of a preceding volume, and that the practical application of those general principles is alone the object of the present.

The chapters devoted to injuries of the head and brain, and to diseases of the eye, furnish a good epitome of the present state of practice in these important parts of surgery; that on diseases of the scalp is derived chiefly from Mr. Erichsen's excellent treatise. The chapter on affections of the neck is carefully and judiciously written. The following are the author's conclusions respecting the diseases in which bronchotomy or tracheotomy should be employed:

Bronchotomy, then, is available in the following cases: 1. In the case of foreign bodies lodged in the air passages. Extrusion, independently of this operation, is and ought to be the exception to the general rule. 2. In suspended animation; when we cannot otherwise effect with certainty artificial inflation of the lungs. 3. In spasm of the glottis. Threatened asphyxia from external injury may depend on this causee-perhaps on a precisely opposite condition; in either case the operation is imperatively demanded to save life. There is the same necessity in the spasmodic occlusion of the glottis which attends poisoning by carbonic acid. In laryngismus stridulus we withhold the operation if possible, and trust to general treatment; yet we are aware that urgent circumstances may arise to demand the tracheal wound, at least with the hope of palliation, and perhaps with the hope of affording time for the effectual working of other remedies. 4. In ædema glottidis, chronic or acute, there is no safety but by operation, as soon as the symptoms have become at all urgent. And in the acute cases there is the best hope of speedy discontinuance of the tube, closure of the aperture, and complete restoration of normal respiration. 5. In laryngitis fibrinosa, the operation is as warrantable as in urgent oedema, when the disease is limited to the larynx. But in the great

majority of cases of true croup, in which the whole windpipe with its ramifications is involved, operation is surely to be regarded as a rare exception to the general rule of non-interference; in the early stage it is inexpedient, while mechanical obstruction to respiration is not yet threatened; in the more advanced period it is ineffectual-failing to fulfil the objects of its performance. 6. In purulent laryngitis there is the same necessity for operation and the same good prospect as to its result as in acute oedema. 7. In chronic laryngitis, with thickening, supervention of oedema, through inflammatory accession, may render the operation indispensable to the preservation of life." 8. In simple ulceration the same event may occur as that just mentioned in connexion with mere thickening of the membrane. Or, independently of the occurrence of such an accidental crisis, the operation may be deemed expedient, to assist the action of other remedial means and by effecting early cicatrization to save structure and function. 9. In ulceration and disease of the cartilage operation is likely to be required to save life from threatened asphyxia, but with little or no prospect of discontinuance of the tube's use. 10. In phthisis laryngea, it may be similarly demanded for a temporary object, scarcely with a hope of contributing to a cure, but rather as a means of protraction and palliation. 11. In pressure on the windpipe, caused by the formation of a tumour or abscess, or by impaction of food or a foreign body in the œsophagus or pharynx, operation may be necessary if the obstruction to respiration cannot be otherwise relieved-namely, by removal of the cause, by evacuation of the matter, extirpation or diminution of the tumour, or extension of the impacted substance. 12. In cut throat, tracheotomy is not unfrequently demanded, imperiously, to save life from impending asphyxia, and it may be expedient, at an early period of the case, to avert all such hazard, and to favour as well as permit entire closure of the wound. 13. In glossitis, in tonsillitis, and in extreme cases of pharyngitis, it is required when swelling is so great, rapid, and uncontrollable as otherwise to render fatal asphyxia all but inevitable. 14. In carotid aneurism of large size, when by circumstances we are precluded from speedy recourse to deligation of the artery, life may be suddenly brought into peril by supervention of the diffuse form on the circumscribed, and consequent compression of the windpipe. Bronchotomy then is essential; and the tube will require to be worn until by deligation of the artery we have effected such diminution of the bulk of the tumour as altogether to free the respiratory canal. Thoracic aneurisms, be it remembered, by compressing the air passages, may stimulate the results of inflammatory disease in the larynx; and in such cases no good can be expected to result from bronchotomy.

"In the great majority of instances tracheotomy is preferable to laryngotomy for obvious reasons.' (p. 270.)

From the respiratory we must make a rapid descent to the urino-genital organs, passing by the intermediate parts and their diseases. On the subject of calculous affections we have a chapter occupying about sixty pages, the first nine of which only are allotted to the description and treatment of urinary deposits. This we consider a somewhat meagre allowance for so important a part of pathology, in which the surgeon is equally interested with the physician; and we think a chapter on the principles might with advantage have been dedicated to the subject. The mode of operating recommended by the author in lithotrity is that of Mr. Liston, the greatest authority in the present day on this subject. The following are the directions given for avoiding urinary infiltration, the most serious and frequent of the evil attendants on lithotomy; these, though not new, cannot be too carefully borne in mind:

