under its middle. When the opening, for example, is of the size of an English silver twopenny piece, the round cautery which is applied should equal in circumference that of a shilling. The cauterization of the circumference must be slight, so that only a layer of skin is destroyed of the thickness of strong letter paper. When the operation is finished, the roll of charpie is removed from the canal of the intestine, and the whole of the parts are covered with some handfuls of soft cotton and a compress, over which a broad suspensory or T bandage is applied. The bandage is as frequently renewed as it is soiled, the patient kept on low diet, and a clyster administered daily at least. The granulations which spring up after the separation of the slough are to be protected from the excrements by dressing, afterwards a stimulating ointment is used, assisted by caustic, and any small opening which remains is closed by the running suture and repetition of the actual cautery. This method is best adapted for large scrotal hernia. When there are several small openings, they are treated in the same manner, but when it can be determined that some of the openings are in the lower part of the intestine, or that the smallest portion of excrement passes through them, they are to be first closed, as their cure is more easy." (pp. 723-5.)

Cure of the preternatural anus of a hernia, and of the latter, can only be affected when the scrotal hernia is moderately large, when it contains only a simple loop of intestine, and when the ring is small. Only a strong young subject is fit for the operation.

The condition here is as follows. The contents of the intestine pass from the abdomen into the protruded gut, and then escape through the preternatural anus. The gut at the situation of the opening is large, the other part, particularly when it passes through the ring, is contracted, and when this state has existed long, it is so narrow that only a thick catheter will pass. The intestine frequently lies free in the ring like a reducible hernia, but sometimes adhesions have formed. When the intestinal opening communicates with that in the skin, the skin, sac, and intestine are all adherent to each other.

Treatment when the hernia is moveable. When the loop of intestine is only adherent at the situation of the preternatural anus, and the lower part of this loop is still in some degree wide and extensible, we must endeavour to dilate the rings by division with the knife without opening the sac. Then by gentle manipulation the upper part of the protrusion is gradually returned. This is possible without the use of the knife, if the rings are not very small. Before the wound has become cicatrized, the cautery is to be applied as before directed, and as the opening is diminished the intestine is pushed farther back into the abdomen. When the opening is perfectly closed, the intestine is replaced as far as possible. The portion of intestine which adheres to the integument is drawn outwards as a diverticulum, afterwards the cellular connexions become lengthened, and the hernia is prevented from reappearing by a truss.

Treatment of preternatural anus in a small adherent hernia consists— 1, in destruction (verödung) or removal of the adherent loop of intestine; 2, in forming a common preternatural anus; 3, in healing the latter. We shall follow our author's description of this operation, as he says he has thus exactly detailed the state and treatment of a man 28 years of age, who, in a year, was cured perfectly of a scrotal hernia of the size of a fist, and of a preternatural anus which opened into it.

"The operation commences with division of the scrotal integument, and opening of the hernial sac, just as in the operation for hernia. The opening being

carried to two thirds of the length of the tumour, the spot is reached where the loop of intestine passes through the ring. Without separating the adhesions at the ring, their union with the neck of the sac is to be loosened. When this is completed, the intestine is cut through close before the ring, first dividing the part in which the anal opening exists, and then, at the same height, the part which passes into the abdominal cavity. If the two intestinal extremities are not closely adherent to each other, their sides turned towards each other are to be united at their edge by a thread passing between their serous surfaces. The separated perforated loop, with contracted canal and hypertrophied walls, is loosened and removed from the hernial sac, and also any degenerated portion of the sac and scrotal integument.

"After the bleeding has ceased the cavity is filled with loose charpie, strips of plaster laid over it, and the whole covered by charpie, a compress, and T bandage. "The bandage is removed as often as it is soiled, free evacuation of the excrement attended to, and after some weeks, pressing backwards of the intestinal extremities into the abdomen is effected by balls of charpie laid against their openings. The condition is then the same as if the loop of intestine had been lost by strangulated hernia, and a common preternatural anus had been formed. After some months, when the hernial sac is obliterated, when there is a free passage to the intestinal extremities, when the adhesions have become extensible, then the preternatural anus is to be treated exactly in the manner before described, by the application of the ivory crutch and elastic truss. If the inferior extremity be considerably contracted, it is to be gradually distended by tents; but if the crutch can be first brought to bear upon one of its walls, its gradual dilatation will be thus readily effected. Lastly, when the two extremities have been pressed deeply backwards into the abdomen, so that they lie with their openings towards each other, the excrements begin to pass by the anus, and the cure approaches. Closure of the external opening in the scrotum here offers little difficulty, as the intestinal extremities lie at a considerable distance from it, and no integument has been lost. The actual cautery is here seldom necessary, as the use of caustic will close any remaining fistula." (pp. 726-7.)

