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could separate the volitional from the reflex motor fibres,in the same way that we can isolate the cerebral and spinalcentres, we should find irritation of the purely cerebral nerveswould produce no movements whatever. Throughout thebody generally the spinal and cerebral nerves lie side by sidein the same fasciculi; but in one instance, as we shall have iagain to remark, Nature appears to have given the experimentnecessary for determining this point. The levator palpebraeis never affected by spasmodic action ; irritation of thisnerve, though indisputably a motor nerve, does not producecontraction of the levator muscle. These observations pointto a further train of thought. The vis nervosa acting in thespinal nerves, cannot be identical with the force acting involuntary nerves. They may be found to bear a relation toeach other somewhat similar to that which exists between

magnetism and electricity. This is a most interesting pointin animal dynamics. The study of the animal imponderables,the vis nervosa of spinal nerves, the vis mentalis of cerebralnerves, and the irritability of the muscular fibre, form the veryhighest department of physiology.

It is the glory of our author that he should have traced insuch a beautiful manner the laws of action of the imponder-able element, acting in and through the spinal system, placingit before us for examination in its reflex, centric, and retro-grade forms of action in health and in disease.

The Anatomy of the Spinal System.Thus much, then, for the discovery of the excito-motor

system. It is preëminentlya physiological discovery. Butthe anatomy of the system has not been neglected by theauthor. He has long considered the pneumogastric as thegreat internal, and almost purely excitor, nerve, groundinghis conviction on the facts, that the parts to which it is chieflydistributed are among the most insensible organs of the body,though this itself is one of the largest nerves; and upon theother fact of its immense excitor power, and its demonstrablerelation with all the reflex nerves of respiration, deglutition,&c. He has been accustomed to look on the nerve of thelevator palpebrae as offering the purest anatomy of a reflexmotor nerve. But Dr. Marshall Hall has always contendedthat his physiological experiments have proved the existenceof a special anatomy for the excito-motor system; of a classof nerves, excitor, but not sentient, and of another class ofnerves, motor, but not voluntary,-the two classes of nervesbeing keyed by their centre, the true spinal marrow. In

his admirable letter, in the present number of THE LANCET,he claims, by facts arrayed with mathematical precision,and in his own terse and incisive language, that there is thesame proof of the anatomy of the excitor-motor system asthere is of the anatomy of the cerebral system. This is mosttrue. The same kind of proofs in observation, in experiment,in pathology, by which we get the obvious proof that thebrain is the central organ of the psychical motions, equallymaintain that the spinal marrow is the centre of the physicalmotions-that it is to the nervous system what the heart isto the blood. The same proofs which prove the existenceof sensitive and voluntary nerves prove the reality of ex-citor and reflex-motor nerves. The spinal system is, in itssphere, as important as the cerebral system. And if wecould fancy the spinal system to have been discovered first,we may feel sure that those who now deny the excito-motor system a special anatomy, would then have denied oneto the brain. According to the spirit of such reasoners, thecerebral system owns its territory less by proved right thanby prior possession. In the anatomy of the spinal marrow,there have been supplemental workers, whose claims we shallhave to consider; but we now, once for all, say, that to thefirst discoverer the idea and the proof of this anatomy is due.

Recapitulation.In concluding this portion of our review, we would reca-

pitulate the chief points. The principle of action in these

functions,-their anatomy, in incident and reflex-motor nervesconnected by their nervous centre, their excito-motor cha-racter, their reflex form, the CLASS of objects; the generali-zation, the power, the anatomy, the function, the grand pur-poses ; with the further application (as we shall show in thesucceeding portion of our review) to the diagnosis, the pa-thology, and the therapeutics of a great class of disease,-this is the work of Dr. Marshall Hall. We know of nothingso original, so diffusive, so developmental in its character, asthe true spinal system. It seems as if it was left to our scien-tific labourer, guided by one scientific fact, to detail the prin-ciple, the form, the manner, the anatomy, the physiology, thepathology, and the therapeutics, of a great department in theanimal oeconomy.

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FOREIGN DEPARTMENT.

M. CIVIALE ON THE VALUE OF INSTRUMENTS IN THE DIAGNOSIS

OF DISEASES OF THE BLADDER.

