and we should be indeed wanting in courtesy if we did not take every opportunity of expressing our gratitude and the gratitude of the profession in England generally for the great liberality with which these costly volumes have been distributed not only to the public libraries and journals, but also to private individuals in this country. We observe, with very great pleasure, that the volumes embodying the complete medical history of the whole war, of which these are but detached portions, are advanced in preparation, and the first instalment of them may shortly be expected.

Meanwhile, we turn to the present treatise on one of the most difficult and most contested points of military surgery.

Every hospital surgeon will readily concede that a compound fracture laying open the hip-joint, whether from a gun-shot or from other injury, is as a general rule a fatal accident. The question on which opinions are divided is what rules of treatment does experience suggest whereby the greatest proportion can be saved? By some it is taught that primary amputation is in these injuries universally fatal, and therefore should be banished from surgical practice, while secondary amputation is looked on with favour. Others are in favour of excision, primary or secondary; others prefer, as a general rule, the expectant treatment. The author of the above official report (Assistant-Surgeon Otis, Curator of the Army Medical Museum, U.S.) does not affect to settle these questions, but merely to bring forward materials for their discussion, supplementing these materials by the opinions expressed by those from whose practice they were collected. The pamphlet by Dr. Eve is, as far as the statement of amputation is concerned, embodied in the official report, with some discrepancies which are too trivial to mention.

The report enumerates and tabulates sixty-one cases of amputation for gun-shot wound performed previously to the war under consideration, and gives the references and results of 111 cases of amputation in civil practice. To these are added more or less detailed histories of fifty-three operations performed during the American civil war, all for gun-shot injury, nineteen of which were performed by Southern, or rebel, surgeons, and are included in Dr. Eve's pamphlet. These amputations are divided by the reporter into four classes. 1. Primary, i. e. performed before consecutive inflammation had set in, the duration of which period, he says, will very rarely be found to exceed twenty-four hours. 2. Intermediary, performed during the persistence of the inflammatory stage, a variable period, usually included between the day after the reception of the injury and some time in the second or third month.

3.

Secondary, or those performed at a period when the inflammation had abated, and the lesions had become, in a measure, local and analogous to chronic disease. And, 4. Re-amputation, after previous amputation lower down. We confess that we do not see the advantage of the separation between the second and third classes in cases like these where the notes are so imperfect as to lead to grave doubts whether so difficult a distinction has been at all correctly adhered to. Out of the fifty-three fresh cases included in the report, nineteen were primary. All the patients were known to have died of the direct results of the operation, except three. Out of these three, one was in excellent health at the date of publication of the Report, more than four years after the operation. The other two were known to be alive, and in good condition, in one case two months, and in the other six months after amputation. If all the cases previously published be added to this list, of which not one is known to have survived, and we concede the reality of recovery in the two cases left incomplete, we shall have forty-four primary amputations with three recoveries. Although this is a black list, it certainly proves that recovery is not impossible, and encourages the performance of the operation in cases otherwise hopeless. Such, for instance, was one of the Southern cases which recovered. The surgeon was close to the man when he received his wound. The femoral vessels were lacerated, and the upper part of the femur smashed to pieces by a large fragment of shell. Compression was kept up so that the man did not bleed to death, while hasty preparations were made for amputation literally sur le champ. The patient recovered without an unpleasant symptom. But such cases as this can only occur very rarely, and the most that we can say after perusing the report is that primary amputation at the hip is not necessarily fatal, but that it is so so very often that it ought not to be performed when the slightest prospect of recovery exists without it, and this is the general effect of the opinions of the surgeons quoted in the report. In the second, or "intermediary" category (i. e. those amputations performed during the presence of inflammatory symptoms) eighteen American cases are included, which were all fatal; of sixteen cases which are added from previously published sources, two recovered, so that the average mortality, if we could trust to the classification, would be shown to be about the same as in primary amputation. In the third class, or that of "secondary" amputations, in the narrow sense here sought to be introduced

The official reporter hesitates to admit these as cases of complete recovery, but the fact is proved from Dr. Eve's pamphlet, for both these cases occurred in the Southern army.

(when the inflammatory phenomena have wholly passed away) only nine fresh cases are reported, two of which recovered, and eighty previously published, five of which recovered. While unsatisfied of the scientific accuracy of the classification, we are quite ready to admit that in this, as in every other kind of amputation for injury, the prospect of survival is better the more completely the surgical fever following the injury has passed away. Finally, eight re-amputations are tabulated (all of which, except one, occurred in this war), and of which one half recovered. As an appendix, fifty-six miscellaneous cases (not American) are briefly referred to, the details of which are imperfect. The total gives 161 cases, with 142 deaths. Of the nineteen who were not known to have died, the reporter classes three as uncertain, but, as we have stated above, if this intends to include the two primary amputations in the Southern army, the reality of recovery seems in those cases completely proved.

