responding depression of the handle of the knife or gorget will be required to secure the continued adaptation of the two instruments. The staff may be left in the hands of the assistant until the incision of the prostate is completed, by which means the operator can pass his left fore-finger along the side of the knife whilst dividing the prostate, and ascertain if this incision of the gland is sufficient. Mr. Stanley, however recommends the operator to take the staff himself, as is generally done, and we think there can be no doubt of the general propriety of the advice.

"The knife or the gorget having been withdrawn, the staff is to be taken in the right hand, and the left fore-finger passed along it into the bladder. The staff is then to be withdrawn, and is to be ascertained by the finger to what part of the bladder the forceps should be directed, that they may immediately touch the stone. On withdrawing the finger, the forceps, with their blades closed, are to be passed slowly through the wound, and inclined upwards as they approach the bladder, carefully observing when they enter its cavity.

"Upon the foregoing plan, the staff will be the conductor of the finger into the bladder, and the finger the conductor of the forceps. The introduction of the finger is useful to ascertain the situation of the stone, and, by separating the sides of the incision in the prostate, to facilitate the passage of the forceps. By allowing the staff to remain in the bladder until the finger has entered its cavity, the beaked or probe-pointed knife can be readily conducted to the bladder, for the purpose of enlarging the incision of the prostate, should this have been inadequately made; and if, from an unusual firmness of the prostate, the sides of the incision through it do not readily yield, much difficulty may be experienced in discovering the passage to the bladder, when the staff has been withdrawn, and its aid, as a conductor of the finger, is thereby lost. So many sources of difficulty are avoided by a strict adherence to the rule of not withdrawing the staff until the finger has fairly entered the bladder, that it cannot be pressed too strongly upon the attention of the operator.

"When the blades of the forceps happen to be passed to the upper or to the under surface of the stone, it may be seized directly they are opened. But when the forceps touch the stone only on its anterior surface, it is necessary, in opening the blades, to advance them a little, otherwise, in separating, they will recede from the stone.

"When the first attempt to seize the stone has failed, the forceps should be directly withdrawn, and the finger introduced into the bladder, to change the situation and position of the stone. But the finger may not reach the stone; a scoop or other instrument must then be introduced, to dislodge the stone from its unfavorable situation, and it is scarcely necessary to mention the importance of introducing into the bladder but few instruments, and these as gently as possible. A stone lodged in the lower part of the bladder has in some instances been raised, and its position changed, by the finger introduced into the rectum." 12.

But, as Mr. Stanley, justly remarks, rules will avail little to meet the various difficulties which may arise in the progress of this dark operation, and much must depend after all on the tact and dexterity of the operator. The forcible contraction of the bladder on the stone may resist its seizure :—or the stone may be partially encysted or lodged within the orifice of the ureter: -or it may adhere in some degree to the mucous membrane of the bladder:- —or there may be an hour-glass contraction of that organ. In most of these cases the peculiarity is discovered during the operation, and some may be generally suspected from the occurrence of any unusual circumstance in sounding the patient.

"Whether the operation has been completed by a knife or by a gorget, some resistance to the progress of the stone through the wound may be expected. This resistance may be in the prostate or in the external parts; but in either case, it will yield to the skilful use of the forceps, provided that the incisions have been properly made, that the stone is not unusually large, and that the prostate has undergone no change in its structure.

"The skilful management of the forceps consists in pressing their blades gently against the sides of the wound, first in one direction, then in another, but especially downwards,* and in drawing them outwards slowly, that time may be allowed for the yielding of the surrounding parts. Laceration, or severe contusion, of the sides of the wound will probably be followed by suppuration, which, by spreading extensively through the surrounding cellular tissu, may be destructive of life. With these circumstances in his mind, the operator must judge to what extent the effort to extract the stone may be safely persevered in, and when he ought to desist, for the purpose of enlarging the wound with the knife in the situation where there is the most resistance.

"When the resistance to the progress of the stone is in the prostate, although the left side of the gland has been divided to the usual extent, it will be better to cut into its right side than to extend the incision of the left at the risk of wounding the pudendal artery, or of cutting the coats of the bladder beyond its neck.†

"When the resistance to the progress of the stone is in the external parts, the incision of these must be enlarged towards the tuberosity of the left ischium.

"The extraction of the stone must be directly followed by the introduction of the finger into the bladder, for the purpose of examining every part of its internal surface; and this must be carefully done, as there may be a second stone not readily discoverable in consequence of its being lodged in a recess of the bladder at its fundus or elsewhere.

"And it is necessary to examine the surface of the stone. A particle of it may have been chipped off, and retained either in the tract of the wound or in the bladder. Unless it can be discovered in the wound, and thence dislodged by the end of the finger, a stream of warm water must be directed with a good syringe through the wound to the cavity of the bladder, to detach the particle of stone which may be sticking to its mucous membrane." 15.

