of emphysema are so well known that we shall not dwell on them here. It is only necessary to say that the first symptom which marks the presence of the lobar form of the disease is frequently only increasing dyspnoea and a general feeling of oppression, or "smothering of the chest," as the patient terms it. This may be developed in patients of young or middle age who have escaped those severe bronchitic attacks which in others lay the foundation of the emphysematous affection. The frequency of the development of asthmatic symptoms in the course of extensive emphysema has led many writers to confound the two diseases. Their intrinsic difference is, however, fully recognised by the English school of physicians. The pamphlet of Dr. C. J. Berger, On Asthma,' which has lately appeared in France, is devoted to the establishment of the position that asthma is a nervous affection independent of any organic disease; and, amongst other, to English readers, unnecessary discussions, he combats the conclusions at which Louis arrived, that as emphysema is commonly present in asthma, the organic lesion is the cause of the latter. His work concludes with a recommendation, in the treatment of the asthmatic, of that system of passive exercise, frictions, &c., to which the French give the name of "massage." The title of the work, 'Guide de l'Asthmatique,' is evidence that it is as much intended for the general as the professional reader. In discussing the physical signs of emphysema, Dr. Waters especially notices the rale crepitant sec à grosses bulles which Laennec believed to be peculiar to, and pathognomonic of, the disease. The existence of this peculiar sound has been denied by many writers. Dr. Waters, however, thinks that he has met with it occasionally in emphysematous patients; he differs, however, from Laennec as to its mode of production. Laennec described it as a dry râle produced by the distension of the emphysematous tissue. Dr. Waters, on the contrary, thinks it is produced by fluid in the finer air-passages. If this be the case, we cannot agree with him that, "as a sign of emphysema, the râle is important, and may assist in confirming a diagnosis." It resolves itself into a mere variety of sub-crepitant râle. These hair-splitting distinctions only tend to throw discredit on the art of physical diagnosis. Dr. Waters' chapters on the Sequelae, Complications, and Treatment of Emphysema are sensible and practical. The treatment he recommends for the lobar form arising from mal-nutrition is essentially tonic, and of all remedies the preparations of iron have proved in his hands of most avail. He says he was led to employ iron from a knowledge of its value in those diseases which are dependent on mal-nutrition and cachexia, especially Bright's disease and fatty degeneration of the heart. A treatment commenced on theory is too frequently found to fail when put to the practical test; but this was not the case in the present instance. Dr. Waters asserts that he has employed iron in a large number of cases, and has found its administration of so much benefit that he considers it the most valuable medicinal agent we possess for the treatment of emphysema. The ethereal tincture of the acetate seems to be his favourite preparation, especially when the case is com66-XXXIII.

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plicated with bronchitis. In the treatment of those severe attacks of bronchitis which so frequently jeopardize emphysematous patients, Dr. Waters recommends the stimulating plan of treatment, and he gives some cases which illustrate the benefits to be derived from wine and brandy under conditions of almost hopeless aspect. He has also tried the administration of turpentine in drachm to half-ounce doses in a case where alcoholic stimulants have failed in rallying the patient from a state of semi-asphyxia, produced by the supervention of acute bronchitis on emphysema. The effect of the turpentine seemed to be that of increasing the power of expectoration, relieving dyspnoea, and diminishing effusion into the bronchial tubes. The patient recovered. The few remarks on the treatment of the chronic forms of bronchitis, and of the other complications of emphysema-asthma, cardiac disease, dropsy, &c.—with which Dr. Waters concludes his essay, accord with his views of the pathology of the disease. To combat the conditions of anæmia and atrophy by a tonic regimen and medicines, and to subdue intercurrent attacks of bronchitis by counter-irritation and expectorants, are the main features of the plan recommended.

In conclusion, we would add that we think Dr. Waters, in the work we have noticed, has fully maintained the high position as a careful and diligent investigator, in which his work On the Anatomy of the Healthy Lung' originally placed him.

REVIEW II.