FROM the moment my opinion is formed on the aptitude ofthe organs to admit of the use of the sound, and to bear it fora sufficient length of time, I at once commence its employ-ment. The method varies according to the object in view.If I wish to satisfy myself of the existence of a calculus,attended or not with organic lesions, the plan differs as thebladder is capacious or otherwise. In the latter case, if theviscus contracts energetically; if it contains only a smallquantity of urine at the time the sound is introduced; if theliquid is forced out; our first endeavour should be, to preventit passing away, either by means of the finger, or other means.We must proceed to sound the patient in the ordinary way;but besides this, it will be necessary to rotate the sound, bywhich movement the point of the instrument will be turnedtowards the rectum. The point must be turned towards allsides of the lower part of the bladder, which, as is well known,is less deep, and in some cases of enlargement of the prostate,represents a sort of cul de sac. But at the same time, caremust be taken that the point of the sound does not rub pain-fully against the surface of the bladder, by the surgeon lower-ing the hand which presses on the handle, so that the viscusshould have less size, and the curved portion of the instru-ment be as long as possible.By means of this manosuvre, we are enabled, with soundshaving a slight curve, to execute without pain, and with alldesirable precision, an exploration of the bladder, whichcannot be done in the usual way, or in so satisfactory amanner, by other means.Another modification, which is even more important, inas-

much as we find it very often applicable, consists in injectingthe bladder several times successively with lukewarm water,when the bladder contracts with energy; or with cold waterunder opposite circumstances. In this way we are enabled tolet the bladder pass from a state of repletion to that of emp-tiness, several times successively, so as to vary its form andcapacity; almost always the organ momentarily becomes con-tracted to such an extent, that not only the surface to beexplored is much diminished in size, but the walls of thebladder collapse on the instrument, so that the stone, if thebladder contain one, is readily felt.In simple cases it is rare for the surgeon not to discover a

calculus, however small it may be. But in cases where thebladder presents columns, enlargements of the prostate, orswelling in the neighbourhood of the neck, one essay will beinsufficient; nor must we depend upon the sound alone. Forinstance, when a prostatic tumour, or fungus, exists on theinferior surface of the neck of the bladder, the sound maydepress the swelling, or thrust it back, so as to conceal anysmall stone lodged behind this duplicature. Moreover, it isoften difficult to discover a foreign body in this situation, eitherby catheterism,or by other means, of which Delpech and othershave given examples. I have succeeded, in many instances,by employing a sound with a short point, and bent very much,and by turning the point downwards behind the tumour, and bymoving it laterally. If any doubts exist, they may be clearedup by means of the lithoclaste, which should be preferred tothe trilabe; whereas, we should have recourse to the last, if,notwithstanding repeated injections of cold water, the bladderdoes not contract, but presents so large a size that the soundis unable to explore it to a sufficient extent.

If it be our object to discover the presence, not of a foreignbody, but of an organic lesion, we must follow a different plan.

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It may not be advantageous to proceed to explore the internalsurface of the bladder, previously to separating the walls, byinjections of lukewarm water, and in maintaining them sepa-rated. It will be necessary to place the patient in the positionspoken of above, so that the abdominal viscera do not pressupon the bladder. We must recollect, that in the normalstate the bladder, distended by an injection, presents an uni-form surface, on which the sound may be passed without ourrecognising either projections or unevenness, although it isonly in particular cases that a practised hand can be deceived,but feel the orifices of the ureters. Hence every inequalityor prominence which the sound may meet with must be re-garded as an abnormal state. We must now determine thesituation, which is generally easy enough; as to the form, size,or character of the tumour, these are points which oftenpresent great difficulties. But we know beforehand, at leastapproximately, in what these tumours or inequalities consist.Pathological anatomy teaches us that it is a question eitherof unusual hypertrophy of the muscular fibres of the bladder,or a partial thickening of the walls of the organ, or more fre-quently of prostatic or fungous tumours. These last have aregular position, which simplifies the question at once. Withregard to expansions or tumours of a fungous character, thereis a much greater degree of uncertainty, as these morbid pro.ductions are susceptible of numerous varieties. Neverthelesswe know that they are met with more particularly in the neigh-bourhood of the neck, or lower portion of the bladder, and thatthey are rare in other portions. These data, connected withan exact knowledge of the position of the trigone 1Jésical, give,if not an absolute knowledge, at least sufficient informationto guide us in selecting other means, of which I shall subse-quently speak.When the surgeon discovers, by means of the sound, a

prominence towards the posterior portion of the bladder, hecan easily distinguish if he has to treat a muscular column;for in that case he meets with, not only one, but many suchcolumns, and the point of the instrument jumps from one tothe other.

