tended errors of foreign writers with those of the English, with a view evidently, of increasing the weight of culpability he attaches to the latter in the eyes of the public. Thus, after descanting upon the pretended failures which attend English practice, as collected from the popular writings of Messrs. Newnham, Bowes, and Cliston, the only authors quoted by Dr. Broussr is, this critic proceeds to observe, "Ce n'est pas seulement dans leurs echecs que les medecins Anglais sont redoubtables. Leurs querisons m'ont souvent fait trembler;" and he then quotes, in support of it, the history of a case taken from the New-York Repository!

A worthy contemporary of ours had, on one occasion, taken much pains to develop the "Systeme Physiologique" to the English readers in his Journal; and, being struck with the great truths it contains Samidst much dross, without stopping to inquire whether those truths belonged really to the French physician, or to those of another na tion, as we have shown in the present article, condescended to extol the system itself, as well as the author, in a very flattering manner. Unfortunately for the value which our contemporary may attach to the praises he might have expected from Broussais in return, his better judgment induced him to add to his eulogium of the French system some very appropriate remarks on the use of certain therapeutical means, which Broussais had either condemned or neglected. This circumstance has drawn upon the reviewer of the "Systeme Physiologique" the wrath of its author, who cannot admit that any thing is wanting to its perfection; and, in the chapter which we have been analysing, he declares, that his "confrère d'Angleterre, bien qu'avec l'intention de se montrer impartial, a cédé a l'influence de la doctrine empiricoBrownienne de son pays et que cette influence l'a exposé, malgré ses bonnes intentions, aux reproches d'inconsequence et de légèraté.” But sure we are that the "confrère d'Angleterre" knows fully how to appreciate both the encomiums and the condemnation of our author, of whose impartiality we have already given some few specimens, and of whose modesty the following may be taken as two out of two hundred examples:

"C'est des cours particuliers que je fais que les vérités dont brille la doctrine physiologique se sont repandues dans le commerce social et se sont introduites parmi les médecins."*" Si j'en crois mou prés. sentiment elle doit avoir prochainement sur la population une influence plus marquée que la découverte de la vaccine."+

Having proceeded thus far in our analysis of Dr. Broussais' two volumes, it becomes almost unnecessary to follow him in his examination of the Spanish and the French Schools. The former is too insigni ficant, in reality, to deserve much notice; and the latter will find much more powerful defenders amongst the many very illustrious men of whom France can boast, if they should think it adviseable to notice the misrepresentations of one who has equally condemned Barthez, Bordeu, Pinel, Cabanis, et la médecine Française en géneral."+

Preface, p. iv.

+ Idem, p. xii.

A defence of the French school against the attacks of Dr. Broussais has just made its appearance: it is from the pep of M. AUTHEN AC, D. m.

Memoria sopra il Metodo di Estrarre la Pietra dalla Vescica Orinaria per la via dell'Intestino Retto. Di ANDREA VACCA BERLINGHIERI, Professore di Clinica Chirurgica nell'Imp. E. R. Univ. di Pisa, Car. dell'Ordine del Merito sotto il Titolo di S. Giuseppe, e Membro di molte illustri Accademie Europee. 8vo. pp. 82. Pisa, 1821.

THE objects of this memoir are to render more generally known, in Italy, the author says, the new mode of operating for the stone proposed by Dr. SANSON, (an account of which was given, a short time since, in this Journal;) to render evident the advantages of this mode of operating; and to support the propriety of it, not only by reasoning, but also by some cases of a very important character: and, as facts persuade more than theory, Professor Vaccà thinks that he may hope to be more successful than Dr. Sanson had been in his endeavours to make surgeons in general adopt this, as he considers it, improvement in the art of surgery.

We shall give an abstract of the most remarkable parts of this mċmoir, (which merits every praise due to a work equally characterized by candour, liberality, and intelligence,) without adducing any considerations of our own on the merits of the practice which Professor Vacca advocates. The Professor has evidently thought well on this subject, and has presented a very perspicuous view of its relative advantages; whilst the modifications he has effected on the mode of Sanson show, as far as the evidence of six cases extends, that the principal relative disadvantage of it resulted from a circumstance which might, without much difficulty, be obviated. Of the two chief objections to the method of Sanson,-the consequences of the wound of the rectum, which appertain especially to the part itself; and the passage of fecal matter into the bladder, and, hence, a recto-vesical fistula ;*-the latter alone, the Professor considers, is of any validity, and it is this which he has obviated by the modification of the operation above alluded to. The method of Professor Vaccà consists in cutting the urethra, the prostate, and the neck of the bladder, and avoiding the bas-fond of this viscus. In this operation, the incision of the intestine is at least an inch lower than that of the neck of the bladder, and the edges of the wound of the lower part keep in contact except when the urine is passed, and the parietes of the intestine serve as a valve which opposes the passage of feces into the bladder. The truth of these statements is proved by the six cases in which the operation in question was performed by Professor Vaccà.