A System of Surgery, Theoretical and Practical; in Treatises by various Authors. Edited by T. HOLMES, M. A. Cantab., Assistant-Surgeon to St. George's Hospital, and Surgeon to the Hospital for Sick Children. In Four Volumes. Vol. III.-London, 1862. pp. 916. THE third volume of Mr. Holmes's 'System of Surgery' has been for more than a twelvemonth before the profession. We owe an ample apology to our readers for having so long delayed calling their attention to its contents. The volume contains essays on subjects of operative surgery, and on the diseases and injuries of the organs of special sense of the air-passages, as far as they can be thought surgical in their nature, and of the organs of locomotion and innervation. The last essay in the present volume, upon the diseases of the tongue, is the commencement of the series relating to the diseases and injuries of the organs of digestion.

The first essay in this volume is by Mr. Thomas Smith, upon subjects of Minor Surgery. Many of the subjects usually considered to be matters of minor surgery are treated in other parts of the present work, under the special diseases or particular localities with which they are more immediately connected. The writer has aimed only at giving a brief description of such proceedings as are of general application in the treatment of many and various diseases.

Of the many implements-unimposing in appearance which the surgeon has at hand in his consulting-room, or carries with him in his pocket in going his rounds, few are of more importance, from the fre

quency with which they are brought into use, than the ordinary calico roller" roller," we presume, in the surgeon's hand, the "bandage" when applied upon the person of the patient. Elastic materials are less generally useful as "binders;" they fail in one of the chief purposes of a bandage-that of making sufficient pressure for the purpose of steadying the muscles, or, as Mr. Smith describes it, that of "maintaining uniform pressure on subjacent parts." A sufficient amount of firmness is needed in the cloth from which the bandage is made, provided the texture is not too close to hinder the use of pin and needle to fix it when applied.

In these days of labour-sparing machinery, we have often wondered to see in our hospitals that the rollers, which are dispensed with no sparing hand in the wards and out-patient rooms, continue to be made by manually tearing the cloth into strips, and rolling these strips one by one into shape. A machine of very simple construction would do all the work. In Madrid we have understood that such a machine has long been in use.1

The spiral bandage, taking his example from its use upon the trunk as well as the extremities, receives due notice at Mr. Smith's hand, as being by far the most general in its application. The rules given in most manuals of surgery for the application of it-upon the leg, for. instance-are few and simple, and, with the aid of an illustrative engraving, are intelligible enough to the student. Yet they seem made chiefly for model legs, or for patients who can be kept for a considerable part of their day in the recumbent position, or under a limited allowance of bodily exercise, for the purpose of clinical demonstration. The best description we remember to have seen is that given in Mr. Hunt's Guide to the Treatment of Diseases of the Skin.' There is a rough and ready way of doing the job, not very easily reduced into a systematic treatise. The nurse often manages to make the bandage hold on for a longer time than her master. One of the best practical lessons on the subject we remember to have received in our early practice was from a gouty patient—a large, powerful man, with a lower extremity of proportionate size. Neglecting the orthodox rule to reverse the roller, folding it upon itself in making each time the circumference of the limb, where it increases in size, he had learned on his own person, when the turn became necessary above the ankle, to carry the head of the roller by one spiral turn above the muscles of the calf, and to bring it spirally downwards from that part toward the ankle. From this reversal of our accustomed practice, he was not conscious of having found any inconvenience from the distension of the veins. The practice may be adopted where we are able to allow the patient his usual exercise.

To give the requisite amount of support above the knee-in the thigh, for instance, as in the trunk-a towel, which is always at hand in a sick-room, forms a very efficient bandage. It is easily applied, and with a few stitches from a needle and thread, the necessary variety of pressure can be always obtained. In the hypogastric region, the 1 Some of our hospitals possess machines by which the strips of cloth, after they have been made by hand, are wound tightly into rollers.

most urgent call for pressure is after parturition, for the purpose of securing contraction of the uterus, when it is inclined to dilate with internal hæmorrhage. The spiral bandage, in the form of a double figure of eight, passing round the groins, is here most useful in keeping the bandage and compress in place, and restraining the partially-contracted uterus within its proper pelvic resting-place.