The result certainly tends to establish the soundness of the advice given by the best military surgeons of modern times, to avoid the amputation at the hip-joint as a primary proceeding. In desperate cases, it is no doubt justifiable, and a life may here and there be saved by it, but such cases will be of the rarest. The chief interest of the question, however, now is as to the value of the operation as a secondary proceeding. In this inquiry we must distinguish two classes of cases, the one where the mischief is limited to the upper end of the femur, the other where chronic osteo-myelitis has invaded that bone in the whole or a great part of its extent. In the former class it seems probable that excision will be found to give better results than amputation. Thus, in Dr. Eve's pamphlet, we find a table of thirteen cases of "Resections at the Hip-joint," of which four survived entirely, one fell into the enemy's hands, and probably died, and one would, it was thought, have recovered, but for want of nourishment, to which he succumbed two months after the operation. It must be admitted, however, that Dr. Eve's table is not accompanied by sufficient details to render it entirely satisfactory, nor is this surprising, considering the nature of the service to which it refers. As far as it goes,

1 We cannot refrain from giving the last few lines of Dr. Eve's pamphlet. Whatever our feelings may be as to the political aspects of the war, no surgeon can feel otherwise than proud of the heroic exertions of our colleagues to save life in the dreadful circumstances which surrounded the Southern Army. Dr. Eve thus compares the Southern statistics, as far as he had been able to collect them, with those at that time issued from the Surgeon-General's office of the United States army :

"In Circular No. 6, Oct. 1865, War Department, Surgeon-General's Office, Washington City, is given a table of twenty-one hip-joint amputations with three successful results. One of these is proved to have been erroneous, which reduces

however, it shows that the cases of resection are on the whole less fatal than those of amputation, doubtless because they are less often primary. But the most difficult question remains still for future experience to solve. We can hardly doubt that the following opinion is correct, given by Dr. Gilmore of Alabama, who himself amputated at the hip three times, and performed excision three times (and with one success in each) during this war:

"I recollect some six cases, that would have required amputation at this joint, which recovered without an unpleasant symptom. One case wounded at the battle of Fredericksburg, a Mississipian; two cases wounded at Chancellorsville, Georgians, and the remaining cases wounded at Gettysburg, two of them of Kershaw's South Carolina Brigade, and the other of a Georgia Brigade.

"I believe that one third of the cases of gunshot wounds of the femur, usually supposed to require amputation at the hip joint, will recover if left entirely to the efforts of nature; and I am confident that a much larger percentage will die if subjected to either amputation or resection." (P. 12.)

That this is the correct view of the case is becoming more and more generally admitted; but we have little doubt that the experience of future wars will enable surgeons to contribute more authentic data than seem to exist at present for determining the actual results of the expectant treatment in these formidable injuries. With regard, again, to cases of chronic osteo-myelitis of the femur, its symptoms and the indications for amputation, much remains for future inquirers to supply. Meanwhile, the present volume contains some useful material.

The reader must not imagine that these returns of the SurgeonGeneral are complete, and comprise all the cases of each kind which occurred; but they bear internal evidence of disinterested accuracy, and we believe that they may be trusted to as unselected and impartial. For statistical purposes a large and unselected return is nearly as good as a complete one.

The Surgeon-General has also been so good as to send us his "annual report," comprising the total of deaths to strength, and such like official details. The only thing which strikes us in this document is the results of the examination of army the cases of recovery to one in ten, being precisely double the mortality that my statistics make it to have been in the Southern service; and of thirty-two cases of resection or excision of the head of the femur only four recovered, being a recovery of only one in eight, a fatality nearly four times greater than on the Southern side.

"Thus has the investigation of this interesting subject during the past two months, by the request issued from the office of the Surgeon-General, led the searcher unwittingly to a most favourable result on the side least expected when we consider the destitute and isolated condition of the South during the war."

surgeons, and which we commend to the attention of our own examiners.

"Number of candidates invited, two hundred and seventy-two (272); number fully examined and found qualified, forty-eight (48); withdrawn before their examinations were concluded, twenty-one (21); rejected after full examination, ninety-one (91); failed to appear, one hundred and twelve (112)—of these, forty-seven (47) were recommended and appointed, one (1) declined before appointment, and two (2) declined after appointment."

Thus, out of 160 candidates who appeared to compete, only forty-four ultimately got into the service. Clearly the U.S. army board do not err on the side of laxity.

ART. III.-Essays on Physiological Subjects. By GILBERT W. CHILD, M.D., of Exeter College, Oxford, M.R.C.P., &c.

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ON first taking up this small volume we were at a loss to understand what had induced Dr. Child to republish the few papers which form it in the shape of a separate volume. The preface, however, explains the matter. It seems that Dr. Child had always intended to collect into one body the various essays which he might publish, but that he had been compelled "by special circumstances to do so somewhat prematurely, and before his collection had reached any considerable bulk. By these "special circumstances" is, we presume, meant the fact that the author is a candidate for the scientific chair vacated by Dr. Daubeny's death at Oxford; and that he was desirous of showing the electors that he had not stood aloof from the physiological questions which have been afloat of late years, but had taken an active interest in them. This object is, doubtless, a perfectly justifiable one: and we must admit that this volume, so far as it goes, is evidence of the fact which we suppose Dr. Child is desirous of establishing. Although the papers in this volume appeared originally at various times and in various publications, they are not devoid of all connection with each other. The link between them is, indeed, sufficient to give a kind of unity to the whole book, which might as properly have been called "Essays on Subjects connected with Generation " as "Essays on Physiological Subjects," for it is with generation in some aspect or other that each of the essays is concerned. The first deals with the fertilization of orchids, the second with the effects of close inter-breeding, and the remaining two with the vexed question of spontaneous generation.

The first of the four papers is a reprint from the 'Spectator,' and consists of a review of Mr. Darwin's admirable work on the