central authorities seriously to undertake to remedy the most unsatisfactory state of the insane of the metropolitan department of France, by resolving to erect several new asylums in the country, fitted for their proper care and treatment. These reports will consequently be read with much interest, and their appearance will mark an epoch in the history of insanity in France.

*

The bulk of M. Girard's book is occupied with the statistical history of the Auxerre Asylum during a period of twenty years. He examines and analyses his statistics, and briefly records the deductions he arrives at. Nevertheless, he is careful to note in his Preface that his facts and opinions are based on the experience of only one institution; and that to render them more satisfactory and trustworthy in several particulars, it is necessary to collect similar statistics from other asylums in order to institute a comparison, and thus, by a knowledge of peculiarities affecting the people in the several districts, their occupations and modes of life, together with the meteorological and geological conditions existing, to check, so to speak, the conclusions deducible from the history of one asylum by those gathered from others.

The subjects of the several chapters are, The Movement of the Population of the Asylum of Auxerre; The Causes of Insanity; The Mode of Attack; The Duration; The Prognosis; The Cure; The Mortality; Incidental Affections; Seclusion; Causes of Epilepsy, and the Morbid Anatomy of Insanity. These several topics are studied statistically, and illustrated by numerous well-compiled and copious tables. His Introduction contains an apology for statistics as applied to the study of medicine, and defends their use and value. The chapter on Causes is very elaborate; and the careful records of his institution have enabled him to construct tables showing the influence of the seasons on insanity, as well as that of the barometric and thermometric conditions of the atmosphere, and that of the winds, of elevation of country, &c.

The character of the book-viz., a sort of catalogue of conclusions deducible from an extensive collection of statistics-forbids the attempt to give an analytical review of it. It must be studied by each one for himself in order to become acquainted with its contents and their value. To the diligent inquirer into the nature and causes of insanity it affords an ample store of facts, calculated to throw light on many debatable points.

The author intimates in his Preface that he has a collection of other facts"illustrating the state of the intelligence; of the moral sensibility and of the will in insanity; the functional changes; the organism involved by the existence of mental derangement; the disordered condition of the digestive functions; of the circulation; of the secretions of the liver, kidneys, skin, &c., in the affection." We hope to see these observations shortly published. To interpret the many mysteries clouding the whole subject of mental aberration we need a large accumulation of facts, collected at the present day with the aid of present enlightenment and of the modern means of research; and it is to physicians similarly circumstanced to M. Girard de Cailleux that

we rather must look for these facts, than to those who are still charged with the multitudinous and onerous duties of asylum management.

ART. XI.-Outlines of Surgery; being an Epitome of the Lectures on the Principles and Practice of Surgery delivered at St. Thomas's Hospital. By F. LE GROS CLARK, Surgeon to the Hospital, Consulting Surgeon to the Western General Dispensary, &c.-London. pp. 256.

In the early part of his career the surgical student often feels the want of some readable introductory handbook which, short of completeness, may serve to convey to him information on subjects of which he otherwise often continues ignorant until informed of them in a too-crowded detail. Such a book as this lies before us under the name of ' Outlines of Clinical Lectures, by one of the Surgeons of St. Thomas's.' In its present form and dimensions we argue that it will prove of constant utility to the student, and hope to see it pass through many editions. It is not, like too many modern books, intended mainly for reference; and we may affirm that, with slight literary merit or pretensions, it is deserving of the notice of the medical world for the subject-matter's sake. Such a work is open, we allow, to the accusation of being mistakable for a " Popular Treatise on Surgery," a class of production we should abstain from approving; but it will be disappointing to sly patients, chemists, and back-woodsmen, who may indulge themselves in the acquisition of it, to find that the treatment of disease is that part of the performance which is left, designedly no doubt, the most deficient in elaboration.

En attendant the publication of the lectures of which the present outlines are the first fruits, we shall remark upon the merit of the work as it stands. It is intended, the author informs us in his Preface, as an encouragement to the clinical industry of students, and, as we interpret his remarks, to serve them in lieu of larger books. It is not a mere framework like Tyrrel's Syllabus,' nor a systematized handbook like that of Druitt. We are ourselves of opinion that the occasional perusal by the student of the best class of monographs on disease forms a healthy kind of reading for him at every stage of his career, though they may cause a little delay in passing his examinations. Clinical study is of course to be regarded as the great field of industrial improvement; still, as has been said-it is not enough to look for a thing, it is well to be informed where you are to look for it.

