"Only one case of resection of this joint was admitted from India; but there is another case where a secondary operation was performed at Fort Pitt, in a patient who is returned as a wound of the joint.

"In the Crimean war the head of the humerus was removed twice as a primary operation during the first period of the war, or that ending March, 1855, and eight times during the second. One of the two first-mentioned ended in death, and of the 8 subsequent operations only 1 proved fatal. The head of the bone was five times removed as a secondary operation, without a single casualty. In addition to these, there was a case in which the head of the bone, and a large portion of the scapula, broken into fragments, were removed.

"Out of the total number, then, of 16 cases, 3 deaths took place, or 18-9 per cent. Had this operation not been resorted to, amputation at the shoulderjoint, it is believed, would have become necessary in all.” (p. 102.)

We have quoted Dr. Williamson's statement as it stands, but the reader will observe that he does not account for more than two deaths; and if this is the real number, it would make the return even more favourable to the operation.

Of resection of the elbow, the return stands thus:

In the Crimean war, 22 operations in all were done on the elbow-joint, of which 3 ended fatally, and 2 more deaths took place after secondary amputation-in all a total of 5 deaths, or 22 per cent. of the cases treated. This percentage slightly exceeds that of resection of the shoulder-joint, but in both instances resection afforded a much more favourable result as to the mortality than amputation." (p. 108.)

The subject of resection is further illustrated by the recital of a most extraordinary and most gratifying case under Dr. Williamson's own care, in which he removed the whole of the ulna, the head and neck of the radius, and two inches of the end of the humerus, on account of disease. The wound united by the first intention, and at the time at which the account was written (four months after the operation), the patient "could bend his fore-arm, raise his hand behind his head, and lift a twenty-eight pound weight from the ground; he could also pronate and supinate the hand; there was no anchylosis of the wrist-joint, and he could use his fingers well." (p. 108.)

Let us now turn to gun-shot wounds of the chest; and as on this subject Dr. Fraser's work claims precedence as a regular "treatise," we will endeavour to lay its arguments before our readers, and see how far his conclusions bear the test of the facts which Dr. Williamson has produced.

Dr. Fraser's treatise was originally written, as he informs us in the preface, for the Transactions of the Medico-Chirurgical Society,' and its publication furnishes a sufficient justification to the Council for its non-appearance in their volume. Without denying the merits which portions of it possess, and wishing to give all due credit to Dr. Fraser as a zealous and honest inquirer after truth, we cannot see how it would have been possible for such a society as the Medico-Chirurgical to have sanctioned by their authority a treatise so hastily written that the author himself refutes his own principal conclusion, and which is besides rather controversial than demonstrative.

Dr. Fraser's object in this treatise (and it is a very rational and worthy object) is to show that the diagnosis of a wound of the lung in gun-shot injuries to the chest is frequently arrived at rather hastily, and that no one of the ordinary signs can be exclusively relied on as proving that diagnosis. The signs enumerated by Dr. Fraser as having been relied on to prove that the lung is implicated in a wound of the chest are dyspnoea, hæmoptysis, emphysema, pneumonia, pleuritis, and tromatopnoea (or the passage of air by the wound); and the method which he adopts is to review each of these symptoms in succession, with a view of proving that it may be absent when the lung is wounded and present when it is not, and that therefore it is of little value as a diagnostic sign. What, we would ask, is the inference? That there are other symptoms of wound of the lung? If so, why are they not set forth in this treatise? That wounds of the lung cannot be diagnosed? That we trust is not Dr. Fraser's meaning; yet it is the conclusion to which a stranger to the subject would most likely be brought on reading the book. Take any ordinary disease, collect its symptoms out of one of the text-books. Is it not usually true of each of the symptoms, that the disease may occur without them, and that they may occur without the disease? Does this destroy their worth as symptoms of the disease? Not to any one who knows that a disease is judged of from the assemblage of its symptoms, not from the individual signs taken separately. We object, therefore, in limine, to this method of Dr. Fraser of discussing the individual signs separately, as being a waste of space; and a much more powerful objection, to our mind, to his treatise, is that it is based upon cases either so imperfectly observed or so badly reported, that no conclusion can possibly be drawn from them. Thus, at p. 52 a table is given which is described by the author as "a highly-interesting and valuable table" (vide p. 47), but in which the same strange negligence in language and matter prevails which disfigure other parts of this treatise. The collection is headed "A tabular statement of symptoms in thirty cases of lung-wound," yet in many of the cases it is expressly stated that the lungs were not wounded, so that we presume lung-wound must be a misprint. In no less than eleven of the cases, no symptoms whatever are mentioned as having occurred, and if we turn to the notes of the same cases which are scattered through the book, we find that many are so loosely reported, that no conclusions can be drawn from them. Thus the first case in the table is quoted on p. 79 as follows:-"John Maher, aged twenty-five, 57th Regiment, was wounded at the unsuccessful attack on the Redan on the 18th of June; ball passed through both lungs; died on the 21st of June." Surely, before conclusions can be safely founded on published cases, we must have them somewhat more carefully reported than this. Several experiments on animals also are recorded, but they do not seem to have been sufficiently carefully devised or sufficiently connected with each other to prove anything except that severe wounds may be inflicted on these poor beasts without any very marked symptoms being observed, and therefore rather savour, to our mind, of cruelty. Nevertheless, some very striking and well-observed