"To obviate it the following points are of essential importance: Maintain the reflexion of the ileo-vesical fascia entire, at the base of the prostate, that gland being

not divided throughout its whole extent by the knife, but rather first notched, and then dilated by the finger and forceps. Make the general wound conical in form, the base at the integument of the perineum the truncated apex at the prostate. Make the general wound also sloping in form, its fall being from the prostate obliquely downwards-cutting obliquely up to the bladder, not directly into it; also arranging the patient's trunk in bed so as to favour this sloping form, obviously so well calculated for the ready draining away of the urine. In using the finger in dilatation avoid all laceration, torn parts being but ill disposed for rapid plastic exudation. Retain the tube for the necessary number of hours, and keep it clear from coagulum or other source of obstruction. I have latterly thought it advisable to use a somewhat larger tube than that in general use, in the belief that it is better adapted for preventing urinary infiltration; as, while it affords a more ready exit for that fluid, it compresses the track of the deep wound, and may be supposed to afford a very effectual barrier to entrance of urine into the cellular tissue. Further experience of its use is, however, necessary, to determine whether or not it may do harm by delaying the closure of the wound and exciting inflammation at the neck of the bladder. Further, the risk by infiltration is certainly diminished by not operating unless the urinary organs and general system are free from excitement, the kidney acting healthily, and the urine in a satisfactory condition; and also by maintaining after the operation a supply of urine which is bland as well as copious, mainly aqueous, and containing but a sparing amount of saline matter. For if infiltration do occur to some extent, it will be less hazardous to part and system under such circumstances than if the infiltrated urine were the scanty and acrid urine of fever or of renal disease." (p. 460.)

On the subject of the treatment of aneurism by pressure on the artery above the tumour, the author has the following observations:

"Popliteal aneurism is probably the most common of all external aneurisms; and hitherto the Hunterian application of ligature to the superficial femoral has been the only approved mode of treatment. Latterly, however, as formerly explained, (Principles, p. 457,) the application of pressure instead of the ligature has been proposed. And experience is almost daily giving direct and undoubted testimony to the efficacy of the practice. There are some patients, doubtless, who may prove intolerant of pressure, and there may be others who prefer the apparent certainty of the knife and ligature to the apparent uncertainty and delay of the compressor; but the vast majority of cases are assuredly capable of cure by pressure properly applied, without risk, with but little pain or inconvenience, and without any wearisome amount of privation or confinement. The skin which is to bear the pressure is protected by a layer of thick soap plaister, and that again may be covered by leather. And more than one compressor is used, or at least pressure is made at different parts at different times; so that the burthen of it may not all be thrown on one point, but by being subdivided among several points may be rendered much more tolerable. Using several instruments along the course of the vessel in the thigh, they may be slackened and tightened alternately; or the same instrument may be shifted in its site with a like effect. It is never to be forgotten that all severity of pressure is unnecessary that it is not essential that it should be such as to arrest the arterial flow at the compressed point-that, on the contrary, consolidation of the artery is more likely to take place when a slow, and gentle, and feeding circulation remains. And it is also important to remember that should this mode of treatment fail, it by no means interferes with the subsequent performance of the ordinary operation, but, on the contrary, renders its success all the more probable." (p. 609.)

We had occasion to remark on certain little peculiarities of style in the former volume, which we thought might with advantage be altered. These, if they have not wholly disappeared in the present, appear, we are

bound to say, in a very mitigated form; and we feel no hesitation in recommending Professor Miller's two volumes as affording to the student what the author intended, namely, a complete Text Book of Surgery. Taken altogether, indeed, the work is one of a highly creditable kind, and full of such proofs both of talent and knowledge, as justify us in expecting something of yet higher mark and likelihood from its accomplished author.

ART. XVI.

Leçons sur les Maladies de la Peau, professées à l'Ecole de Médecine de Paris en 1841, 1842, 1843, 1844. Par ALPH. CAZENAVE, Médecin de l'Hôpital Saint Louis, &c. Livraisons I, II, III.-Paris, 1845-6. Lectures on Diseases of the Skin delivered in the College of Medicine at Paris in 1841, 1842, 1843, 1844. Illustrated by coloured plates. By ALPH. CAZENAVE, Physician to the Hospital of Saint Louis, &c. Parts I, II, III.-Paris, 1815-6. Folio.

WE hail with real pleasure the appearance of the work whose title heads this notice, and which is now in course of publication at Paris. The specimens before us are in every way worthy of the distinguished name which M. Cazenave has acquired as a dermatologist, and do honour to the celebrated institution-the Hospital of Saint Louis-to which the author has been attached, in the capacities of student and physician, for more than twenty years. The illustrations are extremely beautiful as works of art, and are faithful transcripts of the diseases which they are intended to represent. We have had an opportunity of comparing some of these plates with the actual cases, in the Hospital, from which they were drawn, and were gratified with the fidelity of the copies.

M. Cazenave proposes to complete his work in twelve Parts, one to appear every other month, and each Part to contain five coloured plates, folio, with about twenty pages of text, at the moderate price of 10s. It is sufficient for the present merely to direct our readers' attention to the work, reserving for a future period, when it shall be complete, a more extended examination of its contents. Before dismissing it, however, we may state briefly the plan the author proposes to follow. M. Cazenave has taught for several years, both at the Ecole de Médecine and at the Hospital of St. Louis, the necessity of viewing the subject of cutaneous pathology in a more philosophical light than has hitherto been done by those who have studied and practised that branch of medicine. It is not sufficient to know the character of an eruption,-to be able to tell whether it belongs to the vesicular, papular, or pustular groups. Although accuracy of diagnosis and a precise nomenclature are elements of the first importance in the study of this class of diseases, still they are not (although the contrary has been too generally believed) the only requisites necessary for forming correct principles of treatment. We must endeavour to disclose the intimate nature of the diseases themselves-as far as they can be ascertained—and thereby arrive at a knowledge of those general laws which regulate their progress and duration. Microscopical anatomy, by giving us more pre