Schroeder van der Kolk followed up this clue, and the general result of his inquiries leads to this—that in those patients who bit their tongue, the capillaries of the hypoglossus, the corpus olivare, and the raphe were considerably enlarged as compared with those of the vagus; while the reverse was the case in those who did not bite their tongue. We have not space to enter into this matter more in detail; those who are interested in the question have doubtless already read enough to induce them to supply the deficiencies of our very meagre outline by reference to the volume.

It only remains for us to say a word upon what the author calls the rational treatment of the disease. What has preceded will at once suggest that derivatives are the main agents upon which he relies; digitalis and other sedatives are lauded, but setons, issues, and the actual cautery applied in the vicinity of the medulla oblongata, are his sheet-anchors. He admits that nitrate of silver, zinc, and other remedies may have occasionally cured epilepsy; but when they have done so, he attributes the effect to the sedative effect they have exercised upon the intestines or upon the organs whose exalted sensibility proved an irritant of the medulla oblongata, probably in the same way as the semi-divided spinal cord of Brown-Séquard's epileptic rabbits.

We, too, have used setons and issues, as many have done before us, sometimes with advantage, more frequently without benefit to our patients. That there are many cases in which they constitute a part of a rational treatment, we believe; but we must demur to this being made our chief remedy, until empiricism or science demonstrates them to be so. With all deference, we would say that the distinguished Utrecht Professor fails to establish a uniformity, either in the morbid process or in the treatment; though we can scarcely refuse to admit that he goes far to demonstrate the site of the morbid condition which induces the epileptic paroxysm, or, to use an antiquated term, its proximate cause.

REVIEW VII.

On the Diseases and Injuries of the Joints-Clinical and Pathological Observations. By THOMAS BRYANT, F.R.C.S., Assistant-Surgeon, Surgical Registrar, and Lecturer on Operative Surgery at Guy's Hospital.-London, 1859. pp. 273.

Ir is almost superfluous to say of a work by one of the surgeons of Guy's Hospital, that it is based upon honest experience and sound pathology. The profession owes so much to the contributions of this school that such praises have become commonplace. A great reputation, however, is, in one sense, a dangerous antagonist, and there is no wonder if people are apt to ask of a book emanating from so celebrated a school, whether it quite sustains the well-won reputation of its hospital. We are not disposed to say that Mr. Bryant's book does not: true, we expected something more; we had hoped for a complete treatise instead of a mere series of Clinical and Pathological Observations; but Mr. Bryant is the best judge as to whether his present experience justifies him in attempting the more ambitious task, and if

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it does not, we must be content with a less systematic work. If in the following observations we appear to dwell more on the defects than the merits of this book, it is only with a hope that we may stimulate Mr. Bryant to continue labours which have already borne good fruit, and to apply them to the production of something which shall last beyond the ephemeral collections of "cases," and "observations"-things that pass out of notice almost as soon as published—and which shall clearly indicate the progress of our science on a matter on which no good English book has been written during the many years which have elapsed since Sir B. Brodie first put this subject on a scientific foundation.

The author disclaims for his work the title of a treatise, and certainly could not have made good any such assumption; yet it is more than a mere collection of cases illustrated by remarks, although notes of cases form far too large a proportion of the matter. A book which, in 273 small octavo pages, contains notes, more or less full, of eighty-eight cases, cannot be pleasant reading. It is notorious that almost every reader skips over the paragraph headed CASE, in order to arrive at the deduction, which he can remember, freed from the tedious details, which he is sure to forget. Our first suggestion, therefore, to Mr. Bryant would be to discard the formal notes of at least two-thirds of his cases, and trust to his text for embodying the results of his experience. No one will be in any danger of suspecting that he does not write from a long and studious observation of nature, and most of these cases prove nothing more. In the next place, it will not, we hope, be considered presumptuous in us to suggest that style should be a little more attended to in the present day. Slipshod English and inaccurate grammar were little thought of in the time of Astley Cooper, but we have reformed all this, and it is now expected of a surgeon that he should write like a member of a learned profession. Such phrases as "chronic disease in a passive or curative condition," "forcible extension was employed with only a good result," "neither generally recommending or condemning," "mobility of the articulation may be painful," might be quoted out of almost every page of Mr. Bryant's work; while the oddest printer's errors have been allowed to stand, such as writing the name of the celebrated Russian surgeon "Perigott" (p. 146), "more than he could bare" (p. 94), and the like. It is true that the primary aim of a surgical book is to teach practical surgery, but a little care would be well bestowed in putting the instruction in such a form as a man of liberal education would read with pleasure.

