Part Second. REVIEWS. Clinical Lectures and Essays. By Sir JAMES PAGET, Bart., F.R.S., D.C.L. Oxon., LL.D. Cantab., etc. Edited by HOWARD MARSH, F.R.C.S., Assistant-Surgeon to St Bartholomew's Hospital. London: Longmans, Green, and Co.: 1875. WHEN the profession is honoured, and its knowledge extended by having the matured wisdom and experience of one of the masters of his art laid before them, clothed in language of singular fitness and beauty, which has in every page the graces, not only of high culture, but of innate refinement of heart and mind, the reviewer's task is a pleasure. He has to accept, not to criticise; to enrich, and yet tantalize his readers by quotation, rather than amuse them by highly-spiced condemnation. Even when differing from Sir James, either in theory or practice, it is impossible to avoid the feeling that he may be right after all, and that at least he is satisfied in his own mind as to what he says, else he would not have said it; for his modesty is as great as his experience, and he has neither self-consciousness nor self-assertion. Of the sixteen subjects treated in this work, all are not of equal importance, nor treated with equal detail. In some the author has been less happy, less assured, less confident, but every page has some wise thought or axiom-the outcome and result of a large and very exceptional kind of experience. There is no attempt at systematic lecturing, historical completeness, or precision of details these may be better given by younger men; but in each lecture there is an attempt to lift the student or practitioner into the same high platform which the author himself has at last attained, after his forty years of practice. In his really too modest preface (but still quite honest, and characteristic in its modesty), Sir James says he intends his work for "students and those who have too few opportunities of studying surgery in either large practice or large books." In this we disagree with him, as we think that hospital surgeons and teachers will probably profit more by the work than their younger and less-favoured brethren. The greater part of the work has already been published in some form or other; rescued from the pages of weekly journals or yearly reports. The material is now bound up in a readable form, with good type, and corrections-with also some excellent notes by the editor, whose work has been well done. The first lecture is on the various risks of operation. It tempts quotation in its entirety, but one or two passages must suffice: แ Where then shall we find the lowest rates of mortality and other mischiefs? Perhaps you may find them in a class whom you may often study here. We have a large number of printing-offices in the neighbourhood of the hospital; and every office employs many boys from twelve to sixteen years old; and hardly a week passes but we have one or more of these boys brought in crushed by the printing-machines. Fingers, hands, and arms are thus mutilated; and I know no class of patients that recover more remarkably. Not only do they not die, but their wounds heal steadily and quickly; they escape erysipelas and spreading suppurations and secondary hæmorrhages; and often, when, to save any piece of a hand, we leave bits of skin that seem as if they could not live, they yet do live and grow good scars. I know no class of persons who are better subjects for operations than these boys. As Mr Callender1 has pointed out, our success with them helps to bring us the credit of a very low rate of mortality in amputations of the upper extremity." (P. 4.) "For the over-fat are certainly a bad class, especially when their fatness is not hereditary, but may be referred in any degree to their over-eating, soaking, indolence, and defective excretions. The worst of this class are such as have soft, loose, flabby, and yellow fat, and I think you may know them by their bellies being pendulous and more prominent than even their thick subcutaneous fat accounts for; for this shape tells of thick omental fat, and, I suppose, of defective portal circulation. I know no operations in which I more nearly despair of doing good than in those for umbilical hernia or for compound fractures in people that are over-fat after this fashion. Nothing short of the clearest evidence of necessity or of great probable good should lead you to advise cutting operations in people of this kind. Do lithotrity for them rather than lithotomy; incline against amputations for even bad compound fractures; and, wherever you can-as, for instance, for cutaneous cysts, hæmorrhoids, and the smaller examples of scirrhous mammary cancers-use caustics rather than the knife or ligature." (P. 14.) After hearing Sir James say " a secondary amputation is a confession of either a mistake or a disappointment," we are not surprised to find that he counsels "waiting," rather than amputation, in the course of an erysipelas or a chronic pyæmia. On the relation of disease of heart to chloroform and operations, few will disagree with the following: "Diseases of the heart are, on the whole, much less serious hindrances to recovery from operations than you might suppose. Doubtless, patients with very weak fatty hearts are in some greater danger from chloroform than others are; but when it is cautiously given, even these may take it safely; and I have never heard or seen anything that would make me think the administration of chloroform