teriorly and the spine of the scapula posteriorly, was quite dull on percussion. No respiration could be heard at any part of this side, except immediately below the clavicle before, and in the interscapular region behind, where it possessed a pure tubular character. The voice was more shrill than natural in the left interscapular region, but was indistinct below the clavicle, and scarcely at all audible in any other part of the side. Mr. Cock, at my request, performed the operation of paracentesis; and, having first used the explorator to certify the presence of fluid, introduced a small trochar at the posterior and inferior part of the left side of the chest. About six ounces of clear greenish-yellow serum were drawn off, with slight relief to the patient. Ordered, Pil. Hydrarg. gr. iv. Opii gr. ss. m. ft. Pil. nocte maneque sum. Liq. Potassæ m. xv. Potassii Iodidi gr. iij. Inf. Gentian. C. 3iss. m. ft. haustus ter die sumend. "Dec. 2-This day his pulse were considerably fuller and stronger, and there existed some heat of skin, with a flushed face. In other respects he was the Ordered, same. Ven. Sect. ad 3viij.-Empl. Lyttæ lateri sinistro.-Pergat. "Jan. 6.-The febrile symptoms were immediately and permanently subdued by the venesection; but his dyspnoea and other symptoms continued nearly as before, and the physical signs of his complaint were unchanged. He had hitherto continued the medicines first prescribed: the blister had risen and discharged freely. He was certainly not better, though not considered materially worse; but late in the evening of this day Mr. Cock and I were called to him, in consequence of excessive dyspnoea threatening suffocation, arising from the increased accumulation of the effused fluid. Upon our arrival he was gasping for breath, propped up in bed by pillows, with much anxiety of expression, a clammy state of the surface and feeble pulse. The chest was again tapped at the same part as before; and, by the assistance of pressure upon the ribs, thirteen ounces of the same kind of fluid as before were evacuated. In a few minutes he felt no inconvenience whatever from the operation, and in a very short time expressed himself as being much relieved thereby. From this time his recovery commenced." The blister and other remedies were continued, the dulness gradually decreasing and breathing easier. The respiratory murmur is gradually returning to all parts of the lungs-mouth tender from mercury. From this time he continued free from the thoracic symptoms, though he was twice obliged to return to the hospital for venereal eruptions. This is decidedly an excellent case. The recovery seems to be complete. Case 3.-E. M. an Irish sailor, aged 58, who had been at the battle of Algiers, admitted 7th April 1842, for fractured ribs. He had been run over by a cart. In a fortnight he was made an out-patient; but a day or two afterwards, was seized with great oppression of breathing, anxiety of countenance, sense of suffocation, &c. On removing the bandage, the left side was unnaturally resonant on percussion. The respiratory murmur deficient in the left side-nothing remarkable in right side. Venesection to six or eight ounces-calomel, opium, and antimony. It was considered that pneumo-thorax had taken place in the left side, from laceration of the lung. To be bled to eight ounces-opium to be given every six hours, with mild nourishment. He improved progressively, and in a few weeks, was able to walk about. After this, he again complained of pain in the right side, where there was dulness, and want of costal elevation. Pleuritic effusion was suspected. Blue pill and opium at night-a cathartic in the morning-and iodine in the day. He got worse-muco-purulent, and ultimately purulent expectoration took place, and it became evident that fluid was accumulated in the right side. The explorator was introduced, but no fluid came forth. He lingered for nearly three months, and then sank. Dissection. The instrument was found to have neither penetrated the lung, nor to have entered any collection of fluid. It had entered the diaphragm. There were extensive pleural adhesions. Both lungs appeared sound in situ; but on taking off the coats of adhesive matter, the finger passed into a narrow and defined cavity in the right pleura, containing three or four pints of seropurulent fluid. It contained no air. The cavity was lined with a dense layer of coagulable lymph. The lung itself was firm from compression, and a part was solid. There was a communication found between the extremity of a bronchial tube and the defined cavity in the serous membrane above alluded to. There was a small cavity capable of containing a pullet's egg in the apex of the left lung, filled with a dark-coloured fluid. "Whether I was correct in the opinion I expressed as to the presence of pneumo-thorax upon the left side in this case, and the air was subsequently absorbed, must remain undetermined. The existence of a cavity close to the surface of the lung renders it not improbable that such had really been the case, particularly when taken in connection with the sudden supervention of symptoms which usually accompany that accident. Whether the patient would have been permanently benefited by the evacuation of the fluid effused on the right side must also continue uncertain; though the very little disease existing in other parts induces me to think that such a result might have followed a more successful operation." 