There are, it may be said, two main divisions in the work before us, one of which, constituted by the last section, stands somewhat in the attitude of excuse for the other. This last section comprises those subjects which, with something like repetition, are the most amply treated of; and, indeed, it leaves nothing to be desired either in vigour or completeness: it is every way satisfactory, the author having somewhat overstepped the narrow bounds he has prescribed to himself elsewhere. The preceding sections, where the art and science of surgery is sought to be comprised in less than two hundred pages, have

fallen somewhat short of accomplishment, for the obvious reason that one part must necessarily suffer to give full development to the rest; and the promise has not been very fully maintained to make the enunciation of great principles the main feature of the book. By such method alone could it have been included in its present proportions.

As may be expected in a digest of surgical matters of great importance by so well-known a surgeon, omission rather than error will suggest itself on the most critical survey. We confess we have read the chapter on the diagnosis of certain fractures with more satisfaction than any other part, but some there are which approach it in excellence. A chapter on suspended animation and the use of chloroform follows it. In advocating the use of the anesthetic, the author bids us observe that the vapour of chloroform not only pollutes the air but prevents this from exercising its decarbonizing influence on the blood: he also insists on the practical advantage of a previous arrangement or compact with the patient, directing and obliging him to indicate by some mark of intelligence (pressing the assistant's hand, or other sign) the boundary beyond which volition, and with it sensibility, ceases.

The author's description of congestion, in the early part of the work, will give a fair idea of his style and method.

"Passive hyperæmia," he says, "or congestion, is the effect of mechanical obstruction, as where a vein is compressed or plugged. The consequence of such venous obstruction is distension of the capillaries, and, if continued, infiltration of tissues from excessive exudation of liquor sanguinis. Thus, oedema or local dropsy, ascites or abdominal dropsy, and anasarca or general dropsy, are produced. In this filtering process through the porous vessels the nutritive quality of the liquor sanguinis is modified by changes in the proportion of albumen and salts; so that, although the quantity of blood actually present in a part affected is unnaturally large, it is blood despoiled of its nutritive and stimulating properties, and therefore valueless for growth. Thus, congestion is an atropic condition; and its effect is the same as where there is simply a deficient supply of nutrient blood, without detention, as proved by the feebleness of muscular tissue, which is the seat of such congestion, the occurrence of ulcers in varicose limbs, &c."

The description of lithotomy is brief and good. We offer it the more willingly as a proper attention is given to making a free external incision, and to the management of the staff-two points of importance

"The operation of removing a stone from the bladder by cutting is performed by making a lateral incision in the perinæum, between the crus penis and bulb, and thus reaching the membranous part of the urethra, which is then perforated; and the left side of the prostate is next divided to an extent sufficient to allow the introduction of the forefinger: a pair of forceps is then guided through this opening into the bladder and the stone seized. Various cutting instruments are employed, but a grooved staff of full size, either curved or straight, is essential to guide the operator in entering the urethra and bladder. If the operator take the staff into his own hand, when he enters the bladder it should be either straight or moderately curved; if he entrust it throughout to an assistant, it should have a large and long curve, and should be held immovable and well hooked-up under the pubes. The desiderata in this, the lateral operation, are:-1. To make an external, free and well-depending opening. 2. To

open the urethra as far back as convenient. 3. To make a definite and sufficient opening in prostate. 4. To take care that all the cellular tissue intervening between the external wound and prostatic opening be freely divided. To accomplish these objects, the external incision should commence on the left side of the raphé, about an inch in the front of the anus, and be carried downwards and outwards between it and the tuberosity of the ischium. When the staff is depressed by the operator, it is safer to lay aside the scalpel with which the urethra is opened, and to substitute a beaked knife or gorget for incising the prostate, &c."