"In case the separated adherent loop of intestine should be left, in order to avoid an extensive wound, it would be advisable to destroy (veröden) its canal, by drawing a thick cotton wick through it, and, if necessary, this may be covered with an irritating ointment." (p. 728.)

The transplantation of an autoplastic flap is only required in the treatment of artificial anus, when the skin surrounding the orifice is hard, inextensible, and altered in structure; if it be soft, pliant, and extensible, the opening, even if large, may be closed with the running suture. If a ridge exist, it must, of course, be first removed, either by pressure or by the enterotome. It is unnecessary to describe the details of the operation; but Dieffenbach insists that the transplanted flap shall not completely obstruct the exit of the fæces in the first instance. His earlier operations sometimes failed from neglecting this precaution, and he, therefore, fastens the flap by suture in two thirds of its circumference only, the anterior border being left free to allow the fæces to escape. When the operation is completed, water is injected under the flap, and then charpie introduced beneath it, and the whole supported by strips of adhesive plaster, the free edge of the flap, however, being left uncovered. The chief point in the after treatment is to endeavour to prevent the passage of fæces for as long a period as possible, which is sought to be effected by perfect quiet, dry food in small quantity, small doses of opium, and small enemata of castor oil and camomile. If the dressings, on careful examination, do not appear soiled, they are not disturbed for three or four days; if soiled, they must be immediately renewed. The sutures should

be removed about the eighth day. When the attached portion of the flap has completely united, the issue of fæces should not be opposed by strong pressure, but merely impeded by charpie, and endeavours made to heal the opening by granulation, by the application of resinous ointments, &c.; generally the opening gradually contracts to a mere fistula, which, by proper management, finally heals. If, however, the flap unites imperfectly, it is very apt to contract towards its base; which must, as far as possible, be counteracted by the judicious application of pressure, and keeping it on the stretch by adhesive strips of plaster, while granulation of its edges is at the same time promoted by resinous ointment. Fomentations with camomile sometimes appear to be extremely useful.

The formation of a bridge-like flap is preferable when the skin on, at least, one side of the opening is healthy and extensible-the orifice is circumscribed by two long concave incisions, vertical, transverse, or oblique, according to the existence and position of cicatrices, and the included skin is smoothly dissected away. An incision is now made parallel to one of the wounded edges. The strip of skin thus isolated must be one third wider than the opening. Its inner border is fixed with hooked forceps, and it is dissected from the subjacent parts in the interspace between the two incisions, and when thus completely free, except at its two extremities, it is drawn over the opening and attached to the opposite edge. The after treatment is the same as when a pediculated flap is transplanted.

We have space for but little comment on the foregoing summary of Dieffenbach's practice. We regard simple pressure on the ridge with great apprehension, because of the absence of a point d'appui, on the wall of the intestine, where it is attached to parietes of the abdomen, whence the risk is incurred of the adhesions in this situation being torn. But Mr. Trant's instrument (which, as we happen to know, Dieffenbach has seen) is free from this objection; for it supplies the point d'appui, and, consequently, there is no danger of the bowel being torn from its attachment. We cannot pretend to deny that the running suture may often be useful, and sometimes indispensable; but we are strongly inclined to the opinion that Dupuytren's compressor would in many, perhaps most, instances efficiently and more conveniently replace it. The use of the actual cautery is, we are sure, quite too much neglected by British surgeons. The extraordinary tendency of the cicatrix of a burn to contract is a familiar fact; whence we may appreciate the amount of contraction that may result from a circular cicatrix thus produced.

We always feel much hesitation in pronouncing any opinion respecting a point on which we have had no practical experience; but we must confess that we have detailed Dr. Dieffenbach's proceedings for the cure of a hernia concurrently with that of artificial anus, as a curiosity of operative surgery. When Dr. Dieffenbach published an account of his outrageous operation for stammering, by sub-mucous section of the base of the tongue, he said it was an operation not to be undertaken save by those endowed with the "operative temperament;" and we think the temperament in question should be possessed in very full measure, and, perhaps, coupled with the absence of some other qualities which we need not specify, to induce a surgeon to imitate the proceedings detailed at the commencement of our 35th page.

ART. II.

Nosologia Positiva. Scritta da VINCENZIO LANZA, Dottore in Medicina, Professore nella Cattedra di Medicina Pratica della Regia Universita' degli Studi di Napoli, Medico Primario e Direttore della Clinica dello Spedale della Pace, &c. &c.-Napoli, 1841-2.

Positive Nosology. By V. LANZA, M.D., Professor of the Practice of Physic in the Royal University of Naples, &c.-Naples, 1841-2. 2 vols. 8vo, pp. 608-760.

