the smallest doubt that he has experienced all the advantages, which he describes, from the dereliction of a stimulating diet. For we know, from observation and experience, that extreme temperance, both in respect to solid food and to fermented and spirituous liquors, is decidedly beneficial in many chronic complaints; we believe that we are all in the habit of taking more of those things, than is perfectly wholesome; and we have often wished that we could prevail upon our patients to abstain more completely from both. We know, too, that the sensation of thirst is materially diminished or superseded by such abstinence. But we should deem it the worst of medical philosophy, if we were thence to conclude, that all mankind, under every form of health and disease, would be benefited by such rigid abstinence. There are fully as many cases on record of remedial effects, not less complete and decisive than those experienced by our author, from the diæta aquea, as it has been called by Cyrillus and others, when common water was employed, as well as from drinking the water of certain springs, as those of Malvern, Ilkley, &c. And in the alleviation of cancerous complaints, Mr Pearson and others have successfully resorted to an aqueous regimen, without the aid of a still: but farther experience has produced evidence, not less equivocal, of the occasional mischief of such a lowering system. In a word, he must be very ignorant of the history of medicine, and of the difficulty of ascertaining truth in that science, who, from five and twenty brief and imperfect trials of any remedy or regimen, concludes that the same results will generally or even frequently ensue. Let him look to the history of Peruvian bark, digitalis, electricity, factitious airs, metallic tractors, the Pulvis antilyssus of Mead, in short of every expedient and drug employed in medicine, for a confirmation of this fact. And until chemical analysis and often-repeated observation shall concur to prove the deleterious and arsenical properties of spring water, we shall take leave to rank that opinion with the notion of the arsenic of the circulating fluids, engendered by sunshine "about the year fifteen hundred."

We shall conclude with noticing our author's opinion respecting the state of human intellect, under the present carnivorous system. He is persuaded, with Mr Locke, that a large portion of mankind is "on the brink of insanity;" and he seems to think that in the true healthy state of nature, there would be no such condition of the intellect as we term genius. For although he is not prepared to say, perhaps, with Cabanis, the French physician, that all genius is disease;" yet, he affirms," there are many circumstances and indications which lead to a suspicion that extraordinary abilities of every sort are, in the present state of mankind, the result of the principle of vitality struggling against the progress of diseased action." (p. 146.) How far this philosophical

philosophcal and luminous view of the intellectual nature of man may be considered as affording a specimen of the progress, which our author has made, by dint of vegetable diet, towards the natural state, we must leave to our readers to determine. For, we must confess, it lies beyond the reach of our faculties, which are, doubtless, at present, too much entangled in the viscosity of the matter of death.

What is to be the subject of the second part of our author's essay, we are nowhere informed; but it is incidentally mentioned (p. 67, note) that the third and fourth parts will treat of Poverty and War.

III.—IV.

Appendix to a Proposal for a new manner of cutting for the Stone: containing an account of some Cases operated on after that manner, in the Royal Infirmary of Edinburgh. By JOHN THOMSON, M. D. Professor of Surgery to the Royal College of Surgeons, and Regius Professor of Military Surgery in the University of Edinburgh. 8vo. pp. 74. Edinburgh, 1810.

Essay on some of the Stages of the Operation of Cutting for the Stone: Illustrated with an Engraving. By CHARLES BRANDON TRYE, F. R. S. 8vo. pp. 49. London, 1811.

BOTH OTH these pamphlets are composed by men of education and ability, who have been hospital surgeons for many years: they are entitled, therefore, to the threefold attention which practical observation, natural talent, and acquired instruction jointly deserve. Dr Thomson's proposal was fully described in the Fourth Volume of our Journal, and he has here published six cases in which he employed the instruments in the operation of lithotomy, which appeared to him preferable to those in common use. Some incorrect and exaggerated statements regarding two of these cases were circulated at Edinburgh, it seems, by Mr John Bell. Dr Thomson, influenced by a strong feeling of honour and duty, has printed these cases from the journals of the Infirmary, in order that the public should possess correct means of judging of the truth of such statements; he completely exposes the unfairness of them, and exculpates himself and the

surgical

surgical department of the Infirmary from the obloquy which was intended to be cast upon them. The history is of that detailed circumstantial kind which the importance of the subject required. It is because we have no such minute accounts of the success and failure of the operation, that so much labour in vain, so many avoidable difficulties, so much fruitless expenditure of ingenuity, is incurred by every new proposal for performing lithotomy. The experience of preceding operators has been in too great a degree lost to our use, and instead of profiting by past success or miscarriages, surgeons are often obliged, through ignorance of their precise causes, to repeat the old blunders before they can detect them.

Of the circumstances mentioned in Dr Thomson's narrative, the only two which arrest our particular notice, are the case of Robert Walker, and the form of the staff used in the operations.

Robert Walker, aged 50, was cut by Dr Thomson on the 5th of July 1808, in the usual lateral method, except that after the membraneous part of the urethra was divided, a straight groov ed staff was pushed along the groove of the curved staff into the bladder. The curved being withdrawn, and the stone felt with the straight staff, the incision into the bladder was made with a large scalpel, conducted along the groove of the staff, with its edge turned upwards and outwards. The stone was then felt by the point of the finger introduced into the bladder, and again by the forceps, introduced along a blunt gorget; but on endeavouring to lay hold of it, it appeared to recede before the forceps, and could not afterwards be discovered with that instrument. The curved staff was twice introduced through the urethra, and the stone distinctiy felt; but after repeated fruitless endeavours to discover, and lay hold of it with the forceps, the patient appearing considerably exhausted, it was deemed expedient to desist for the present from all further attempts, and to put him to bed.