cases may be found scattered through the volume, which prove at any rate the danger of trusting too much to any one or two symptoms of lung-wound as pathognomonic, and go far to justify Dr. Fraser's general conclusion. "Although I would not place implicit reliance on any one of the heretofore-accepted signs of lung-wound, if there were three or more of them present, I should consider their concurrence as strong presumptive proofs." (p. 87.) But the author mars the force of his reasoning by curious inconsistencies, which are either due to extreme negligence in writing or to confusion of ideas; thus, in speaking of tromatopnoea, or the passage of air through the wound, he says:

"I am, indeed, of opinion that when the lung is really wounded this tromatopnœa must cease; thus, when a small opening is made into the thoracic cavity without wounding the lung, air will pass freely out and in during respiration; but if the opening be enlarged, and the lung be so wounded that there is a direct communication formed with the opened pleural cavity, the entrance and exit of air will cease, from the simple physical fact that all opposition is removed, and no confined body of air is subjected to the alternate movements of the thorax." (p. 86.)

out

Yet the author goes on to say, in the next sentence but one, of nine fatal cases noticed by the author, in which the lungs were wounded, it (viz., tromatopnoea) was present in two." So that it is quite clear that the statement made above is too general, and that if the author wished to give definite value to his researches on this point, he should have endeavoured to appreciate the influence of the size of the external wound and of the rent in the lung, the conditions of the lung in respect to adhesions, &c., upon this symptom, and so to have shown in what circumstances tromatopnoea may be taken as decisive of a wound in the lung, and when, on the other hand, we may hope that the pleura only is opened.

The strangest statement, however, is one which is made in summing up the result of the whole book (a "physiological summary," as Dr. Fraser calls it). In this summary it is broadly laid down:

"That in the human subject, as well as in animals, an actual wound in the substance of the lung is always, sooner or later, mortal; not from the effects of inflammatory action, but, in recent cases, from a sudden cessation of aeration in either the whole or portions of one or two lungs, or sudden hæmorrhage." (p. 140.)

proper

In opposition to this, Dr. Fraser himself says, "There are cases in which recovery has taken place when the substance of the lung was wounded" (p. 8); and refers to a case related by Larrey, "in which recovery took place, and there was no doubt that the lung was wounded." (p. 11.) A very interesting case,* and one which would have been very valuable to Dr. Fraser had he met with it before the publication of his treatise, is found at p. 31 of Dr. Williamson's work, with a beautiful representation of the parts, in which the lung had been wounded, but the patient survived eleven months, and then died

* [See also a remarkable case given by Mr. Forde in the Medico-Chirurgical Transactions, vol. xx. p. 378.-ED.]

of gangrene of the opposite lung, from some unexplained cause, but influenced, as Dr. Williamson supposes, in some manner, by the old wound, which had never soundly healed. The track of the ball was found still open and lined by a membrane, on which the bronchial tubes opened; the exit of the ball had been kept open by necrosed bone. We may notice that here, if anywhere, according to Dr. Fraser's reasoning, tromatopnoea should have been absent, since the wound communicated directly with the air tubes, and consequently there was no resistance to the passage of air by the natural way; yet it is stated distinctly that "air escaped on expiration and coughing.

