hollow to the anus. A probe having been introduced at the external opening of the fistula, serves as a director for the probe-pointed knife, which will be felt in the rectum by the surgeon's left fore finger. If the fistula should not have penetrated the gut, the bistoury should be pushed through its side. The probe may now be withdrawn, and the operation completed by bringing the knife out with its point applied to the finger which was in the intestine; and thus all between the edge of the knife and the anus must be divided. A soft piece of lint should now be placed in the wound, and remain until it is loosened by suppuration, and all the future dressings should be mild and unirritating. The callosities, of which surgeons have complained so much in these cases, arise from injudicious treatment, and particularly from the use of caustic and stimulating applications.

Prolapsus ani. The internal coat of the gut may be protruded through the sphincter; or a portion of the intestine with all its coats may descend. Causes which weaken the sphincter, and such as force the intestine downwards, contribute to this affection. Costiveness, tenesmus kept up by hemorrhoids, ascarides, fistula in ano, stone, &c. are of this kind. The cause should be removed when that is practicable. The gut must be replaced, but previously clysters, fomentations and poultices, or leeches, and cold washes, are necessary, Horizontal posture, and avoiding costiveness, are very important points. A compress and bandage may be necessary to retain the replaced gut; and astringent clysters have been advised. If the protruded part has become indurated, thickened, and painful, and will not admit of reduction, it may be extirpated. Sometimes an introsusception, commencing at the cæcum, has protruded at the anus. This case is quite beyond the powers of art. Prolapsus, inversio, and retroversio uteri,

are considered under the article MIDWIFERY.

LITHOTOMY.

The existence of a stone in the bladder causes various symptoms in the bladder itself, and others in neighbouring parts. The former are frequent inclination to void the urine, which sometimes stops suddenly from the stone mechanically obstructing its passage; pain in making water, and particularly after the discharge, from the bladder contracting on the foreign body; mucus, and

sometimes blood in the urine, and pain on exercise. The latter are an uneasiness and itching at the end of the penis, leading the person to draw and elongate the prepuce; sense of weight in the perineum; tenesmus; numbness of the thighs, &c. These symptoms come on in fits. In order to ascertain the fact, a solid steel instrument, shaped like a catheter, and called a sound, is introduced into the bladder, where its point, meeting the stone, gives decided information to the surgeon. It must be moved in various directions after its introduction, as it may not immediately or easily come in contact with the stone. The operation should never be performed, unless the stone can be plainly felt before the operation: the rectum should be previously emptied, but it is more advantageous for the bladder to be full. The patient is to be placed with his pelvis at the edge of a table, and the staff introduced into the bladder. The thighs and legs are then bent so as to enable him to grasp the soles of the feet with his hands, and the limbs are retained in this position by broad garters, doubled and placed by means of a noose round the wrists, carried over the back of the hand, and inside of the foot; then brought up again, and continued round the wrist and ankle, and firmly tied. The staff is shaped like a sound or catheter, and has a groove for conducting a cutting instrument into the bladder. An assistant standing on the patient's right side holds the handle of the staff with one hand, making its convexity project in the perineum, and draws aside the scrotum with the other. An in

cision should be made through the integuments, commencing on the left side of the raphe of the perineum, just opposite to the membranous part of the urethra, and continued obliquely downwards and outwards for about three inches between the anus and ischium. The transversalis perinei should then be cut through, and the membranous part of the urethra freely opened, so as to expose the groove of the staff. The beak of the gorget is now introduced into the groove, and the operator takes the handle of the staff into his left hand, holding the gorget in his right. He then thrusts the gorget into the bladder, keeping its beak in close contact with the groove of the staff, and bringing the handle of the latter instrument downwards and forwards, in order to raise its point, and make its direction coincide with the axis of the bladder. The cutting edge of the gorget, by this mode of introduction, divides the prostate gland and neck

Riece of sheet lead. The issues must be kept open until the complaints have entirely disappeared.

AMPUTATION.

In whatever part this is performed, the surgeon's object is the same, viz. to save enough of the surrounding soft parts to cover the extremity of the bone, and enough of skin to cover the whole. The stump is always treated as a wound which should be united by the first intention; its sides are therefore brought together, and retained in apposition by straps of adhesive plaster, and appropriate bandages. By this, which is the improved me. thod of modern surgery, introduced by Mr. Alanson of Liverpool, the wound made by removing a thigh is often agglu. tinated in forty-eight hours, and the patient consequently escapes the dreadful pain and irritation, and vehement sympathetic affection of the constitution, which almost invariably attended the old practice of dressing the stump with dry lint as an open wound, and consequently healing by means of granulation and cicatrization, instead of adhesion.