87. Case 4.-A girl, aged nine years, was brought to the hospital as an outpatient, (Sept. 7, 1843,) but was admitted under Dr. Hughes. Five weeks previously was attacked with inflammation of the bowels. A fortnight before admission was seized with severe pain in the left side, catching her breath-also pains in the head and limbs. She had cough and large expectoration, bowels open. On examination, the respiration was much hurried-dyspnoea-pulse 140. "Physical Signs.-Enlargement and fulness of the left side were obvious upon inspection. The intercostal spaces were level with the ribs, which were but slightly elevated during inspiration, and were thereby forcibly contrasted with those of the opposite side. The circumference of the chest measured twenty-three and a half inches; and by passing a tape below the nipple, from the spinous processes to the centre of the sternum, the admeasurement of the right side was found to be eleven inches, while that of the left reached twelve inches and one-third. There existed general dulness of the left side on percussion, together with absence, or great distance of respiration, and of the voice, though these could be but imperfectly investigated from the continual restlessness of the little patient. The heart could not be felt, though it was indistinctly heard below the left nipple; it was both heard and felt on the right of the sternum. The dulness on percussion existed up to, and indeed was most marked in its character below, the left clavicle, in which situation tubular breathing and imperfect pectoriloquism could be distinguished. The right side presented nothing remarkable, excepting the position of the heart." Next day Mr. Cock introduced the explorator in the left side. A few drops of pus escaped, while some purulent expectoration appeared from the mouth. On the introduction of a small trochar a jet of serum escaped-first limpid and then tinged with blood. The canula was withdrawn. From this time she gradually, but entirely recovered. The author candidly states that he doubts whether the operation, in this case, did any good. It is quite evident that it did no harm. It also shewed that the operation is not necessarily a dangerous one. Case 5.-This was one of partial recovery from hydrothorax, ascites, diarrhoea, phthisis. Paracentesis twice performed. The patient was a female, aged 23, and liable, from childhood, to cough. She was the mother of four children. About eleven weeks before admission, the abdomen began to enlarge, and the cough was more troublesome. She could only lie in the semi-erect position— urine scanty and high-coloured-great dyspnoea-pale face-tongue cleanemaciation-diarrhoea-abdominal fluctuation-no tumor of liver or spleenpulse 140, feeble. "The entire chest moved imperfectly upon inspiration. Marked dulness existed anteriorly upon the right side as high as the mamma, and posteriorly upon the left side up to the angle of the scapula. Absence or distance of the respiration, and decrease of the normal resonance of the voice, were obvious in the latter situation. Below the clavicles, but especially below the right, the respiration was hoarse, and mixed with mucous rattles. The impulse of the heart was felt nearer to the sternum than is usual; but the rhythm of the organ was normal, and the sounds were scarcely otherwise. As the diarrhoea required immediate attention in her weakened state she was ordered, Pulv. Kino C. gr. x. omni nocte sumend. ; et Pulv. Creta C. c Opio gr. x. ex. Mist. Mucilag. ter die; with Arrow-root and Beef-tea for diet. She continued without much alteration till the 28th; when the diarrhoea having been checked, though the tongue was still red and scabrous, the urine in very small quantity, the dyspnoea increasing, and decubitus equally or more difficult, she was ordered, Potassii Iodidi gr. ij. Liq. Potass. m. xv. Inf. Gentian. C. Ziss. ter die.