specially dangerous in any such patients with diseased hearts as a reasonable man would think of operating on. I have known it administered to patients with considerable valvular disease without any appearance of danger; and certainly, in any such case, the risk of chloroform would be less than that of the pain and alarm attending any considerable operation performed without it." (P. 30.) "I do not know by how many times the risks of a given operation are increased in any patient who has albuminuria, but I do know that you will find it a safe rule never to perform any operation without an acquaintance with the manner in which the patient's kidneys discharge their function; and never to perform one, except under something like compulsion, on a patient whose urine is constantly albuminous. I do not say that you should never operate on such a patient, for the exigencies of the local disease may justify you, as they may justify you in operating in the advanced phthisis; but be clear that you operate against heavy odds; for even if the patient do not die with erysipelas, 1 St Bartholomew Hospital Reports, vol. v. p. 248. or pyæmia, or some other form of diseased blood, he will be apt to linger with a wound half-healed, till at last he dies of his renal disease, just as if you had done nothing." (P. 39.) "By the way, let me tell you of a symptom which must make you especially cautious if you have to catheterize elderly or old men. If they are passing large quantities of pale urine of very low specific gravity, whether containing a trace of albumen or not, they will be in danger from even the most gentle catheterism. For this condition of the urine is often due to some advanced defect of action in the kidneys, and catheterism will be followed by inflammation of the bladder, and the so-called urinary fever, and death will hardly be escaped." (P. 44.) "If I may venture on a large general statement upon such a point, I will say that each man's capacity for bearing a surgical operation may be best measured by the power of his excretory organs in the circumstances in which the operation will place him. But the means of regulating this power, or of increasing it, must be as various as are the patients themselves. You must study the whole matter very carefully; and I hope I shall not have wasted either your time or my own if I shall have enabled you to start from the point which, after many years' work, I have reached." (P. 50.) The Calamities of Surgery is a fit name for a most interesting chapter. Both in common sense and sound surgical principle, the following can hardly be surpassed "First, don't be too ready to operate in your own houses or in your own rooms. It is a thing too commonly done, and always involves a risk which should not be incurred without need. Mr Thomas Blizard, who was in his time one of the most distinguished surgeons in London, when he began practice in the city, was once consulted at his house by a merchant of great wealth and influence, who thought he would patronize the young man; for he knew his family. He called on Mr Blizard one morning, showed him a cyst on his back, and asked him to remove it; and he removed it then and there. The merchant went away, caught cold, had erysipelas, and died in ten days. I do not know what amount of unhappiness the case excited at the time; but I know that Mr Blizard told it in after life with the greatest regret; and that, as a measurable amount of part of the calamity to himself, his income fell 50 per cent. after that year, and was not quickly recovered. It rose to a very large amount before he retired, but 50 per cent. for a year was the amount of damage which he sustained by not observing the rule, of not operating in your own rooms without a real need of doing so. You may do an operation there with all dexterity and care; but you do not know what the patient will do afterwards. Especially, let me advise you not to sound a patient for the first time, or to pass a catheter in a man of questionable general health for the first time, in your own room." (P. 65.) And as to needless operations : "Again in cases of varicocele: patients come to you, begging for cure; and nearly all of them are merely nervous, hypochrondriacal, morbidly-brained people, who are in fright about varicoceles, which they suppose to be the causes of impotence and wasting of the testicle. Now, no varicocele, to the best of my belief, ever did cause impotence or waste a testicle. But the operation for varicocele is not altogether free from danger. A most skilful operator for this disease reported, the other day, a case in which he himself operated, and the patient very nearly lost his life. Once, also, I saw a young man with pyæmia following an operation for varicocele, which had been done very skilfully. Through this pyæmia he had acute suppurative inflammation of his right shoulder, his right knee, and his left hip; and they were all spoiled, and he very nearly died. I doubt whether ninety-nine operations for vari VOL. XXI.