The author enters into an examination of the relative merits of the several modes of lithotomy hitherto proposed, the results of which lead him to infer that the recto-vesical operation "seems to unite all the principal advantages, and present the smallest inconveniences.". "It is not necessary," he says, " to recal to the mind of the reader knowledge of minute anatomy, to persuade him that there is no point of the perineum nearer to the bladder than that which corresponds This occurred in the cases of Dupuytren, Barbantini, and of Professor Geri,

at Turin.

to the anterior part of the sphincter of the anus. Not much ingenuity is requisite to enable us to conceive that, on dividing this point of the sphincter, the parietes of the rectum, the membranous portion of the urethra and the prostate, by an incision which intersects but few soft parts, we shall have procured a very ample space for the entry of the finger, the forceps, and the passage of the stone; because we profit by the natural aperture of the anus, as well as by the cavity of the rec tum. The grossest anatomical information is sufficient to lead any person to perceive that an incision which intersects the sphincter of the anus in its anterior part, the membranous portion of the urethra in the median line of its anterior paries, the neck of the bladder, the prostate, and the lower surface of the bladder, in the same line, does not ever encounter any important vessel, or any other part interesting to life. It is clear that, by this method, the stone has to pass between the rami of the ischium, where they are most distant from each other, and where, consequently, they leave ample space for the passage of the largest stone. It is also evident, that the direction and the shortness of the wound render impossible any extravasation of urine, as well as facilitate the egress of any fragments which may have remained in the bladder after the operation. The traject of the wound being shorter than in the other method, the surgeon can penetrate far into the bladder with his finger; ascertain the form, volume, and direction, of the stone; and, according to its situation, easily seize and extract it. In the recto-vesical operation, we avoid the danger of wounding large. vessels in the perineum; we may extract large stones as well as in the high operation; whilst this method is devoid of the inconvenience of exposing the peritoneum, and submitting it to the hazard of being wounded by the surgeon, or the other very serious accident of rendering easy the extravasation of urine."

Professor Vaccà thought favourably of the high operation a few years since; but the results of his experience, and further considerations on it, have led him to alter his opinion in this instance. Notwithstanding the presence of a catheter in the bladder, effusion of urine into the cavity of the pelvis took place in the cases in which he performed the high operation, and this in a female as well as in male patients. This he considers the chief relative disadvantage of this operation, though much difficulty in it ensued, in one case, (where the subject was a man twenty-five years of age,) from another cause that had not, we believe, been previously noticed: that is, from violent contraction of the abdominal muscles, after they had been cut, which rendered the wound so thick as not to admit even a finger without extreme difficulty, and obliged the operator to postpone the extraction of the stone to a subsequent period. The same reasons which lead Professor Vaccà to prefer the recto-vesical operation in man, militate, he thinks, in favour of the vagino-vesical operation in woman.

The author has performed the recto-vesical operation in six instances. In four of these cases, (the subjects of which were patients of the ages of 38, 74, 38, and 2, years,) the results were of the most favourable kind: in one (the subject of which was five years old,) a

little fistulous communication existed between the rectum and the bladder for nearly a year after the operation. This resulted, the author thinks, from the surgeon into whose care the patient was given, (in the absence of the Professor,) having neglected to touch the edges of the wound of the intestine with argentum nitratum,* (a practice adopted by Professor Vaccà, as soon as inflammation has subsided and suppuration established, and effected throughout the whole traject of the wound that corresponds with the incision of the intestine and the perineum.) In the other case, the patient (a man seventy years old,) died on the fourth day after the operation. Dissection showed inflammation of the peritoneum and of the left kidney. The cellular substance which united the anterior part of the bladder to the pubes was also gorged with blood, and bedewed with puriform serum. The parietes of the bladder, at its upper and anterior surface, were much thickened; there was puriform serum between its muscular and peri. toneal tunics: the internal membrane was gangrenous, and presented, at its left lateral portion, some protuberances which contained several very small fragments of stone. It appears that the stone had been adherent to this point. The wound, also, presented a gangrenous appearance. The liver was very voluminous, and occupied a great part of the left hypochondrium.