However skilfully applied, all these bandages serve only a temporary purpose. The "immovable apparatus," as we call the apparatus for restraining the contained parts from motion, which is required for chronic cases, should answer its purpose without needing frequent application or readjusting, and should not offer any obstacle to the surgeon's examination, if he wish to make one. The ease with which the surgeon can remove the apparatus, or can open it in part, is a circumstance requiring consideration in the choice of material, quite as much as the ease with which he can apply it in the first instance, or the efficiency of its purpose to keep the confined parts at rest and immovable. The materials mentioned by writers are as various as are the diseases or lesions to which they are applicable. A practitioner in the country, of extensive experience, tells us that it has long been his practice, when summoned to a simple case of fracture of the leg, to desire some paste to be made, and to ask for an old newspaper or two. With these materials he makes a very efficient immovable apparatus," and he finds the patient's progress in every way satisfactory under the treatment.

Among the different subjects of Mr. Smith's essay, vaccination receives a share of his attention. It is entitled to the prominent place it holds in professional estimation from the increased importance now given to the operation in the educational curriculum of the examining boards. It seems to be one of the numerous operations which each practitioner performs most successfully in his own way. The attempts which have been made to prescribe a "normal" mode of performing the operation, and of preserving the lymph, do not appear more likely to be attended with uniformity of practice than attempts at one line of practice in the greater operation of amputation.

Mr. Lister, of Glasgow, contributes an essay upon the operation of Amputation, in which he traces with careful industry the history of the operation and the different improvements-the backward and forward journeys-in this important department of surgery. "While the human frame remains liable to derangement from accident and disease, the removal of hopelessly disordered parts, in the way most conducive to the safety and future comfort of the sufferer, will ever be a noble object of surgical effort." We observe that Mr. Lister's acceptance of the word amputation does not apply to the removal of all parts. Thus amputation of the breast, the testis, and other parts, escapes notice in this volume.

What always kept the old surgeons back in this operation was, the fear of hæmorrhage. It was not the want of the tourniquet only; for at an early period some kind of bandage was used to check the flow of blood during the operation. It was the want of the modern ligature,

or other means to seal effectually the open mouths of the divided vessels, after the part had been removed.

The history of the tourniquet, the invention of it, the improvements and the disuse of it, are matters as curious as the history of the operation of amputation itself. Louis, it seems, was the first operator who, after the general adoption of the tourniquet, avoided the use of it in muscular parts (in the thigh, for instance), and preferred compression made by the finger of an assistant at a point nearer to the trunk, where the flow of blood could be effectually checked, without (as he thought) hindering the contraction of the divided muscles. Such a mode of controlling the hæmorrhage has been thought to have the additional recommendation that it does not so much interfere with the return of the blood by the veins. The late Mr. Liston, to whom we are indebted for many improvements in practical surgery, was one of the most persistent advocates of this practice of digital compression. Before his death, we have been informed-but after the publication of the latest edition of his writings-he abandoned this practice, and adopted the tourniquet. The objections made to the use of the tourniquet apply, we think, with less force to the instrument itself, than to the mode in which it is adjusted at the time of operation-often, it may be observed, with an evident want of appreciation of the elementary principles of mechanics. If the strap is properly passed through the lower platform, so as to tighten easily by turning the screw, and if the pad is placed so as to make due counter-pressure against the screw, it will seldom be found that any considerable amount of blood is lost, or that the pressure required to hinder that from happening has interfered, to any appreciable extent, with the free retraction of the divided muscles.

When it became a matter of certainty that the surgeon could control the hæmorrhage during the performance of his operation, and that he could secure the patient against the recurrence of the bleeding from the divided blood-vessels, the operation itself lost part of its terrors. It was an easy matter to cut the soft parts of a limb with a knife, and to divide the bone with a saw; but something more was required to secure one of the two great objects proposed in amputation—the usefulness of the stump. The earliest great improvement in the operation was that suggested and afterwards practised by Cheselden, of so making the necessary incisions that the soft parts, especially the integument, should be of a greater length than the bone. This was effected in the circular method by the "double incision," the skin and fat being turned back before the muscular substance was divided.

Of the different modern modes of performing the operation (in all of which this important object is attained), Mr. Lister, following the teaching of the Scotch schools (if he will allow us to use such an expression), gives the preference decidedly-too decidedly, we thinkto that by flaps. His directions for the performance of the particular amputations in the extremities are in every case applicable to that mode exclusively. "Its great merit," he says, "is its facility and speed; for the flaps are cut with great rapidity, and when they are drawn up by the assistant, the bone is exposed with the utmost readiness at the