On a review, then, of the diagnostic portion of Dr. Fraser's work, we would say that he appears to have succeeded in showing that the symptoms usually relied on are more frequently present when the lungs are not wounded, and more frequently absent when they are, than has been generally supposed; but that his treatise adds little to our knowledge of the positive diagnosis of these cases, and that he has been led by haste and argumentative zeal to put his conclusions far more absolutely than his facts warrant.

An interesting point in these injuries of the thorax is the question of the treatment proposed by Mr. Guthrie in cases of wounds of the diaphragm, where that injury can be diagnosed, and the patient is in danger of dying from phrenic hernia-viz., to cut into the belly and draw the viscera out of the thorax, and so by reducing the hernia save the patient's life. Interesting cases may be found on this head in Dr. Fraser (pp. 94 et seq.), and in Dr. Williamson's book there is a beautiful engraving (p. 36) of the parts in a case of this kind. We think a study of these cases will convince any dispassionate reader that the suggestion is in the highest degree unpractical and dangerous. Unpractical, because the diagnosis can never be made with certainty, unless in very recent cases, when the accompanying lesions must forbid the thought of any such operation, and when, indeed, Mr. Guthrie himself (see Fraser, p. 98) afterwards allowed that it could not be put in practice; reserving it for secondary cases, where the patient has recovered, with a hole in the diaphragm, through which the abdominal viscera afterwards protrude and become strangulated. Dr. Williamson's cases will show, if any cases were required for the purpose, that this condition can hardly ever be diagnosed with accuracy enough to warrant an operation; and if Mr. Guthrie's idea is correct, that a wound in the diaphragm never heals, to what purpose would it be to submit the patient to so frightful an operation when, if the viscera could be drawn out of the thorax, no means exist for closing the hernial opening, or keeping the viscera from immediately passing. through it again?

A very important portion of Dr. Fraser's treatise remains to be noticed-viz., that in which he speaks of the treatment of wounds of the chest. Here he reasons strongly against the necessity of the copious and indiscriminate bloodletting which is, or was lately, prescribed for such injuries; and we must say that the cases he has adduced, together with the notes of those reported by Dr. Williamson

(so far as the latter are fully reported), are enough to create some little doubt, at any rate, whether bleeding can be so necessary to the cure of these wounds as some would still have us believe. Many cases may be found here in which wounds of the chest, which would by most people be diagnosed as involving the lung, recovered without bleeding; and others in which the fatal progress and the distressing symptoms seemed little affected by copious bloodletting. Dr. Fraser seems opposed to bleeding altogether; but we have no doubt that his theoretical reason for it-viz., because pneumonia is, as he believes, a rare complication of wound of the lung is erroneous. There is every reason, however, to believe that the pneumonia which follows a wound of the lung is often, perhaps usually, only as much as is sufficient and necessary for its closure, and that if bleeding would affect it at all, it would be injuriously. On this subject, as on so many others, the truth seems to lie between the extreme partisans on either side, and the symptoms of each case will doubtless furnish the best guide to practice. With the limited experience that we have in London of gun-shot wounds, we cannot affect to give any opinion on this subject; but we can entertain no doubt of the relief which we have seen from small and cautious venesection in cases of fractured ribs with wound of the lung, and should certainly expect similar results in gun-shot injuries.

REVIEW XV.

A Manual of the Philosophy of Voice and Speech, especially in Relation to the English Language and the Art of Public Speaking. By JAMES HUNT, Ph.D., &c.-London, 1859. 8vo. pp. 438.

THIS book treats of so many branches of knowledge, that a doubt naturally arises as to the competency of any one individual to deal with them all. Such diversified subjects as physiology and the cuneiform characters, music and pathology, typography and therapeutics, hieroglyphics and acoustics, anatomy and oratory, with others not more cognate than these, must be allowed to furnish a range of inquiry rather trying to the abilities and information of the writer who ventures upon it. Dr. Hunt does indeed request the reader to bear in mind,

"That in a volume like the present, comprehending such a variety of topics which have individually been frequently discussed by the most eminent writers, the amount of original matter cannot be very large; but professing to be merely a manual, it is of much less consequence that the opinions advanced should be new, than that they should be true."-(Preface.)

But in order to compile with accuracy on any subject, it is indispensable that a writer should himself have a very good general acquaintance with that subject; and hence it happens that those works in which a single author ranges adventurously through too wide a field of research frequently exhibit gross ignorance on several points, and no very satisfactory information on any.

Whatever may be the qualifications of Dr. Hunt for the production of such a work as that before us, we must, on our own part, disclaim