If a fungous production exists, the surgeon can equally dis-tinguish it, particularly when the swelling is isolated, promi-nent, and of a certain consistence. In causing the point orcurved portion of the sound to pass over it, we can appreciate,at least approximately, what is the hardness, the prominence,and even its means of insertion, and this by means of thepower of displacement which we are capable of impressingupon it by pressure exercised upon it in different directions.But it must be readily allowed that these notions are difficultto be obtained, and even in simple cases that they are uncer-tain and insufficient; in fact, if the tumour has only the cha-racters I have just indicated; if the complaint is but at itscommencement; if, as generally happens, the parts in theneighbourhood of the vesical surface are no longer in a normalstate, an examination with the instrument teaches us scarcelyanything, even to the surgeon who has the greatest experiencein these matters. I have met with several cases, one of whichis a recent instance, in which fungous tufts of considerablesize had not been recognised by practitioners who call them-selves very clever.In regard to the morbid productions situated near to the

neck of the bladder, we can obtain, by means of the sound,data of high value, to which surgeons have not paid sufficientattention. In the normal state, when a sound, with a slightcurve, has entered the bladder, the walls of which are sepa-rated by means of injections, we can easily rotate the curvedportion of the instrument. In cases of fungous or prostatictumours, this movement is arrested; the point of the soundstrikes against the tumour, and does not advance. If we

attempt to rotate it in the opposite direction, the same thinghappens. Now a morbid production can alone occasion this.But it suffices only to pass the instrument a little furtherinto the bladder, where rotation can be readily performed.The distance that it is necessary to push forward the instru-ment gives the surgeon an idea of the prominence caused bythis tumour.The inclination of the instrument either to the right or

left at the moment it passes the internal orifice of the urethra,and which can be calculated by the analogous inclination ofthe external rings of the sound, enables us to judge of thesituation or the size of the swelling, particularly when it occu-pies the sides of the neck of the bladder.

If the tumour is situated in the trigone, and if it be largeand hard, the sound will be arrested on entering the bladder,and the extent to which it will be necessarv to lower thehand which introduces the sound, in order that it may passabove the tumour, furnishes important indications.

If the tumour projects into the bladder, and if, in its pro-gress, the instrument depresses it, or thrusts it towards theposterior surface, it will have a tendency to recoil as soon asthe pressure ceases, and on applying itself to the convexityof the curved portion of the instrument, it will tend to thrustit (the instrument) out of the bladder. This effect shows usthat it extends a considerable distance posteriorly, for it doesnot take place when the straight portion of the instrumentpasses on the tumour. Notwithstanding all the improvementswhich catheterism has undergone, it is still far from procuringus all the information which we require in practice. In cases

I of calculi, it affords us but vague approximative results, withregard to their size, hardness, and number. As to the morbidproductions of the neck or fundus of the bladder, the datawhich it furnishes are still more imperfect; for even whenthe sound reveals their existence, it leaves you almost alwaysin doubt as to their development, their form, consistence, and,probably, on their mode of insertion into the sides of thebladder, the knowledge of which becomes of so much import-ance in the treatment. Lastly, in complicated cases, be theyof stone or tumours, simple catheterism is very often perfectlyuseless.

In these different circumstances, the instruments used inlithotrity furnish data which fill up these gaps left by cathe-terism, at least in cases where the disease is not sufficientlyadvanced to reject the intervention of our art.The trilabe and the lithoclaste deserve particularly to be

taken into consideration. We may likewise have recourse tothe percuteur, and the articulated curved instrument, thevalue of which has, however, been overrated, as may be easilyconceived in taking the trouble to study the mechanism ofthese instruments.Of all our exploring agents, the trilabe is the most advan-

tageous. To employ it, (previous to withdrawing the soundwith which we have commenced sounding the patient,) weshould first inject a quantity of water varying in proportionto the object we have in view.

If it be our object to recognise a small calculus which hasescaped detection with the sound, two or three ounces of fluidwill suffice, and the instrument is arranged so as to allow thewater to pass off during the examination ; and the walls ofthe viscus, at length coming in contact with the instrument,we are enabled to discover the smallest quantity of gravel.

If the bladder has so far lost its contractibility that coldinjections fail, though frequently repeated, in causing it tocontract, we likewise introduce only a small quantity of water;and as this is not thrown out in jets, we are able to prolongthe operation without fatiguing the patient. In this case, weseparate the branches of the trilabe a little more than in thepreceding case, so as to augment the extent of the exploringsurface. Moreover, it will be well to vary this surface bywithdrawing the branches of the instrument into the sheath,or in causing them again to project.