— "Oct. 29. The dyspnoea and orthopnoea having increased rather than diminished, and dulness on percussion, together with absence of the respiration and the voice, nearly perfect immobility and slight enlargement of the left side, and partial displacement of the heart having been distinctly ascertained to exist, Mr. Cock, at my request, introduced, first the explorator, and then a small trochar, between the eighth and ninth ribs posteriorly, and drew off seven ounces of clear, yellowish serum. The patient felt almost immediately relieved. On the next night she was able to lie much lower in bed. The left side was found less extensively dull on percussion, and the heart less displaced towards the right side. Pleuritic rubbing was now distinctly heard below the left clavicle; the cough was still troublesome; the expectoration scanty and mucous; but the urine was considerably increased in quantity. Pulse still 140.” The dyspnoea having again increased, the trochar was introduced, and fifteen ounces of slightly sanguineous serum were drawn off, with great relief. In the course of a fortnight she was so far recovered, as to leave the hospital and return to her friends. "She was able to lie down in bed, and to turn upon either sideher appetite was good-improved in strength and flesh-pulse still 128." Dr. Hughes saw her a fortnight after she left the hospital, and she continued much in the same state. Although this cannot, of course, be pronounced positively as a case of recovery; yet it is not very far from it, and is well worthy of record. We can only make room for one more case. Case 6.-H. S., aged 19 years, had been exposed to cold, in wine-vaults, and experienced an attack of pleurisy two years previously. Admitted Dec. 2, 1840, with cough and expectoration. He is emaciated-nocturnal perspirationsdyspnoea-œdema of the ancles-entire right side dull on percussion—the left resonant, with puerile respiration. Can only lie on right side. In the night of the 15th December he was suddenly seized with violent cough, which continued nearly half an hour, with great sense of suffocation. The expectoration was bloody. Dr. Babington believing that the pleura contained fluid, Mr. Cock introduced the explorator, and afterwards the trochar, when two pints of purulent fluid were drawn off. This was followed by another violent fit of coughing, by which his life was endangered. For some weeks he daily expectorated nearly a pint of matter, apparently containing shreds of hydatids. In about two months he began to cough less, and to gain flesh. He shortly afterwards left the hospital in tolerable health, and was seen more than a year after dismissal, perfectly well. We have thus given our readers a full abstract of six out of ten cases recorded in the work before us; and we can hardly believe that they will differ from us in the opinion, that the said paper is worthy of the authors, and of the valuable work in which it appears. OBSERVATIONS ON LITHOTOMY.-[Guy's Hospital Reports, April, 1844.] In the first volume of the Reports, Mr. Cooper communicated some observations, of a valuable practical character, on Lithotomy, which we noticed at the time. In the present number, we find a continuation of the paper. Ten cases are first related, the nature of which may be gathered from their heads : CASE I. Calculus Vesica-Operation. Urine passed through natural passage on third day-Rapid Recovery. CASE II. Calculus Vesica-Symptoms excessive, but relieved by Medicine— Operation-Recovery. CASE III. Calculus Vesica-Operation—quite well in three weeks. CASE V. Calculus Vesica-Small Stone-Water passed by Natural Passage six days after Operation, and Patient quite well at the end of three weeks. CASE VI. Lithotomy after Lithotrity. CASE VII. Calculus Vesica-Strumous Constitution-Small Stone-Water passed by Natural Passage eight days after the Operation. CASE VIII. Calculus Vesica-Operation-Large Stone-Recovery. CASE X. Urinary Calculus-Sequela of Typhus Fever-Operation-Recovery. We don't see that it is necessary to narrate cases whose titles speak so intelligibly for them. Amongst other observations of Mr. Cooper's we find the following: "As regards the patients best adapted for the operation of lithotomy, little doubt can be entertained but that its success is much greater in children than in those who have arrived at the period of puberty; and that persons from the age of twenty-four to forty-five bear the operation worse than at any other period of life. The favourable result of the operation in children has been attributed to the smaller size of the vessels of the perinæum, and of those of the organs of generation. I think, however, this opinion is derived more from reasoning than from observation; as in those who die after the operation of lithotomy, a great majority, hereafter to be shewn, will be found to have died from peritonitis, connected with some diseased state of the viscera, and chiefly of the