In amputation of the thigh, surgeons used to cut at once down to the bone, and saw that through; but in order to save more soft parts, and thereby to avoid the projection of the bone, which commonly attended that method, the double incision was devised; by which the skin and muscles are divided separately. More difficulty is experienced here than in any other amputation, in saving muscles enough to cover the bone, which, in this particular instance, is especially desirable, from the the pressure which the end of the stump must experience in supporting the weight of the body. The sound leg should be tied to the table, and the tourniquet applied on the inside of the thigh. The limb should be cut off as near to the knee as possible. A circular incision should then be made by the surgeon, standing on the outside of the limb, through the skin and adipous substance. The integuments should be drawn upwards by an assistant, and any cellular connection that prevents their retraction should be divided. A cut should now be carried through the loose muscles, at the part to which the skin has been withdrawn, and when they have retracted, those which are fixed to the bone should be divided at the point to which the former had retracted. The latter may be separated from the surface of the bone, for a short distance,

by a common scalpel, to allow of the bone being sawed higher up than it could be otherwise. This part of the operation should follow, the surface of the wound being kept out of the way of the saw, by means of a retractor, which is a piece of linen somewhat broader than the stump, torn at one end, in its middle part, to the extent of about eight or ten inches. It is applied by placing the exposed part of the bone in the slit, and drawing the ends of the linen upward on each side of the stump. Besides defending the surface of the wound from the teeth of the saw, the retractor will undoubtedly enable the operator to saw the bone higher up than he otherwise could do. The femoral artery should be drawn out by means of a pair of forceps, and tied separately; other large arteries should also be secured, without including any of the surrounding soft parts. Smaller branches must be taken up with the tenaculum. It is necessary to slacken the tourniquet, in order to discover the vessels. The wound should then be thoroughly cleansed from all coagulated blood, by means of a soft sponge and water, and one end of each ligature removed. The skin and muscles are now to be placed over the bone, in such a direction that the wound shall ap pear only as a line across the face of the stump, with the angles at each side, from which the ligatures should be brought out. The skin is supported by long strips of adhesive plaster, applied at right angles to the line of union of the wound; the ligatures are guarded by lint spread with spermaceti-cerate; and a linen roller is carried round from above downwards, two cross pieces having first been put over the end of the stump. The dressings should not be moved for four days.

In amputating the leg, the bones should be sawn through, about four inches below the patela. The tourniquet is applied in the lower part of the thigh. After cutting through the skin, which should be drawn upwards, it must be reflected from the flat surface of the tibia, and front of the leg, so as to cover those parts which could not be covered by any large muscle. The calf is then to be cut through, by an oblique incision slanting upwards; the rest of the muscles, and the interosseous ligament, should be divided by a double-edged knife; called a catlin, and the bones sawn, after the previous application of a double tailed

retractor.

In amputating the arm, or fore-arm, we should preserve as great a length of the limb as the case will allow.

Amputation of the shoulder joint has been done in various ways. An incision should 'be carried through the skin and deltoid muscle down to the bone, from the front of the joint, a little below the clavicle, obliquely downwards and outwards. The deltoid should then be turned up so as to expose the head of the bone, which must be brought entirely into view, by dividing the orbicular ligament all round. One cut of an amputating knife will then separate the limb. The axillary artery should be immediately tied. This vessel must be firmly compressed, by an assistant, above the clavicles, during the whole of the operation.

The fingers and toes should be removed at their joints. Make a circular incision through the skin, about one third of an inch below the articulation; draw the integuments up, and cut through one la. teral ligament of the joint, which you can then dislocate. The remaining connec tions are easily divided. Bring the skin together over the end of the bone. If you amputate at the first joint, make two cuts, one at the back, and the other towards the front; these must meet when the bone is removed. It is sometimes necessary to tie the arteries.

Paronychia, or whitlow, is an abscess occurring about the nails, or still more deeply under the soft parts of the fingers. In the latter case, swelling of the arm, inflammation of the lymphatics, and considerable constitutional disturbance, frequently attend. The complaint is always very painful, attended with great throb. bing; and often terminating in the loss of the nail. We should, if possible, prevent suppuration, by the employment of local antiphlogistic means. If these do not succeed, a soft poultice may be used, and the collection should be opened as soon as possible.

Venesection. When a vein is to be opened in any part of the body, pressure must be made on the vessel, between the place where the puncture is to be made and the heart. This prevents the return of blood through the vessel, makes it swell, and become conspicuous. As the supply of blood is still continued through the arteries, the vein bleeds freely when it is opened; but care must be taken, particularly in the arm, not to apply the ligature so tightly as to stop the pulse. The bandage should be placed a little above the elbow, and the most prominent and conspicuous vein may be opened; excepting that if equally convenient, one would avoid the vessel lying over the brachial artery.

The vein may be fixed by placing the thumb of the left band a little befow the place where it is designed to introduce the lancet. That instrument should be pushed obliquely into the vein, and when its point is a little within the cavity, the opening may be rendered sufficiently large by carrying the front edge forward and upward, so as to bring it out of the part. In many cases, where we wish to make a sudden impression on the vascular system, we make the opening longer than usual, that the blood may be withdrawn more suddenly, and cause fainting. The stream may be accelerated, by putting the muscles of the fore-arm into action. It stops when the ligature is removed, or, at least, if the surgeon press with his left thumb below the vein. The sides of the incision should be placed in contact, and maintained in that condition by a small compress of linen, bound on with the bleeding fillet applied in the form of the figure of eight. In opening the external jugular vein, the pressure must be made with the surgeon's finger; and the compress should be fastened by means of sticking plaster. The temporal artery may be opened by a simple puncture; and the bleeding may al ways be stopped by a compress fastened by means of sticking plaster. The operation of bleeding may be followed by various unpleasant consequences; as ecchymosis round the vein, inflammation of the integuments, absorbents, fascia, or vein itself. The former symptom generally disappears of itself in a week or ten days; the others may be treated according to the general principles of surgical practice.