If we are desirous of knowing the dimensions of a largestone, we employ the trilabe with long branches, which shouldbe separated from one another as far as possible ; the bladdershould then be injected with as much fluid as it will contain;this should not be allowed to escape during our manoeuvres,which occasion more suffering than in the preceding instances.If we are unable to seize the stone at once, we should dis.continue our attempts.When we wish to determine the volume, situation, or hard-

ness, of a fungous tumour, the presence of which we have as-certained by means of the sound, as well as its mode ofinsertion on the surface of the bladder, and its degree of sen-sibility, we should fill the bladder with water to such an extentthat the patient feels an urgent desire to make water; andtaking an instrument of moderate size, the lithotriteur ofwhich does not exactly fill the cavity of the trilabe, so that itsmovements may be more easy; and having fixed the tumourwithin the grasp of the branches, if we seize and compress it,by means of movements given to the instrument, in front orsideways, we are .enabled to judge if the pedicule is long orshort, if it be slender or of considerable volume.When the swelling exists in the neighbourhood of the neck

of the bladder, we withdraw the trilabe until the back of thebranches comes in contact with the internal orifice of theurethra, so as to distend it. The traction, however, must notbe continued so as to produce pain ; but from the moment wefeel resistance, we should give the instrument, which thus

I forms a sort of funnel, slight lateral movements, so that the, branches, or at least one of them, if it happens to be placed onthe summit of the tumour, may slip towards the base ; in thisposition, a morbid production is the only body which can

place itself between the branches and project in that situation,

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and this can be ascertained by means of the lithotriteur, whichenables us to judge of its size with more facility as we judgeof the proportion of the separation of the branches. If onlyslight vegetations exist, we open the instrument so little asonly to prevent it passing out of the bladder when we attemptto withdraw it, say to an extent of six or eight lines. Thus,these preliminary means, even the mere introduction of asound, suffice to let us know what is the volume of thetumour.When the disease is confined to simple vegetations, we may

recognise them exactly, by causing the instrument to revolve e ’,open close to the neck of the bladder, either by passing thebranches upon it, or, after having applied it against the orificeof the canal, in giving the lithotriteur a to-and-fro motion.We are enabled to feel them, but not seize them, by means ofthe trilabe ; although they may project among its branches,still they readily slip away.

It is likewise by revolving the trilabe open that we distin-guish the inequalities on the internal surface of the bladderformed by fungosities. I have already observed that we areable to distinguish the muscular columns best by means ofthe sound.The lithoclaste with flat and large branches, no more than

the trilabe, is useful in establishing the existence of vege-tations on the sides of the bladder. It merits, however, ourpreference, when we wish to lay hold of these productions,with the view of either determining the volume or their modeof insertion, or breaking them up and destroying them, ifthere be reason for doing it.

I have never employed the articulated curved instrumentin seizing the fungous tumour of the neck of the bladder,judging from theory it might be applied to this purpose.Whatever instrument we employ, we can usually ascertain

if the tumour is pediculated, or has a large base. In the lastcase, we find great difficulty in,seizing or fixing it, for thebranches of the instrument always have a tendency to slipfrom the base to the point, which cannot happen whenthe tumour is pediculated. It is worth determining if thedifficulties-depend upon the situation of the swelling, or anill-executed examination-a distinction which cannot be as-certained unless the surgeon possesses an exact knowledgeof mechanism and of the organs which lie is called on toexamine.

It always happens, that with care the manipulations whichI have indicated, rather than described, furnish me with datawhich I can in vain look for from other sources. I shallconclude this article by announcing succinctly this recentfact :A resident in the neighbourhood of Paris had complained

for some time of considerable derangement in the passing ofhis water. The progressive increase in the symptoms, not-withstanding the numerous means employed, determined him ’,to become a patient of mine. I then learned that some clever

surgeons had in vain sounded him, that injections had beenemployed during a long period, and that his medical attendantshad exhausted the list of remedies usually employed in casesof vesical catarrh and haematmia, which were considered theleading symptoms in the case. In examining the bladder bymeans of the trilabe, recognised the existence of an enormousfungous tuft implanted on the posterior surface of the viscus.I seized this tuft and tore it away, without the patient per-ceiving anything particular. I brought away with the instru-ment apart which passed with difficulty the meatus. During theday and the following night, three other masses were expelledwith the urine. Instead of the accidents which might havebeen dreaded as a consequence of this operation, the patientexperienced considerable amendment; the urine ceased tocontain coagulum, and it became only of a darker colour, andcatarrhal. At a later period, I examined afresh the bladder,which still presented inequalities on its posterior surface, butthe prominence was not of sufficient size to enable me toseize it. The patient returned home, and promised to call onme should any symptoms relapse.The operation was performed in the presence of a large