To the general abstract above given, we shall add the detail of the process of the operation, according to the method of Professor Vaccà, as it is described by the author himself.

The necessary instruments are only a common grooved staff, an ordinary straight bistoury, forceps, and, in some cases, a perfectly straight probe-pointed bistoury.

The patient being placed and secured as for the lateral operation, the staff is passed into the bladder, and then confided to an assistant, who is to hold it firmly in an axis perpendicular to the pubis, without inclining it either to the right or the left, and keep the groove of it pressed against the median line of the urethra, opposite to the raphé. The surgeon then takes the bistoury in his right hand, so that he may cut with it from within outwardly; that is to say, with the cutting edge turned upwards, and the fore-finger and thumb on the point of conjunction of the blade with the handle, so that both of them may be grasped. The fore-finger of the left hand is then oiled, and one of the sides of the bistoury pressed very firmly against its palmar surface, so that its cutting edge may be a little below the upper surface of the finger, and form with it, as it were, one body, which may be passed into the rectum without wounding the patient. The finger and the bistoury are then introduced through the anus, with the dorsal surface of the finger opposite to the sacrum, and advanced to the distance of ten or twelve lines from the verge of the anus; the finger is to be pressed

* This patient was received again into the hospital, after the lapse of the period above-mentioned, and the caustic applied. When this memoir was published, (April the 24th, 1821,) the wound "was in such a state as to lead the author to hope that it would be completely cured in a very short time ;" and then only from four to six drops of urine passed by the tistula, whilst several ounces were eva. cuated by the urethra.

against the posterior, or sacral, surface of the rectum, in order that a subsequent necessary change in the position of the instrument may be effected: this change is made by means of the right hand, and consists in applying the back of the instrument to the palmar surface of the finger, and its cutting edge to the anterior part of the intestine, exactly in a line corresponding with the raphe of the perineum. The finger, which had been introduced to facilitate the change of the position of the bistoury, is then pressed forward against the instrument, the cutting edge and point of which, being fixed in the anterior part of the intestine, whilst the right haud, drawing the knife from the intestine, will co-operate in making an incision of the anterior paries of the intestine, the cellular texture situate between this and the urethra, and the external sphincter of the anus; beyond which sphincter the incision should not extend above the distance of eight or nine lines in the perineum. On this being effected, (which is done in an instant,) the operator removes the left fore-finger from the bistoury, alters the di rection of this finger, turning to the left its dorsal surface, and at the same time, by a light movement, changes the position of the instrument; so that its cutting edge, which had been turned upwards and towards the operator, is placed in an exactly opposite direction. The operator now passes the end of his left fore-finger into the wound, exactly on a parallel with the incision in the sphincter, and seeks, with the edge of the nail (which should always be long when this operation is performed), the groove of the sound through the parietes of the urethra. On the groove being found, the bistoury is carried, with its back upwards, to just above the nail of the left fore-finger, and the urethra is cut by the instrument; which, with the nail of the fore. finger, enters the groove of the staff still held by the assistant in the situation before described. The instrument is now thrust forward, by the right hand, into the bladder, and the neck of this viscus divided to a greater or less extent, according to the notions that may have been formed of the bulk and figure of the stone. As we are very apt to err in this point, it is adviseable that the wound in the neck of the bladder and prostate should be rather small, as it can very easily be enlarged subsequently, should this prove necessary. On this incision being completed, the finger is passed (having the staff as a guide,) into the bladder. We can then judge, by means of this finger, of the size of the wound, as well as of the size and form of the stone, and, according to the indications of this examination, be induced to enlarge the incision, or let it remain of its present dimensions. If it be thought" proper to extend it, the bistoury already used may serve for this purpose; but, as the point of the ordinary bistoury might embarrass the surgeon and expose him to the danger of wounding his finger, and perhaps the bladder, unless it were very expertly managed, it is better to employ here the straight probe-pointed bistoury, by which both these accidents may be avoided. The forceps are passed along the finger into the bladder: all the guides and gorgets invented for conducting the forceps are perfectly useless instruments in this, as well as (the Professor says,) in all the other methods of extracting the stone. The wound after the operation is treated in the ordinary manner: the NO. 272.

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