prefer;"-"The weight of authority is in favour of;"-"It is considered best;"-or, such and such circumstances "render this operation a favorite with most surgeons ;"-give a character of feebleness to the writing, which no one who is acquainted with Dr. Mütter's high reputation as an operating surgeon, would think in any way applicable to the writer. Nor is this effect lessened by the detail of measures which are afterwards unceremoniously dismissed with the remark, that the proposal is merely mentioned "as one of the novelties of the day, and wholly unworthy of our confidence;" or again, that "no surgeon of any note would condescend to employ so puerile a means;" or, "it will soon be remembered merely as one of the idle whims of some inventive genius." The Lectures are rapid sketches of the principal points of interest in a wide field; many of the additions are representations, begun on a more elaborate plan, but hurriedly finished, and less striking in the general result. Mr. Liston, it may be observed, presupposes a certain amount of knowledge of the general principles of surgery, as already given at a former part of the course by his colleague, Professor Cooper; and to this previous instruction he takes occasion to refer from time to time, when he passes lightly over abstract points, and adheres more closely to subjects of a strictly practical nature. Dr. Mütter proceeds on a different plan, and divides his subjects elaborately, as if giving the outline merely of a complete treatise. We can conceive two methods of oral instruction on such a science as surgery, each useful in its way, and yet each on such a perfectly distinct plan as to make it difficult (and only possible in an extended series of lectures) to unite the benefits of both. According to one plan, the lectures might consist of clear and graphic sketches of disease and its appropriate treatment, such as it exists in what may be called its typical forms, and always so connected with the relation of actual cases as to arrest and fix attention by rousing the hearer's sympathy. According to another plan, lectures might be made use of, less as a means of imparting particulars and minutiæ, than as an opportunity of directing the mind of the student in the exercise of thought; of pointing out to him the best and most credible sources whence to derive facts on the several subjects which present themselves; of giving him the valuable habit of arranging his knowledge in the best and closest possible manner, and of helping him to analyse, and to form a just estimate of the comparative value of information derived from different sources. These two objects might, indeed, be borne in mind at the same time, and carried out together by one lecturer, step by step; though we doubt the possibility of its being done in an ordinary course, in which a vast quantity and variety of matter is crowded. It would be a work of still greater labour to blend well together the results of two different minds directed to such different ends. We believe that Professor Mütter, therefore, was in error in wishing partially to combine elements of so different a nature and so difficult of combination; and in attempting to make these lectures (what they were never, to all appearance, intended to be) a complete and independent work. The most important and interesting of the additions made by Dr. Mütter are those on the subject of plastic and other operations for the remedy of deformities and deficiencies, both congenital and acquired, of the soft parts. As the arrangement followed by Mr. Liston is based merely on the locality of the surgical diseases of which he treats, these observations and details of special operations are necessarily scattered through the work. This branch of operative surgery has been cultivated most perseveringly and with great success, by several surgeons in America, amongst whom Professor Mütter occupies a prominent position. His contributions to science, on this head more especially, are as important to the profession as we learn his practice has been creditable to himself and beneficial to those who have fallen under his hands. The principle most clearly established by the repeated and varied trials of plastic operations appears to be that of making as broad and even a pedicle as possible to the transposed flap of skin, in order to leave an efficient vascular and nervous communication between the disturbed and the comparatively non-disturbed parts. The method of twisting the flap upon itself (as in the Indian operation for the formation of a new nose) has, we believe, been adhered to longer and carried out further in this country than the success attendant on it has warranted. A much more successful plan (as Dr. Mütter shows from his own experience and from that of other surgeons) consists in cutting the flap in such a situation, that the direction it is made to assume is inclined at only a small angle from that of the surface from which it is taken. The pedicle need not then be twisted, and may be made broader than when this is requisite; or, still better, where it is practicable, separating the deep attachment of the skin, for some distance on either side of the cicatrix or part to be filled up, sliding the then moveable integument over the subjacent parts until the defective surface is completely covered; and, lastly, securing it in its new position by the usual means. As an illustration of this principle, we may follow Professor Mütter in some of his descriptions of plastic operations. In the fifth Lecture, when treating of the mode of partially restoring the alæ of the nose, we find the following account of an operation performed by the Professor in the case of a gentleman who had lost "the whole of the right ala, as well as the adjacent soft parts, as high up as the os nasi of the same side," leaving a transversely oval opening, which measured three quarters of an inch across and