II. OF THE INCISION OF THE PROSTATE.

The incision of the prostate is the most debateable part of this debateable operation, and we believe that upon it depends the chief risk of failure or chance of success. As, however, the object of the present article is to explain the ordinary and, cæteris paribus, the best method of performing lithotomy, we shall not enter into the litigated questions respecting the extent of the prostatic incision. Mr. Stanley observes that it can scarcely be doubted that the best direction, is the division of its left lobe obliquely outwards and downwards, and that an incision in the prostate cannot be made in any other direction with so little risk of injury to the pudendal artery or to

* "This will be towards the wider part of the space between the rami of the ischia.

"The thin coats of the bladder can scarcely resist the extraction of the stone, and from the incision of the bladder beyond its neck, there will be the danger of infiltration of urine into the pelvis, and of injury to the ureter, so close to the neck of the bladder is its termination in some subjects."

the rectum. An incision capable of easily admitting the finger into the bladder is generally sufficient, and if the stone is unusually large, Mr. Stanley well observes that it is better to determine on the incision of both sides of the prostate, than prolong too far the incision on the left side. By this means an increase of space will be obtained, to be measured not merely by the increased extent of the incision, but by the greater facility with which the neck of the bladder will then yield to the pressure of the forceps. If the stone. be still too large to be safely extracted it should be broken either by a pair of strong forceps with much projecting teeth, or the instrument contrived by Mr. Earle, and described in the 11th Vol. of the Medico-Chirurgical Transactions.

"An exclusive preference is not to be given to the gorget or to the knife for the incision of the prostate. With either instrument, skilfully used, the operation may be well done. With a gorget, properly constructed, there is no risk of wounding the pudendal artery or the rectum, because the limits of the incision are determined by the dimension and form of the instrument. With a knife, in an inexperienced hand, there is not so much certainty of confining the incision within its proper limits.

"A comparison of the gorget with the knife, so far instituted, is favourable to the former; but to the narrow-bladed and beaked knife, first used by Mr. Blizard, an advantage belongs, which a gorget, from the width of its blade, cannot possess. The knife enters the bladder, as Mr. Blizard was accustomed to remark, as easily as a probe. The gorget, on the other hand, must meet resistance in passing through the prostate. Very much less, however, will this resistance be than it has been usually represented when the gorget has been properly made, and it is guided with skill.

"For the young subject, or for a thin adult, the knife is especially suited. It is also to be preferred for any case in which the bladder is closely contracted upon the stone. But for a very fat, or for an old subject, in whom, by the enlargement of the prostate, or the dilatation of the rectum, the bladder is raised much above its natural situation, the gorget is better adapted, on account of the great distance from the perineum at which the prostate and neck of the bladder are, in such instances, situated.

"Other methods of dividing the prostate, and other instruments for doing it, have been recommended: doubtless, some of these are good; but, for the mention of them here, consistently with my present object, it would be necessary for them to be better than those which have been described, and I have not been able to satisfy myself that they are so." 19.

The third section contains some very judicious remarks upon the sound, staff, gorget, and beaked knife, remarks which we would recommend to the attention of the young surgeon. His success will be found to depend much more on these minutiæ than a person at first would imagine, and often have we seen an able and dexterous operator embarrassed by an ill-adapted beak and groove. We must now close our notice of this highly meritorious and modest production. The extent of our analysis shews the esteem in which we hold it, and we trust we may say without suspicion of adulation, that the present brochure of Mr. Stanley does no discredit to the author of the "Manual of Anatomy." We strongly recommend those students who are engaged in the operations on the dead body, to peruse these instructions before they pass to the performance of lithotomy."

VII.

OF SOME SYMPTOMS IN CHILDREN ERRONEOUSLY ATTRIBUTED TO CONGESTION OF THE BRAIN. By Robert Gooch, M. D.

THE above is the title of the sixth chapter of Dr. Gooch's recent publication, and the subject is of very great importance. The chapter opens in a ludicrous manner, considering the gravity of the subject; but the moral inculcated deserves to be remembered.

"I remember when a boy reading a story of two knights-errant who arrived on the opposite sides of a pedestal surmounted by a shield; one declared it was gold, the other that it was silver; growing angry, they proceeded to blows, and after a long fight each was thrown on the opposite side of the shield to that where he began the fight-when both immediately detected their error: the knight who had said it was silver finding that on the opposite side it was gold, and the knight who had said it was gold finding that on the opposite side it was silver. This story, a little modified, is a good illustration of the state of medical opinion in this age, perhaps in all ages; medical men have no occasion to tilt, for they all throng on one and the same side of the shield; they look only at the golden side, and never dream of the possibility that on the opposite side it may be of a different metal." 355.

