materially the value of the articles, which each occupy nearly one hundred pages.

The article on DISEASES OF THE EAR has received a few additions and emendations from the pen of the late Mr. G. Pilcher, but it cannot be said to represent either the most modern views or practice in this department of surgery.

The experience of the Crimean war has been fully brought to bear by Mr. Blenkins on the old Peninsular article on GUNSHOT WOUNDS, and full reference is made to the various professional writers of that period, and also to the manuscript Jacksonian Essay on the subject, by the late Alfred Poland. The abolition of venesection, the employment of anaesthetics, and the preference for primary over secondary amputations, which were established among army surgeons in 1854-56, have been fully borne out by the experiences of the great American war and the more recent Continental struggles. The records of the American civil war, which are the most elaborate which have ever been published, have, we believe, settled in the affirmative another vexed question, the propriety of closing all chest wounds at once, even if it should subsequently become necessary to open the wound or perform paracentesis for collections of fluid. The Crimean preference for excision over amputation in the case of the upper extremity has likewise been maintained everywhere, but the most modern experience in the Franco-Prussian war has condemned excision of the knee for gunshot injuries, and has not given a more favorable result as regards excision of the head of the femur than was experienced in the Crimean or American wars, when the deaths averaged 90 per cent.

HÆMORRHAGIC DIATHESIS is one of a series of articles on the blood, contributed to the present edition of the 'Dictionary,' by the late Mr. Henry Ancell, of which the editor makes prominent mention in his preface to the first volume. We have selected the article on Hæmorrhagic Diathesis as a specimen of the author, because it is obviously more suited to a surgical dictionary than many others of the series, which embraces such subjects as Cholamia, Hydræmia, Hyperinosis, Hypinosis, Heterochymensis, &c., but we cannot express a high opinion of his labours. The article on Hæmorrhagic Diathesis is founded principally upon a paper by Mr. Lane, published in 1840, and evinces little research or personal experience. The lack of these latter qualities is evident also in the other articles from the same pen, Mr. Ancell having produced a series of extracts from the works of others rather than a well-digested résumé of the matter in hand, supported by his own investigations.

INJURIES OF THE HEAD have been entrusted to Mr. John Adams, who has brought the experience of many years, while

surgeon to the London Hospital, to bear upon this interesting subject. In a chapter on Injuries of the Scalp, which he has added to Cooper's article, Mr. Adams recommends the use of sutures in scalp wounds, and denies that their presence tends to produce erysipelas. His remarks, too, on the general treatment of these cases, and especially the avoidance of exposure to cold winds, are most judicious, and the lessons of long experience. Mr. Adams agrees with Mr. Hewett in believing that Pott exaggerated the frequency and pathological importance of his well-known "puffy tumour" as indicative of suppuration on the dura mater, for it often happens that the scalp has sloughed before matter has formed beneath the calvaria.

Mr. Adams agrees with most modern surgeons in believing that fracture by contre-coup is extremely rare, if, indeed, it ever occurs; and the cases of fracture of the base of the skull resulting from falls on the vertex, which were formerly ascribed to contre-coup, are clearly the results of the direct force applied to the base of the skull by the trunk through the vertebral column, and have nothing in common with the laceration of the brain from indirect violence, which undoubtedly occurs, and, as well pointed out by Hilton, especially at those points where the brain is not furnished with the water-cushion formed by the subarachnoid fluid. The fluid which escapes from the ear or into the pharynx, in cases of fracture of the temporal bone, is undoubtedly, in the majority of cases, cerebro-spinal fluid, though a case has been recorded by Holmes, in the 'Pathological Society's Transactions,' in which the fluid was solely from the internal ear. In the treatment of these cases there has been a reaction from over-active treatment to doing nothing, and we are glad, therefore, to note that Mr. Adams recommends the administration of calomel, so as to affect the system as a prophylactic against the meningitis which comes on but too surely in the majority of these cases if left untreated.

The remarks on concussion of the brain are judicious and to the point, though we should be ourselves inclined to lay more stress than is done on the after-care required by patients who have suffered from concussion of either brain or spinal cord. There are unquestionably remote changes in the nervous centres which can be best avoided by the greatest quietude and absolute rest, and the general prescription to go to the sea-side for a week or two to get strong is much too vague, and not seldom leads to disastrous consequences. As a symptom of compression of the brain, Mr. Adams rightly lays great stress upon paralysis as being most constant. He recommends operative interference when it is present, and gives cases supporting the practice of trephining when no depression of the skull exists, for the evacua

tion of blood or matter. To puncture the brain itself for the evacuation of matter is, doubtless, a bold practice, but one which offers the sole chance of saving a patient's life in some circumstances, and a recent case in St. Bartholomew's Hospital would show it not to be so dangerous as supposed. With the present comparative rarity of trephining the occurrence of hernia cerebri has become almost unknown; but Mr. Adams believes it to be generally connected with an abscess and some disintegration of brain-substance, and recommends shaving off the protruding mass, and the subsequent application of pressure, when, if recovery ensues, he believes an increased quantity of fluid in the ventricle restores the equilibrium of pressure.

Mr. Acton's article on IMPOTENCE is an epitome of the views put forth at greater length in his well-known work on the reproductive organs. His remarks on the moral and medical treatment of the various forms of impotence are worthy of all attention, and on the question of marriage he makes the following suggestive observations:

"The writer's experience is that, as a general rule, there is little need to dissuade those from marrying who ought not to do so. Our task is rather in the other direction-to encourage those nervous hypochondriacal people who labour under the delusion that they are unfit to undertake the rational duties of husbands and fathers."