half an inch in its vertical diameter. "Seating myself in front I commenced the operation by inaking, with a small convex-edged bistoury, an incision extending from a few lines above the superior border of the orifice, to a short distance below its inferior, and directed downwards and outwards. It did not penetrate to the bone, but was sufficiently profound to allow a flap about three lines in thickness to be readily detached. This incision was completely on the outside of the cicatrix, a portion of which was subsequently removed, in order to prevent its hardened edges from irritating the raw surface of the flap, which was to be placed immediately upon it One or two arteries were cut across, but the hemorrhage from them was arrested by pressure, until the second incision was made. This commenced at the terminal extremity of the first, and extended horizontally outwards about an inch. A triangular flap was thus marked out, and immediately detached from the subjacent bone by dissecting with the edge of the knife, held nearly parallel to the surface of the cheek. In the execution of this part of the operation two or three arteries of some size were necessarily cut across, and required the application of the ligature. The third incision, which extended from the initial extremity of the first to the point of the nose, was made with a pair of strong scissors, those being preferred to the scalpel, in consequence of this margin of the orifice being, to a certain extent, loose and unsupported. The triangular piece of cicatrix included between the superior extremities of the first and third incisions, was then removed with the scalpel and forceps, and the sharp margin of the inferior portion of the opening also pared off, for reasons already stated. The hemorrhage having been arrested, and the parts properly sponged, the next step of the operation was undertaken. This consisted in the approximation of the first and third incisions, and the application of such measures as were calculated to retain the flap in its proper position. From the free dissection and the yielding character of the subcutaneous cellular tissue of the cheek, no difficulty was experienced in placing the edges in contact; and in order to ensure their perfect and close approximation, four stitches of the interrupted suture, made with saddler's silk, waxed and doubled, were passed. In addition, two or three small adhesive strips were applied to the spaces between the sutures. Finally, in order to prevent adhesion between the flap and the raw surface beneath it, and to give a better shape to the former, a small roll of soft lint, well oiled, was introduced into the new nostril. (p. 173.) The sutures were not removed until the end of the fourth day, when union by the first intention was found to have taken place throughout. About the third week the lower margin of the flap was cut with a pair of scissors to give "the proper curve" to the ala. In consequence also of the septum of the nose being a little drawn to one side, apparently by the contraction of the flap, "the line of union between the base of the flap and the cheek was divided, cutting from within with a small scalpel, held parallel to the surface of the cheek, to the extent of three or four lines." The plug of lint also was increased in size, and a strip of plaster carried across from the tip of the nose over the sound cheek, so as to draw the whole organ in the opposite direction to that towards which it was inclined. "At the end of the sixth week from the day of the first operation. it was determined to execute the third step' in the treatment. This consisted in the division of the skin and cellular tissue at the base of the flap, in a semicircular direction, the convexity of the curve looking outwards. The object of this incision was to give the peculiar rounded margin of an original ala, to diminish the fulness of the cheek where the natural depression should exist, which depression had of necessity been destroyed by the tension of the flap, and to permit a return of the perpendicular position of the deviated septum nasi. The incision was made with a small scalpel, and extended to the bone. In order to prevent the union of its margins, a small roll of oiled lint was introduced into the cut, and a strip of adhesive plaster applied to the tip of the nose, and fastened on the cheek of the sound side. On the third day the dressings were removed, and it was found that the margins of the incisions were nearly cicatrized and beautifully rounded off. This latter change was a very favorable circumstance, as it produced a depression in the exact spot at which it was required, in order to give a proper expression to the face. Had it not taken place there would have remained a sort of inclined plane from the bridge of the nose to the outer portion of the cheek. At the expiration of the ninth week my patient returned home with scarcely a vestige of his deformity remaining." (p. 176.) Truly, American surgeons have very far outstripped their English brethren when they can take into account the "proper expression" of the face. We can, from this, better understand the contempt with which another of their surgical writers, remarking on the subject, designates "the fruits of the dexterous manipulations of most nose-makers" as being, "most frequently, little else than pug-shaped, flabby, and moveable knobs, that look more like small shrivelled potatoes than bona fide human Under the head of cleft-palate, concerning the operations for the relief of which Mr. Liston speaks very discouragingly, Dr. Mütter introduces some admirable, short, and practical observations on the chief sources of difficulty and danger, both at the time of and after the operation; together with a brief detail of the means available for obviating the effects of such untoward and often perplexing circumstances. Dr. Mütter lays great stress on the advantage of simplicity