Dr. G. properly remarks that two sets of symptoms are distinguishable in cases of disease, and require to be discriminated. One set of symptoms forms what may be called the physiognomy of the complaint-the other indicates the morbid state of organization on which the disease depends.

"Two patients complain occasionally of dimness of sight, swimming of the head, singing in the ears, and observe that if they turn the head on one side to look at an object they feel as if they should fall; but the one is plump, florid, and has a full pulse; the other is pale and thin, has cold hands and feet, and a pulse small and feeble. One practitioner bleeds them both; the other bleeds the one, but does all he can to give blood to the other. The latter cures both his patients; the former cures the one but ruins the health of the other; but such is the nature of the human mind that the cases for a preconceived opinion are retained easier than those against it. He remembers his good deed, forgets the other, or calls the case 'anomalous,' and marches on, without the slightest doubt that bleeding is the universal and sovereign remedy for dimness of sight, swimming of the head, and singing in the ears, save and except only in 'anomalous' cases." 357.

Dr. G. is anxious to call the attention of medical men to a disorder of children which he finds invariably attributed to, and treated as, CONGESTION or INFLAMMATION of the brain; but which he is convinced often depends on, or is connected with, an opposite condition of the circulation. It is chiefly indicated by heaviness of head and drowsiness. The age of the little patients is generally from a few months to two years or three. They have, in our author's experience, been rather small of their age, in delicate health, and exposed to debilitating causes.

"The physician finds the child lying on its nurse's lap, unable or unwilling to raise its head, half asleep, one moment opening its eyes, and the next closing them again with a remarkable expression of languor. The tongue is slightly white, the skin is not hot, at

times the nurse remarks that it is colder than natural; in some cases there is at times a slight and transient flush; the bowels I have always seen already disturbed by purgatives, so that I can scarcely say what they are when left to themselves; thus the state which I am describing is marked by heaviness of the head and drowsiness, without any signs of pain, great languor, and a total absence of all active febrile symptoms. The cases which I have seen have been invariably attributed to congestion of the brain, and the remedies employed have been leeches and cold lotions to the head, and purgatives, especially calomel. Under this treatment they have gradually become worse, the languor has increased, the deficiency of heat has become greater and more permanent, the pulse quicker and weaker, and at the end of a few days or a week, or sometimes longer, the little patients have died with symptoms apparently of exhaustion. In two cases, however, I have seen, during the last few hours, symptoms of oppressed brain, as coma, stertorous breathing, and dilated and motionless pupil." 358.

Dr. Gooch relates an instructive case illustrative of the above remarks, where leeches were applied to a child two years old, and the result was fatal. This case and some incidental remarks are so interesting that we shall here insert them.

"A little girl about two years old, small of her age and very delicate, was taken ill with the symptoms which I have above described. She lay dozing, languid, with a cool skin, and a pulse rather weak, but not much quicker than natural. She had no disposition to take nourishment. Her sister having died only a week before of an illness which began exactly in the same way, and which was treated by leeches and purgatives; and some doubts having been entertained by the medical attendant of the propriety of the treatment, leeches were withheld, but the child not being better at the end of two days, the parents, naturally anxious about their only surviving child, consulted another practitioner. The case was immediately decided to be one of cerebral congestion, and three leeches were ordered to be applied to the head. As the nurse was going to apply them, and during the absence of the medical attendants, a friend called in who had been educated for physic, but had never practised it, and who had great influence with the family: he saw the child, said that the doctors were not sufficiently active, and advised the number of leeches to be doubled. Six, therefore, were applied; they bled copiously; but when the medical attendants assembled in the evening they found the aspect of the case totally altered, and that for the worse the child was deadly pale, it had scarcely any pulse, its skin was cold, the pupils were dilated and motionless when light was allowed to fall on them, and when a watch was held to its eyes it seemed not to see; there was no squinting. Did this state of vision depend on the pressure of a fluid effused into the brain since the bleeding, and during this exhausted and feeble state of circulation or did it depend on the circulation of the brain being too languid to support the sensibility of the retina? It is well known that large losses of blood enfeeble vision. I saw a striking instance of this in a lady who flooded to death. When I entered the chamber she had no pulse, and she was tossing about in that restless state which is so fatal a sign in these terrific cases. She could still speak, asked whether I was come, (she knew I had been sent for,) and said 'am I in any danger?-How dark the room is!-I can't see.' The shutters were open, the blind up, and the light from the window facing the bed fell strong on her face. I had the curiosity to lift the lid, and observe the state of the eye; the pupil was completely dilated, and perfectly motionless, though the light fell strong on it. Who can doubt that here the insensibility of the retina depended on the deficiency of its circulation? But to return to the little patient. The next day she had vomited her food several times; it was therefore directed that she should take no other nutriment than a desert spoon-ful of ass's milk every hour, and this was strictly