The elaborate article on INFLAMMATION by Dr. Druitt is one of the most valuable résumés of the entire subject we are acquainted with. In the space of 100 pages Dr. Druitt has been able to display a very profound acquaintance with the literature of his subject, and to discuss all the theories from time to time held by men of authority, while towards the conclusion he has examined the several modes of treatment proposed, giving his own views for and against them. The first section is devoted to a definition of inflammation, which presented great difficulties, and to the question whether inflammation should be regarded as a disease, which Dr. Druitt answers in the affirmative. An analysis of the local and constitutional symptoms of inflammation follows next, and then, in Section 4, we have a general account of the progress and results of inflammation. To this succeeds an exhaustive description of the minute anatomy of inflamed parts, taking the several tissues and membranes in order. The causes of inflammation are discussed at length, which their variety fully justifies, and this section leads naturally to the next equally lengthy one, in which the varieties of inflammation are considered, and a classification is attempted. Lastly, we come to the most interesting portion of the essay, viz. a history of the various theories of inflammation, with the treatment adopted from early days down to the present

time. For this purpose Dr. Druitt has made a rough division of the surgical doctrines of inflammation into seven classes:

"The first is that of ancient surgery, more particularly as represented by Galen, whose doctrines, classification, and very words were copied by succeeding writers, and only became obsolete in the time of Cullen and Hunter. The second began with the beginning of modern science in the seventeenth century, and adopting the vitalistic or pneumo-pathological basis, continued down, through Cullen and Hunter, to Cooper, Abernethy, and the great surgeons of the last generation. A third may comprise the early microscopic school, by which the capillaries were chiefly studied. A fourth coincides with the development of the cell-doctrine. A fifth includes the later ideas of the activity and power of protoplasm or 'germinal matter,' independently of the formation or function of 'cells,' formally so called. A sixth will treat of chemical theories. A seventh of the now popular neuro-pathology."

In the section on treatment Dr. Druitt has discussed all the various systems of treatment with fairness and impartiality, and the whole is well worth perusal. Beginning with preventive treatment, including rest, narcotics, and the antiseptic treatment of Lister, he passes on to expectant treatment, which is summarily dismissed in favour of curative treatment. The remedies for inflammation are subdivided into those which (1) diminish the quantity or the velocity of the blood or its heat; (2) purify it by acting on the excretory organs; (3) allay nervous irritation; (4) support the strength; (5) act specifically in a way we cannot explain; (6) counter-irritants and neurotics. Space will not allow of our following the author through these most interesting pages, which form the conclusion of his able article; but we will venture to place before our readers his own summary in the form of twenty-four general conclusions, which are as follows:

"1. Inflammation cannot be defined as to its essence, so that the best plan is to define it by its accidents as 'a diseased process attended with hyperæmia and exudation,' as we have said above, or with pain, heat, redness, and swelling.

"2. There are certain natural processes which resemble it in some respects, as erection, ovulation, menstruation, lactation, salivation, and the action of the intestinal mucous membrane during digestion.

"3. There are certain morbid processes into which inflammation passes by insensible gradations-to wit, neuralgia, hypertrophy, tumours, benign and malignant, mucous flux, and hyperæmia.

"4. But as neuralgia, hypertrophy, tumours, fluxes, and hyperæmia may (like the best examples of repair) occur without inflammatory symptoms, so it is clear that the term 'inflammatory' applies

to the manner in which these changes take place, that is, if they take place in a rapid, violent, and painful manner (W. Moxon, Analytical Pathology,' Med. Times and Gaz.,' 1870, vol. ii, p. 441). The diagnosis of inflammation is chiefly founded on hyperæmia, heat, exudation, and progressive change.

"5. The superaddition of inflammatory characters to morbid processes brings into play a new order of phenomena, requiring special

treatment.

"6. The essential seats of inflammation are tissues in their minute structure. The vessels, nerves, and lymphatics are instruments, but not essential agents. Yet some inflammations are diseases in a part rather than of it, beginning with capillary embolism or afflux of morbid blood-elements (Beale), or with the intrusion of morbid leucocytes.

"7. Theories of inflammation must be comprehensive, not exclusive. All theories heretofore in vogue have some partial truth, but no one can be accepted as a view of the whole truth. The doctrine of the state of the blood, of humours, of the influence of the nervous system, of the action of vessels, the action of 'cells,' of exudations, of embolism, and of leucocytes, are not incompatible, but may be held as so many parts of a harmonious systom.

"8. Inflammation of any part must be considered an expression of irritation or wronged vitality, of defective resistance to causes disturbing the processes of nutrition, the liability increasing in proportion to the weakness and sensibility. Injury to living tissue renders it incapable,' as Goodfellow has well expressed it, of exercising its proper affinities'-of growing in harmony with the organism of which it forms a part. The same rule holds good, as Virchow has shown, with regard to vegetals as to animals.

"9. It is the characteristic of high health and vigorous life that injuries are healed without nerve-irritation and inflammation, and that morbid states of the blood, from improper food, cold, or the like, are got rid of by the normal processes of oxydation and excretion.

"10. It is under conditions of weak health and lowered vitality that fevers and inflammations are most likely to occur.

"11. There is nothing benevolent nor conservative in fever and inflammation. They are grievous wastes of force and substance, and imply a prodigal production of the lowest amoeboid forms of organization.

12. It is a pernicious doctrine to hold that Nature, feeling herself injured, sets up inflammation to restore the damage or recover the health.' If there be damage, it is the duty of the practitioner to remove causes of irritation and to quiet the nerves, till natural processes of oxydation and elimination shall have got rid of any material cause, and till an injured or fatigued organ can recover its nutrition.

"13. The best result of inflammation is that it sometimes produces a new organ of oxydation or elimination, as in gout, mucous flux, and critical abscess. But as these may risk life and health, it