Leaving these smaller matters, let us see what Mr. Bryant has to say upon a part at least of his subject.

Synovitis and the chronic degeneration of the synovial membrane are first treated of, but without any attempt at originality, at least in the part which treats of inflammation. In considering the termination of synovitis, Mr. Bryant says: "When the joint has suppurated there can be no doubt about the propriety of freely giving exit to its purulent contents by a liberal incision." (p. 27.) This is precisely one of the points which, in a collection of 'Clinical Observations,' should have been most fully illustrated by cases and statistics. If there is "no

doubt" in the minds of surgeons about opening large joints in a state of suppuration, we can testify from personal observation that there is often much hesitation; and a good series of cases in which knee-joints had been saved from amputation or resection by timely incisions, would have done much to encourage the reader in the adoption of a course which is certainly recommended by reason, and we believe sanctioned by great success. Further, it is a point of much interest to determine the general consequences of such incisions. In children they are undoubtedly often followed by complete cure, and in adults it is not at all clear that incurable anchylosis usually follows. The subject is dismissed by Mr. Bryant in a single sentence, and without any allusion to the important difference in prognosis occasioned by the age of the patient.

On the question of the existence of synovial membrane over the articular cartilages in the natural condition, Mr. Bryant's opinion is in the affirmative:

"In a case," he says, "where the ankle had evidently but recently become inflamed, and presented a synovial membrane which was most exquisitely injected, films of recent but firm fibrinous material were poured out over the surface of the cartilage, and beneath this were fine radiating capillary vessels proceeding from the margin; in one spot I carefully raised the deposit of lymph, leaving the injection as clear as ever; it became evident that these capillaries were not, therefore, on the new-formed membrane, but existed either in the cartilage or upon a membrane covering it. This latter was undoubtedly the case; and the fact goes, I think, positively to prove the existence of a layer of synovial membrane over the articular cartilage. But this was not all; anxious to make a microscopical examination of the part, I made a thin section through the cartilage and its vascular covering; the swollen synovial membrane became distinctly visible, covering the cartilage which had undergone the granular form of degeneration, and with care the membrane was separated from its cartilage by means of needles." (pp. 20, 21.)

The observations of Mr. Bryant on the subject of chronic degeneration of the synovial membrane lead him to conclude, with most pathologists of the present day, that the disease is a mere result of chronic inflammation, and that there is nothing peculiar about it. He describes, however, two forms of the disease-the "gelatiniform," aud the "pulpy," of which the inflammatory origin of the former he thinks more clearly proved than of the latter; but we cannot say that he has established any rational ground for the division which he makes, and to us they seem merely two different appearances of the same thing.

Mr. Bryant's views on the pathology of the articular cartilages are probably known to most of our readers, by a paper read before the Medico-Chirurgical Society, and of which an abstract will be found i their 'Proceedings,' vol. i. p. 70. They may be thus summed up in Mr. Bryant's own words:

"The diseases to which articular cartilages are liable may be thus classed. Like other tissues, they may undergo hypertrophy or atrophy, using the latter in its simplest sense. Inflame and ulcerate they cannot, as the presence of vessels in the tissue is generally considered necessary for such processes. But to granular, fatty, and fibrous degeneration they are peculiarly liable; and in these forms of degeneration may be included the processes which have been ŝo variously described by different authors." (p. 42.)

We will not quote more largely from Mr. Bryant's work on this head, as no doubt his views are familiar to most of our readers. The principal fact on which Mr. Bryant dwells is, that as cartilages derive their nutrition from other structures (either the bones or synovial membranes, as he believes), so their diseases are secondary to the affections of these structures. But this order of events is, according to his own showing, not universal.

"There is a form of disease which approaches the nearest to primary disease of the cartilages, in which this structure rapidly disappears, followed by, or connected with, suppuration of the joint; it is seen in patients of middle age who have had an attack of rheumatism, which at last settled in one joint. . The disease is at first confined entirely to the cartilage, involving the synovial membranes in a secondary manner. The cartilage may disappear, and in healthy subjects ankylosis may rapidly take place," &c. (p. 63.)