number of surgeons, both French and foreigners. The manis not cured, and I doubt if he ever will be, but he expe-riences great relief; and now, as it is known with what com-plaint he is attacked, he will not be annoyed any longer withthose empirical nostrums, which, independently of injuringthe constitution, cause a great loss of precious time, duringwhich the disease has made great progress. I will add onemore remark-it is, that fungosities in the form of tufts aresometimes very difficult to distinguish, on account of theslight consistence of the long filaments which constitute theirtumours.—CaxeMe Medico-Chirurgiccde.

BRITISH MEDICAL JOURNALS.

CHROMIC HYDROCEPHALLTS WITHOUT SYMPTOMS DURING LIFE.

DR. BANKS exhibited to the Dublin Pathological Societyspecimens illustrating the case. It is one of the many in-stances which tend to show how obscure and difficult is every-thing connected with the investigation of disease :-

" There was no symptom of cerebral disease, no convulsion,no impairment of intellect, during two years that the patienthad been under Dr. Banks’ observation. The subject of thecase (a male, aged thirty) did, however, state that he had beentreated for water in the brain during infancy. About threemonths before his death, he exhibited signs of phthisis, and acavity was detected in the upper lobe of the right lung. Thedisease went on rapidly to its fatal termination, but there wasno delirium even in its latest stage. On opening the skull,the arachnoid was found slightly opaque; within the brainitself was an immense mass of serous fluid, measuring at leasta quart, distending the lateral ventricles; the substance of thebrain enclosing this was exceedingly thin, but the bones ofthe cranium were of the normal thickness. Here, then, wasan enormous extent of disease within the brain, yet unaccom-panied by any obvious injury to the intellectual powers. Thisman’s memory was quite good, he appeared in possession ofall his faculties, and had neither epilepsy nor spasms of anykind."—-DM&’M ./bM?’K6t.

The perusal of the valuable reports sent forth from time totime by the above Society, and some others of a similar cha-racter founded in the English provinces, has frequently sug-gested the question, why London should be without an insti-tution through which pathological information could be

disseminated. The societies already in existence here havegot more than enough to do, whilst thousands of specimenswhich might be made available are entirely neglected, orscarcely noticed. It was with much pleasure, then, that wereceived, a short time since, a prospectus of the " LondonPathological Society," with its rules and a list of officers; theformer are simple and comprehensive, the latter contains thenames of those who are already distinguished in our science

’

by their zeal and ability. The character which is theirs as

private individuals they will no doubt confer on the Societyas a body; and we therefore look forward with confidence tothe success of the " Pathological Society of London."

THE AGE MOST SUITABLE FOR THE OPERATION OF HARE-LIP

is a question which is still undecided. Dr. BATTERSLEY hascollected the following opinions on the subject, and theyappear in his report on the diseases of children in the samejournal:-"The communication of M. P. Dubois to the Academy of

Medicine has drawn attention to the question of the proprietyof operating for this deformity shortly after birth. Guersant,junior, agrees with him in thinking that the best time for theoperation is immediately after birth, and that if this favour-able opportunity be allowed to pass by, it is better to waittill the eighth, tenth, or twelfth year. He differs in opinionfrom Dubois as to the propriety of allowing the patients to

suck immediately after the operation. He thinks that duringthe first two days they should have nothing but a few dropsof sugared water-and-milk put into their mouth, which willafford quite sufficient nourishment to a new-born infant."Malgaigne has operated, nine hours after birth, on a child

with simple hare-lip, complicated with a wide fissure of thepalate, and of the alveolar process. The operation succeededperfectly; but the child died, on the sixteenth day, from diar-rhoea and aphthae. The cicatrix was found to be admirable,and the separation of the bones was so much lessened, that,had death not occurred, the fissure would undoubtedly havebeen quite obliterated.

" Encouraged by the success of M. Dubois, M. Baudon has’ operated, and with success, on an infant, aged four days, born

with double hare-lip and fissure of the palate. He operatedfirst on the right, and at the end of a fortnight, on the left,side, following exactly the method prescribed by Dubois as

to the daily re-application of the ligatures, and the removalof the needles.

" Mestenhauser, during a practice of thirty-two years, has