Our author writes discouragingly of the practice of gouging bone for the purpose of modifying caries or ulcerative process by inducing new action. He thinks well of the operation of excision of the kneejoint in its proper field of selection. Touching the vexata quæstio of opening the sac in strangulated hernia, he expresses himself as follows:

"If the inexperienced operator elect to leave it unopened, he may do well to bear in mind that he may push back a rupture without relieving the stricture; that he can have no acquaintance with the actual contents of the sac and their condition; and that the inflammatory products within the sac are returned, together with its other contents, into the abdomen, instead of being allowed an external drainage. Inflamed and congested peritoneum, whether of sac or intestine, are not susceptible of ill consequence from exposure or incision as the healthy membrane is; and the assumed analogy between this operation and the taxis is not accurate; inasmuch as the success of the taxis is a measure of the resistant strangulation which may be estimated at much below that of a hernia in which it is necessary to enlarge the opening before the strictured intestine can be returned. As a rule, the advantages would seem to be decidedly in favour of opening the sac; in exceptional cases, especially of small and recently-strangulated femoral hernia, the structure may be divided external

to the sac.

Altogether, there is an incalculable amount of surgical matter in this small volume. The directions for the operation of tracheotomy are clear and good. In treating of injuries of the head, we can only regret that our author has not dwelt a little on the delicate point of practice, bleeding in cases of concussion; by a dash of the pen, he seems to disparage the advantage of it. We have occasionally to remark, in modern practice, that several things which used to be done with caution and judgment are now omitted altogether. This makes the surgeon's task easier, if it does not add to his importance. In that part of the work which is devoted to diseases of the joints, we cannot say that we are satisfied with an account of ulceration of the cartilages which omits to mention pain as a leading symptom. We take this as evidence that the author has not himself suffered from the complication.

"He best can paint them who shall feel them most." Neither does the treatment laid down for this affection fully satisfy us. Finally, we shall, with some deference, submit the following consideration-In a regulated curriculum, which is perhaps a little too much calculated to oppress a conscientious student with feelings of timidity from overstrained anatomical detail, and a preciseness of direction which often partakes of pedantry, we are glad to see books

like the present, which give him some idea of what is the final aim of his teaching. It is quite another thing to associate him with grand manoeuvres of surgery. We hope the tyro may not have to tie large arteries, or force the prostate, &c., except on very great emergencies, without further preparatory study than this work conveys.

ART. XII.-Excursions Scientifiques dans les Asiles d'Aliénés. Par Dr. P. BERTHIER.-Paris, 1862. pp. 104.

Scientific Visits to Lunatic Asylums. By Dr. P. BERTHIER, &c. THE author of this treatise is principal physician of the public asylum of Bourg, in the department of Ain, and has favoured his countrymen with a notice "of his impressions" of the state of a considerable number of the asylums of France, gathered from personal inspection. Although he justly speaks with pride of several of the modern departmental asylums of his native land, he is not sparing of criticism where deserved, and boldly denounces some existing institutions as totally unfit for their purpose and discreditable to the country.

The notes on the several asylums are brief, and afford no very intimate insight into the details of construction or of management. The historical introduction to his account of each asylum will be read with interest, and his English readers will be rather struck with the generally patent fact of the slow progress made by the teachings of Pinel and Esquirol in most departments of France, and of the long strides still required to bring the institutions of many of them to a level with those of our own country. Curiously enough, Dr. Berthier discovers that France took the initiative in framing legal enactments to provide for the due care and treatment of lunatics, though no actual steps were taken in this direction until 1838. He arrives at this conclusion, inasmuch as the first enactment passed in England of which he has any definite knowledge is that of 1846, or eight years after the French decree. His acquaintance with the history of lunacy in England is evidently secondhand, borrowed from the random statements which pass current in France, and are copied and recopied, without any attempt to verify them, by each author who wishes to exhibit his knowledge of the past or present state of lunacy in the kingdom.

This book is honestly written, and the criticisms it advances on the state of many French asylums are well calculated to arouse the attention of the public, and still more of the Imperial Government, to the necessity of interposing with a view to their improvement. Public opinion in France is, however, little exercised and little valued in such questions, which are left to the discretion of the Government; and the operation of this central power appears much less energetic than might be anticipated, being much neutralized by the ignorance and local jealousies of its subordinates in the departments.

To the English physician proposing to visit the institutions for the insane in France, this treatise will serve as a useful guide, and particularly so as it is provided with an itinerary map of the asylums, and of the means of reaching them by road or rail. Moreover, the author