-NO. I. H cocele would do good enough to balance one such calamity; for of the ninetynine operations the majority would have been quite unnecessary. Varicocele can, in a vast majority of cases, be perfectly well managed with a ring, or a truss, or suspensory bandage and cold water, and the operation may be wholly dispensed with the more properly because varicocele is not a mischievous disease, and has nothing to do with the impotence or other sexual distresses that patients ascribe to it." (P. 68.) Under Cases that Bone-setters Cure, we find a good account of treatment of sprains, etc., in which the salient point which strikes us, is a wise warning against a too free use of the cold douche and the elastic bandage, both powerful and dangerous remedies. The four lectures on Strangulated Hernia contain much valuable practical advice on the question of operation when there are no local signs of strangulation; on the significance and importance of vomiting as a symptom, p. 113. On the treatment of omentu n :— "But it sometimes happens, when the abdomen is tense with over-filled intestine, that you cannot return a large piece of omentum without much difficulty. What then? Shall you cut it off or leave it in the sac? I advise you to leave it. I believe that the cutting-off, with the necessary ligatures or other fastenings of vessels, adds to the dangers to life; while the leaving of omentum is only sometimes followed by greater difficulty in the fitting of a truss-a difficulty which is not great enough to justify any risk of life." (P. 137.) On state of intestine : "But the chief questions in these operations are concerned with the state of the strangulated intestine and the manner of dealing with it. You are to judge chiefly from the colour and the tenacity. Use your eyes and your fingers; sometimes your nose; very seldom your ears, for what you may be told about time of strangulation, sensations, and the rest, is as likely to mislead you as to guide aright.' (P. 138.) In reading the six lectures on Nervous Mimicry, we find less firmness of handling, a less assured touch, consequently they are less axiomatic, and less quotable; but they give much information on a difficult subject, of which the author's practice among the higher classes of society has given him a large experience. Regarding the treatment of Carbuncle without incision, recommended in the lecture on this disease, there may be differences of opinion; still, we must accept the reconsidered opinion of one who has had much experience, as showing there is much to be said on both sides of the question. Probably the most valuable lecture, certainly the most difficult to write, is the one on Sexual Hypochondriasis, which, in its scientific method, high-toned morality, and clearness and sweetness of its whole atmosphere, is in refreshing contrast to most of the productions on this difficult subject. We have not time to linger on Gouty Phlebitis, Residual Abscess, or the most interesting personal narrative which enriches the lecture on Dissection Wounds, which ends with the following characteristic sentence, with which we may close this brief notice : "Sir William Lawrence used to say that he had not known any one recover on whose case seven had consulted. Our art has improved. I had the happi ness of being attended by ten: Sir Thomas Watson, Dr Burrows, Sir William Jenner, Dr Gull, Dr Andrew, Dr Gee, Mr Cæsar Hawkins, Mr Savory, Mr Thomas Smith, and Mr Karkeek. In this multitude of counsellors was safety. The gratitude I owe to them is more than I can tell-more than all the evidences of my esteem can ever prove.' (P. 338.) Des Paralysies Bulbaires, etc. etc.: Thèse présentée au Concours pour l'Agrégation, etc. Par le Dr HALLOPEAU. P. 155. Paris: Baillière et Fils. 1875. In this thesis, Dr Hallopeau describes the palsies which have their seat in the medulla oblongata. It contains a useful summary of researches by French physicians, but more particularly Duchenne and Charcot, into those serious palsies which depend upon structural degenerations of the cord and bulb, and which are for the most part progressive and incurable. More especially full descriptions are given of the pathological anatomy and symptoms of labio-glosso-laryngeal paralysis. General spinal paralysis, wasting palsy, and the general paresis of the insane, are also elucidated, and various illustrative cases are detailed. Hysteric, diphtheritic, and hæmorrhagic palsies have briefer notice. Treatment is, however, omitted, and only incidentally referred to in the reports of cases. The researches of British physicians do not seem to be known to Dr Hallopeau; but in so far as the thesis gives a summary of the more recent researches of French physicians, it is a useful work, and manifests signs of care in the production. "Ueber das Virchow's Archiv, Ausgegeben am 15 Februar. IT being now established that, in inflammation, white corpuscles migrate through the walls of the blood vessels, and it being probable that such migration, in limited amount, may even constitute one of the phenomena of ordinary nutrition, it has become a matter of much importance to determine with precision in what manner the corpuscles effect the transit of the vascular wall. Is the wall, as has been suggested by some of the older observers, a homogeneous glue-like membrane, the substance of which is capable of flowing together, and obliterating all trace of the perforations made in it; or are there, as Recklinghausen has suggested, natural openings or pores between the cells of the living epithelium, through which nutrient juices and migrating corpuscles are alike capable of making their escape? It is to the solution of this question that Professor Arnold addresses himself in the present treatise. The methods of experiment which he employs are very simple and familiar; the |