in the form and construction of instruments to be used in these operations, and on the expediency of frequently handling the parts, for some days before operating, so as to "familiarise" the fauces to the presence of foreign bodies. In the eighth Lecture is introduced an interesting account of a case of cancer of the lower lip, in which Professor Mütter removed the diseased parts, and at the same time restored the lip by a plastic operation. The latter step, which consisted in detaching and drawing up from the chin two symmetrical side-flaps, which were then united along the middle line, was ingeniously planned, and appears to have succeeded admirably. The patient remained well when seen after an interval of two years. doubt, however, whether surgeons in this country would not have been satisfied, in the first instance, with getting rid of the disease, and deferring any further proceeding until the tissues near the excised part should have cicatrised, and remained for some considerable period free from any appearance of return of the disease. We The treatment of deformities resulting from burns is also much illustrated in this volume by Dr. Mütter. The author, as is well known, has published, in a separate form, several valuable essays on this subject; but as the principal of these were noticed by us in a recent number (Vol. XXXVIII, p. 396), we must refer to our former article for an account of the improved mode of practice recommended by him. Dr. Mütter agrees with Mr. Liston in strongly reprobating the performance of "ovariotomy" in the present state of our knowledge of the diagnostic signs of ovarian dropsy. He here takes occasion also to introduce part of one of his own lectures, in which this opinion is expressed, with the candid and prudent reservation, "that should the difficulties about to be stated ever, by subsequent observation and research, be removed," he will be ready at once to change his present views, and rank himself among the advocates of the operation. Then follows a good summary of the most important objections that have been urged against the proposal. Large, and we are inclined to think disproportionate, additions are made on the subjects of hemorrhage, cataract, anchylosis, club-foot, and division of tendons, which our limited space obliges us to refrain from noticing further. Dr. Mütter's volume ends very abruptly. By way of completing the last subject (the treatment of calculous complaints), Mr. James Arnott is laid under contribution; and an account of the merits and principles of lithectasy, borrowed from that surgeon's paper, occupies rather more than ten pages. Unfortunately, Mr. Liston is not heard to the end; for his concluding lecture on lithotomy in the male, stone in the urethra, and on calculous and other diseases in the genito-urinary organs of the female is not here published. On referring to the Lancet,' we find that this lecture was reported in two parts, of which one appeared November 15th, the other December 13th, 1845; but neither, we suppose, reached Phila delphia in time for insertion in this volume. In his preface, dated January, 1846, Dr. Mütter says, "It will be observed that this volume contains all the lectures published up to the present date, but does not conclude the course. Another volume will be issued hereafter, should the publication of the lectures be continued." We should not have remarked on this little fact, had it not been a part only of the evidence the work affords of being composed with ill-judged haste; a haste which clearly originated in an anxiety on the part of the publisher to secure the profits of a promising speculation,-making it, as it would seem, quite a secondary consideration whether or not the work should be as worthy as possible of the two distinguished names under whose authority it appears. For this we do not conceive, nor would we for one moment be understood to imply, that the learned Professor of Jefferson College is answerable; but we cannot conscientiously acquit him of all responsibility. In default of a better and juster code of international law for protecting the fair interests and vested rights of authors (years of thought and study vested in print and paper), and defending them from the privateering system of the trade, we should like to see men of Dr. Mütter's character and position in the profession and in society, take their stand on the highest ground, and decline to append their names to hurried productions such as the present undoubtedly is. Nor is it expecting too much from them to do so, for lookers-on can see evident proofs of the ill effect the present system has upon their writings and upon themselves. ART. VIII. Die Acute Entzündung der Serösen Häute der Gehirns und Rückenmarks. Nach eigenen Beobachtungen am Krankenbett geschrieben. Von Dr. JOSEPH NEISSER, Prakt. Arzt zu Berlin.-Berlin, 1845. By Acute Inflammation of the Serous Membranes of the Brain and Spinal AN apology to our readers is, we think, scarcely necessary for introducing to them a practical work on inflammatory affections of the brain. A correct diagnosis and treatment have an important social as well as a technical value. Insanity is considered by many to be a greater evil than death; imprisonment in a lunatics' hospital more distressing than entombment. We are convinced that a more correct diagnosis and treatment in this class of cases, would not only prevent the supervention of that form of chronic cerebral disease which constitutes insanity, but would obviate the serious mistake sometimes made by practitioners in the removal of cases of acute arachnitis to lunatic asylums as cases of mania. We know of more than one family on which the stigma of hereditary tendency to insanity has thus been fixed, and, we believe, we know also cases which have been maltreated in consequence of this mistake. Dr. Neisser's work is divided into three parts: the first part, termed |