kidneys. And, again, during the middle period of life the whole arterial system is in full vigour; and a want of balance in any of the vital functions will suffice for the development of inflammation. "Little need be said as to the after-treatment, beyond what has already been considered; as nothing more requires to be done than paying attention to the secretions, the natural performance of which may be considered as constituting a healthy action: and perhaps there is more danger in interference during Nature's process of reparation after surgical operation, than there is in leaving them wholly to their own constitutional powers,' It appears that Mr. Cooper has operated eighty-four times at Guy's Hospital, and upwards of twenty in private; and that he has lost ten patients-a good share of success. After the preceding cases, Mr. Cooper relates seventeen others, of a more complicated kind. He observes very justly that : "It must appear evident to every one, that the practice of one surgeon, however extensive his opportunity may be, will not suffice to form a complete list of the various difficulties and complications in the operation and after-treatment of stone cases; and it therefore behoves every one who has had experience in this branch of his profession candidly and boldly to state the various circumstances which have occurred to him as impediments in the operation, or led to an unfavourable result. It is not sufficient that fortunate cases only should be published, without reference to unsuccessful results; as otherwise the inexperienced may be induced to believe that lithotomy is an extremely easy operation; and if in their own practice, under such delusion, any thing untoward should occur, they will be by far less capable of combating the difficulties, than if they had been made acquainted with the obstacles which they are to expect as liabilities in the operation. When we consider the great difference in the ages and constitutions of persons operated on for the stone, the variety of calculi both as to composition and size, and the variations in depth and condition of the parts cut through, it cannot be supposed that an accurate opinion can be given from à priori reasoning. In the operation of lithotomy, the surgeon should bear in mind that he must be, however cautious, more or less in the dark as to the difficulties which may present themselves; and it is only by meeting them with calmness and deliberation that the operator can ever hope to encounter them successfully." Case 11, the first of this second batch, was that of a boy three years of age. A short pair of forceps was introduced, but the stone was found to lay a considerable way back, and on attempting to open them, it was found impracticable; they were withdrawn, and re-introduced, but with the same result. A longer pair of forceps were then used, and the stone removed. The child recovered without any unfavourable symptom. Mr. Cooper observes upon the case:--"Those I employed at first were the usual ones intended for children; but I have so frequently found them of an inefficient length, particularly in the instance of a capacious bladder, that I am in the habit of using larger forceps than are generally recommended; and have found considerable facility both in seizing and handling the stone, from the greater length of these instruments." Case 12. A boy, aged 4 years. The stone was supposed to be large-the urethra was small, and the staff necessarily so. It was remarked that the first incision was large; but yet, from the depth of the perinæum, and the smallness of the groove in the staff, there was some difficulty in introducing the point of the knife; which, on being effected, was smoothly and readily passed into the bladder. Mr. Cooper then introduced the fore-finger of the left hand into the bladder; and finding that the prostate grasped his finger, was satisfied that the opening was not sufficient for the size of the stone; he therefore considered it prudent to enlarge the internal incision; when the forceps were introduced, and a rough stone, about the size of a walnut, was immediately removed, without any difficulty. It was observed that not a drop of urine followed the introduction either of the knife or of the forceps. The boy got quite well rapidly. Mr. Cooper considers, and probably with reason, the making the incision in the prostate too small a fault on the right side. He remarks:-"Many surgeons, I believe, are of opinion that less injury is likely to occur from an incised wound, even if it be a little too large, than from a lacerated one, occasioned by drawing the stone through the resisting prostate. But on this point I feel perfectly assured, that the incision through the prostate, made by the knife, should |