In these cases, then, we have, according to Mr. Bryant's statement, an acute disease attended with all the symptoms of inflammation, commencing in the cartilage, and producing its absorption. Whether the old term "ulceration" be retained for this, or the new one proposed by Mr. Bryant, "granular degeneration," be substituted, seems to us more a verbal than a practical question. For ourselves, as the old term at any rate keeps alive in the minds of those who use it the essential idea of the disease—viz., that it is one of the sequelæ of acute inflammation, while the new name rather keeps this connexion out of sight, we should prefer the old term, bearing in mind, of course, that inflammation and ulceration of non-vascular tissues differ in certain easily-described particulars from the usual instances of those processes.

This subject has been most ably treated by Mr. Barwell, in the last number of this Review, and to that paper we would refer our readers for a proof that the terms "inflammation” and “ulceration” may be as rationally used of cartilages as of any other structures. We would refer to the section on "Treatment" appended to Mr. Bryant's account of the diseased condition of the cartilages, as a specimen of the ill effects of the subordinate importance which he has attached to these structures. It has seldom been our lot to see anything in a practical surgical work more meagre and unsatisfactory. In fact, all the chapters on treatment are very slight. This perhaps is intentional in a work which professes to be merely a collection of "observations," but it is not the less to be regretted. We believe a student might read the work from beginning to end, without being aware that any one had ever made an issue for the cure of a diseased joint; and in the only passage, as far as we can discover, where mercury is distinctly spoken of, its use to salivation is unhesitatingly condemned, and perhaps rightly enough in the particular affection which Mr. Bryant is there speaking of-viz., chronic affection of the articular extremities; but surely some opportunity should have been afforded to the reader of learning his author's opinions on two such very important points as the use of issues and salivation in treating the disease which, if Mr. Bryant will not permit us to call it acute inflammation of the cartilages, we hardly know what he would have us denominate it.

On the subject of diseases of the articular ends of the bone, Mr. Bryant is, we think, more happy, and puts in a strong light the important fact that "the majority of the cases which are described by surgeons as strumous or scrofulous disease of a joint depends upon a chronic inflammation in the bone." (p. 72.)

The whole of this section on inflammation of the articular extremities of bone is well worthy of perusal, and its defects only lead us the more to regret that Mr. Bryant did not delay the publication of his book until he had worked it up into a complete treatise on the whole subject. No one who reads this chapter attentively can doubt that Mr. Bryant's experience has been as ample as his industry has been untiring. But, on the other hand, no one can say that the diagnosis is clearly laid down, or the treatment fully and logically prescribed.

On the subject of amputation or excision, Mr. Bryant has a very interesting chapter. He speaks strongly, perhaps too strongly, against excision of the hip; and is hardly more favourable to excision of the knee. On the subject of the comparative mortality of excision of the knee and amputation he makes the following rather startling obser

vations:

"In a paper which I have read before the Medical and Chirurgical Society, I demonstrated that the deaths from amputation of the thigh, including these two last specified classes of cases-[i.e., if we understand Mr. Bryant's meaning, amputations for diseases, or pathological,' as he terms them], was [sic] about one in seven; and this is the least favourable view of the operation. Mr. Butcher and Mr. Price, avowed advocates for excision, give the fatality [a term which Mr. Bryant always uses instead of mortality'] of excision of the knee as one in five, and this shows the most favourable aspect. In the hands of some experienced surgeons the fatality has been more than half. Unless, therefore, the advantages to be gained by preserving the leg can be proved to be so great as to counterbalance this great difference in the risk of the operation of amputation, as performed in a large London hospital, I think it will be difficult to prove that the operation of excision should, as a rule, be preferred." (p. 143.)

We think this argument is pressed rather too far, but the fact is a striking one, and the data on which it is asserted are deserving of very attentive sifting. If the cases on which the returns were made are fairly comparable with each other, one great argument for their favourite operation will be taken out of the mouths of the partisans of resection, and it will be restricted to exceptional cases. Mr. Bryant is not, however, by any means an opponent of conservative surgery, and speaks in terms of just praise of resection of the elbow and shoulder.

A few pages on loose bodies in the joints, and a valuable chapter on inflammation external to the joints, and "bursitis" (a barbarous word, which we trust will not pass into common use), conclude the portion of the work which treats of diseases of the joints, the whole being summed up in a statistical table (p. 174), which shows indeed the large materials from which Mr. Bryant has worked, since it includes 974 cases, but is useless for drawing any practical deduction as to the success of treatment, the majority of the cases (538) being returned as "relieved," a vague way of saying that the case was left incomplete,