WE feel that we have been too long in directing the attention of our readers to these remarkable volumes; because although we have before us only two of a work which it is anticipated will extend to five, still it is of a character which, we humbly conceive, claims for the author the general encouragement of his brethren, and which promises, in return, to be of signal service to the profession, especially under the peculiar circumstances in which it is now placed. If, at the present day, there is one feature of medical literature more striking than another, it is its superfluity and redundance. With much, very much, that is excellent and valuable, there is vastly more that is trashy and contemptible. How many are the cases published which have no existence save in the distorted views of their authors? how many isolated facts brought to light with almost the assured certainty of being lost? and how many the ingenious speculations which scarcely outlive the day that gives them birth? when to these are added the many absurd professional fancies and fallacies which prevail among physicians and their patients, regarding the fashionable medical follies of the day, it must be allowed that there is here an amount of credulity and misdirected labour which with infinite benefit might be entirely suppressed. But how, it may be inquired, is this to be accomplished? We believe that, effectually, it never will;-inasmuch as the cause lies deep in human nature, and will ever and anon, in revolving cycles, be forcing itself into notice. All that can be reasonably expected is that the evil may be restrained though not suppressed; and we believe that works such as the one now before us, by enforcing better principles and especially showing a better example, are calculated efficiently to promote this most desirable end.

The range of Professor Lanza's work is most extensive, including practical medicine and medical surgery, which, scientifically considered, can never be dissociated; and its great object is to withdraw the healing art from the dominion of hypothesis "so that becoming positive" it may advance pari passu with the other natural sciences, and attain that elevation they are now so rapidly reaching. When, some half dozen of years ago, we had occasion to bring the subject of the science in Italy under the notice of our readers, we stated that "the Italian physic was still guided by the spirit of hypothesis ;" and it would certainly be interesting if the evil in that country, long unchecked, and so rendered intolerable by its profusion, were there first to receive a check which in its influences would extend over the rest of Europe, and to Britain, which of all other kingdoms seems at present most to require the pruning of such re

dundancy and prurience. Nor is it the general object and end only of this comprehensive work that we would commend. The execution, as partially exhibited in the volumes before us, has been the labour of the author's lifetime, not only among his patients, but in his study; and with the most intimate knowledge of the sentiments of his predecessors and contemporaries, there is conjoined a remarkable amount of independence and originality. His views frequently startle by their boldness, as much as their novelty, and are withal founded upon a most careful scrutiny of Nature, and a most patient observance of her laws. Seeing the eminent author prominently putting forward these claims, we shall take some pains to represent the ground on which they rest; though, from the perfect originality of the views, and, we venture to add, the provincial peculiarities of his style, it is not always easily done. At the same time, we trust that our readers will not suffer from any deficiencies of ours, nor fail to derive that benefit which we believe that a patient and careful perusal of the pages themselves would assuredly afford.

The preface of a work may be considered in the light of a personal introduction, wherein the author makes his salutation and first impression on the reader. Under this conviction we give Professor Lanza's nearly entire.

"Can medicine," demands our author, "ever be rendered one of the positive sciences, more especially in its application to the cure of disease? Is it necessary ere the healing art attain a character in every way satisfactory and reasonable, that the essence of disease, and the modus operandi of morbific causes, and the appropriate remedies, be ascertained? Lastly, may the processes of ratiocination in medical science from elements which are necessarily obscure, but yet probable, be reduced to conjectures which are simple though isolated? Or, on the contrary, is it necessary, as a first principle, that we start with hypotheses more or less numerous,-hypotheses which are themselves to constitute the system of medicine? The important questions associated with these interrogatories we know, from the writings of Celsus, engaged the serious attention of the ancients, and it is high time now, as most reasonable, that, though long neglected, medical men should again revert to their most serious consideration.

"Hippocrates, as sufficiently appears from his first aphorism, was quite alive to the difficulties which must be encountered in placing the healing art among the positive sciences; but throughout his entire writings he shows that he did not consider the object unattainable; and occasionally he propounds principles in perfect keeping with the design. Celsus, in his examination of the Greek writers, clearly propounded what physic as a positive science ought to be; and accordingly, in the preface of his work, requires the Empirics to accumulate not only clear and positive medicine, but probabilities also concerning the hidden seats of diseases, their anatomico-pathological form, and the influence of their latent causes; and to reject not only from their minds, but also from the art, all that is really obscure; so that idle speculation on the essence of diseases, and the operations of causes and remedies, might be discouraged. But though this celebrated author inculcated those principles in the abstract, he did not steadily observe them in such of his writings as have reached us; nor did he proceed regularly from the lucid description of disease to its cure; but in his interesting monographs often advises remedies without assigning the reason of their selection. Hence, although we may concede to Celsus an apprehension of what physic should be as a positive science, it is certain that he left no precepts for its cultivation in this particular manner.

"Galen was an advocate for the doctrine that the science of medicine should be