PARTICULAR FRACTURES.

We shall say a few words on the most common and important kinds of fracture.

Fracture of the lower jaw may be detect ed by introducing a finger into the mouth and pressing on the front portion of the bone, while the fingers of the other hand are applied on the outside to the back of the bone. Alternate pressure in these situations occasions a very distinguishable crepitus. When the broken ends are adapted to each other, some wetted pasteboard is to be applied along the outer surface and base of the bone; and over this a bandage, with four tails, should be placed. The centre of this bandage is applied to the chin, the two posterior tails tied together at the top of the head, and the other two more posteriorly. The wet pasteboard adapts itself to the figure of the part, and constitutes, when dry, a splint exactly accommodated to the form

of the jaw. All motion of the broken bone should be avoided: hence talking, chewing, &c. are improper; hence, too, the food should be soft, and introduced by a spoon.

The fracture of the clavicle is attended with a displacement of the bone; its scapular portion being drawn downwards and forwards. In order to restore it, let the shoulder be drawn backwards, and the arm raised; then the surgeon should place the fracture in as even a position as he can, cover it with a piece of soap plaster, and keep the shoulder back by means of the figure of eight bandage; the forearm and elbow being well supported by a string. A leather apparatus lacing behind, and having straps to pass in front of the shoulders, similar to the instruments used for girls with the view of keeping the shoulders back, is a more effectual mode of accomplishing the object.

It is often difficult to detect fracture of the ribs. By placing the fingers where pain is felt, or where the blow was received, a crepitus can be distinguished in many cases, on making the patient cough; yet, if the matter be doubtful, the safest plan is to treat the patient as if his ribs were broken. It will be readily seen how emphysema, extravasation of blood, &c. may occur when the bone is displaced inwardly. Our object is to keep the broken ends motionless. Hence, after a piece of soap plaster has been applied externally on the situation of the fracture, a broad roller should be put firmly round the chest, or we may apply an apparatus made expressly for the purpose, consisting of a broad girth, with three or four buckles and straps, which may be tightened at pleasure. Bleeding is proper, unless particular circumstances contraindicate it.

In fractures of the os brachii, after restoring the limb to its natural figure, and putting on a piece of soap plaster, apply a splint, lined with a pad of soft materials, from the acromion to the external condyle, and another from the margin of the axilla to the internal condyle. Some add two others, one before and one behind. They must all be carefully fastened with tapes, and the fore-arm and hand should be well supported by a sling. There is always a distinguishable crepitus in fractures of the fore-arm. After a piece of soap plaster has been applied, two splints must be employ. ed; one is to be placed along the inside, and the other along the outside, of the fore-arm. The limb is to be in the mid state, between pronation and supination; and the inner splint should reach far

enough into the hand to support it, and prevent it from falling into the prone

state.

In fractures of the olecranon the elbow must be placed straight, to approximate as much as possible the broken ends, and the limb must be continued in that position until the patient has recovered.

When the os femoris is broken, there is severe local pain, an incapacity to move the limb, a distinguishable crepitus on motion, and deformity of the part from retraction of the lower portion. The latter appearance will occur more readily, in proportion as the fracture is more oblique; and it arises entirely from the ac tion of the muscles which are fixed in the bone below the fracture, together with the flexors of the knee. Besides the shortening of the limb, produced by the retraction of the lower portion of the frac tured bone, there is another deformity arising from its being rotated outwards; an effect produced by most of the large muscles of the thigh. The higher the fracture, the more difficult is it to prevent displacement. When the neck of the thigh bone is broken, there is severe pain in the groin, much aggravated by motion of the part. The extremity is shortened, the limb turned out, and the trochanter higher than usual towards the pelvis. Yet the limb may be drawn down to its natu ral length, in doing which a crepitus is sometimes perceived. In order to relax as much as possible the muscles which tend to displace the broken bone, a bent position of the thigh and leg was recommended by Mr. Pott. He recommended that the patient should lie on the side of the fracture, with the thigh bent on the pelvis, and the knee half bent. A broad splint well padded should be placed under the thigh, from above the trochanter to below the knee, and another should extend from the groin below the knee on the opposite surface. Narrower splints should occupy the intervals between those on the inside and outside of the thigh. The splints should be fastened as firmly as they can be borne, by means of leathern straps. A patient with a broken os femoris should by no means be placed on a soft bed, as the trunk of the body depresses it into a hollow, and by sliding downwards increases the displace. ment.

Fracture of the patella is generally caused by violent exertion of the muscles, whose tendons are inserted into this bone, and not by direct violence. The upper end of the bone is drawn upwards by the