No inflammatory symptoms came on: the man was tolerably easy, except when he voided urine, and he described the pain as being precisely similar to that which he experienced before the operation. On the fifth day after the operation, the stone was extracted with difficulty by introducing the forceps upon a blunt gorget in the groove of the curved staff. The stone had a rough surface, was an inch and a half long, and nearly the same in breadth. No unfavourable symptom occurred, the wound healed rapidly, and the patient was dismissed cured in a month.

A writer so well qualified as Dr Thomson is to speak on this point of practice, ought not to be heard through a commentator: we shall therefore quote his own words, premising only, that

VOL. VII. No. 28.

we have seen this practice followed in two instances, in which the stone, apparently from its small size, could not be detected by the forceps, but passed through the wound the next day with a gush of urine. Other instances have come under our notice, where we think the operation " en deux temps" would have saved the life of the patient.

"In putting the patient to bed (says Dr T.) in the circumstances which have been described, I followed a rule which I have for several years delivered to the gentlemen attending my surgical lectures, viz.

"That when a stone cannot be felt, after proper incisions have been made into the bladder, and after a careful examination with the fingers, forceps, and searcher, we ought to desist from the use of instruments, to put the patient to bed, and to defer any further attempts at finding the stone, until after the abatement of the fever from the operation. This rule I was led to suggest from my observation of the injurious effects which arise from the friction of the forceps upon the inner surface of the bladder : from my knowledge of the fact that small stones, which could not be felt after the most diligent search at the period of the operation, have afterwards been passed spontaneously through the wound; and likewise from the instances that have been mentioned by practical authors, in which stones remaining in the bladder have been brought nearer to its neck, and placed by nature in a situation more favourable for extraction than when the incisions were first made. It was the consideration of circumstances similar to these, together with the difficulty which occasionally occurs in finding the stone, which probably gave rise to the proposal of the operation for the stone" en deux tems;" in which the incisions were to be made at one period, and the extraction of the stone not attempted till another. It fortunately happens, however, that but few cases require a mode of operating so protractive, ́and necessarily so dejecting to the mind of the patient."---p. 22, 3.

The comparative advantages and disadvantages of this mode of operating, are fully considered in the writings of Camper and Deschamps. What the obstacles were which prevented the detection and consequent extraction of the stone in this case, it is difficult to point out. Dr Thomson conjectures, that the stone was lodged in a lateral sac or pouch of the bladder, from which it projected more or less according to circumstances; and he quotes several cases of sacculated bladders to satisfy the minds of those who are disposed to be sceptical as to the existence of ́such deviations from ordinary structure, because they never chanced to meet with them.

There seems no very good reason to give a decided preference to the instruments which Dr Thomson proposes to be used in dividing the peck of the bladder. He employed them with suc

cess

cess in five cases out of the six, but the operation is rendered more simple, by dispensing with the use of the straight staff; and we never observed any difficulty in carrying the point of the knife forwards along the groove of the common curved staff. The case which terminated fatally, was one that offered the most promising hopes of success: the patient, a boy four years old, died on the fourth day from an attack of bilious fever, without any symptoms of inflammation, or injury from the extraction of the stone. This is an instance of the uncertainty which pervades our-best directed efforts, even in the noble art of chirurgery, and it shows the operation of lithotomy is at all times hazardous and of doubtful issue; "res est solliciti plena timoris."

Mr Trye is an advocate for the cutting-gorget, for so the instrument, the prostatome, which he recommends, may be called. In its favour he offers the successful result of his own practice in the course of twenty-five years, having lost only three cases out of more than forty patients; and if the instrument, not the skill of the operator, insured such success, no doubt Mr Trye would be entitled to praise for contriving the means for dividing the prostate with exactness, and for obviating the possibility of missing the passage into the bladder. He does not assert that the instruments which he uses are superior to those of other surgeons; but he recommends them because he has operated with them on more than the last thirty patients successively, without embarrassment and without loss. The dangers and difficulties of lithotomy appeared to him to arise from the liability of the staff to slip out of the bladder, just before the entrance of the gorget into the prostate gland: to guard against this accident, he employs a staff with the handle made quite straight, then the curve, forming nearly the segment of a circle, and the end nearly straight, forming a right angle with the handle. The next thing was to simplify Hawkins's gorget, and this is done by a a broad double-edged scalpel, with the beak set rather to one side, not exactly in the middle, but so placed that the edge makes an incision two lines broad on the left side, and rather more than half an inch on the right side. This is called the prostatome. Mr Trye asks, " Is it probable that the division of the prostate gland will be done with equal safety and equal precision, if we reject every instrument besides the scalpel ?" We answer yes. Some of the most skilful lithotomists of the present day use the common knife only for making all the necessary incisions into the bladder; and the different shapes of cutting instruments employed by different operators, serve to shew, that manual dexterity and anatomical knowledge can govern and direct the motions of any contrivance, whilst no blunt beak

or