a pillow, knees gently raised and supported, and a little apart. The pelvis should be raised above the level of the shoulders.

The object is to get the stone away from the neck of the bladder. The bladder should hold from four to eight ounces of water. The instrument, warmed and oiled, is now to be gently introduced and passed fully into the bladder. The next step is to seize the stone; this is done by applying the instrument to the stone, so as to seize and lift it, by rotating the instru ment upon the axis of its shaft. When the stone is fairly grasped, the screw is employed to crush it; at the end of the operation it must be seen that the blades are entirely closed and not choked by detritus, while the instrument is withdrawn.

Subsequently, pain must be relieved by opiates. Hip baths and demulcent drinks must be used, to allay irritation. The operation must be repeated at intervals, till every fragment is crushed and expelled.

LITHOTOMY.

There are several methods by which lithotomy may be performed. Ist. The Lateral operation. The bladder may contain a little water; the bowels should be cleared previously by an enema.

A good firm table, 21⁄2 feet high, is necessary for the operation. The patient should lie down and chloroform be administered. The sound or a staff should then be introduced and made to touch the stone, if possible, so that there may be no mistake. The patient should then be placed on his back, with his shoulders raised by a pillow. Then the perineum should be thoroughly exposed; the thighs must be raised and separated; knees bent, and each foot must be grasped with the hand of the same side. The hand and foot must then be firmly bound together with a bandage. The buttocks should be brought to the edge of the table and the perineum shaved. An assistant on each side holds the thighs asunder; the surgeon places the fingers of the left hand on the right buttock, and with the thumb fixes and steadies the integuments of the perineum, taking care not to draw them up. He then makes a free incision of the skin and subjacent tissues, entering the knife just on the left side of the raphé, about one and threequarter inches in front of the anus, and cutting downward to midway between the anus and the tuberosity of the ischium. The blade of the knife should next be run along the surface of the exposed fat and cellular tissue, and then the forefinger of the left hand thrust into the wound, about its middle, and directed upward and forward between the left erector and

accelerator muscles; the finger then feels the groove of the staff in the membranous part of the urethra.

The left forefinger nail is now to be well fixed in the groove of the staff; the knife is slipped in over it, with its flat surface obliquely placed; its points made to slide along the groove toward the bladder, dividing the membranous part of the urethra and the edge of the prostate. The knife being withdrawn, the left forefinger is gently insinuated along the staff.

FIG. 80.

LATERAL OPERATION.

Next the assistant removes the staff and the surgeon introduces the forceps over the finger into the bladder.

2d. The Bilateral operation is performed by making a curved incision, with the convexity upward, from one side of the perineum to the other, carrying it between the anus and the bulb of the urethra, opening the membranous portion of the urethra, and then pushing the bistouri caché into the bladder, by which both sides of the prostate may be divided.

3d. The Recto-vesical operation consists in cutting into the bladder from the rectum, in the middle line behind the prostate.

4th. The High operation is performed in the hypogastric region above the pubes, by making an incision through the linea alba and opening the bladder at its fore and upper part, where it is not covered with peritoneum.

HARE LIP.

Hare lip is a congenital fissure of one or both lips; generally perpendicular, but it may be more or less oblique.

As a rule the division is just below the septum of the nose, but it sometimes corresponds to one of the nostrils.

Hare lip may be single or double; single when the fissure is only on one side, and double when there are two fissures with a small flap of skin between.

In the operation for the relief of hare lip the principle is union by the first intention.

If the case is one of single hare lip, detach freely the lip from the bones

FIG. 81.

HARE LIP.

behind, then pare off the edges of the fissure by means of a small bistoury; care must be taken to cut off a sufficient quantity of the edge, as at the margin the parts are apt to be callous. The surgeon pierces the lip with a narrow knife at the top of the fissure, just under the nose, and carries the instrument downward, so as to shave off the edge of the fissure; the operation is then repeated on the other side, and the two strips are then detached at the upper angle. The parts are now brought together as nicely as possible, and retained in their position by means of the twisted suture. Three pins should be used for the purpose; the first is put at the edge of the red margin of the lip, and the two others at equal distances higher up. Then a long piece of thick silk should be twisted around the pins, and the suture covered with collodion. The pins used should be galvanized, or made of silver; in the absence of these, needles may be employed, when the point should be carefully clipped off after the silk has been twisted around them. If the hare lip is double, the operation should be conducted as in single hare lip, but the closure of the second fissure should not be attempted for at least two weeks after the first operation.

AFFECTIONS OF THE NASAL PASSAGES.

Foreign Bodies in the nares should be removed as soon as possible; their removal may be effected by a small scoop or canula. If they cannot

be brought through the nostrils, they should be gently pushed back into the throat.

Epistaxis, i. e., hemorrhage from the nose, may be produced by injury, by vascular excitement, plethora, or determination of blood to the head, by the suppression of some other discharge, by irritation of the mucous membrane, by passive draining of venous blood, and by a want of tone or contractility in the blood vessels.

Treatment. If the patient be full blooded and plethoric, and subject to headache and giddiness, a purgative should be administered, and the diet regulated; if the bleeding continues, aromatic sulphuric acid should

be given, and if the patient be anæmic, iron and quinine should be used. If it is a passive hemorrhage, depending on general cachexy, the patient should be kept quiet in a cool room; he should lie with his shoulders raised; he should suck and swallow pieces of ice, and should apply ice or ice-cold water to the nose and forehead; and a bladder of the same to the nape of the neck. In persistent cases, plugging the nostrils is necessary. This is done by Bellocq's canula, which is a curved silver tube, in which lies a curved spring, having at the end an eye for the reception of a piece of string; this is drawn into the canula, the curved end of which is passed along the floor of the nostril. The spring is then protruded by pushing the handle, causing the spring and string to appear in the back of the mouth

M

below the soft palate, where it can be secured with the finger and forceps. The end of the string in the pharynx is then brought through the mouth, and a piece of soft sponge is tied to it; then, by pulling the string back through the nose, the sponge is drawn into the posterior opening of the nostril, leaving one end of the string in the corner of the mouth. The anterior nares should then be plugged by a fold of lint passed on the end of the probe and tied in by the nasal end of the string.

FOREIGN BODIES IN AIR PASSAGES.

The foreign body may be impacted in the ventricles of the larynx, or in the trachea, in which case it will probably produce violent spasmodic cough and difficulty of breathing, together with fixed pain in one particular spot, a croupy sound during respiration, readily detected by the stethoscope; loss of voice, and probably acute inflammation.

It may be loose in the trachea, especially if it be a pebble, grain of corn, or coffee, or other smooth substance. In such case the violent coughing and sense of suffocation produced by the first introduction of the article generally subside for a time, but every now and then there are violent fits of coughing and spasmodic difficulty of breathing, during which the substance may be heard by means of the stethoscope.

It may have passed into one of the bronchi, where it is frequently detected by causing a whistling or murmuring sound, and it may be dislodged and driven upward when the patient coughs. The right bronchus is that into which it generally falls.

Treatment. Very little time should be wasted in attempting to get rid of the foreign body, until the operation of laryngotomy or tracheotomy is performed; it may be well, however, if the substance is movable and round, to place the patient on the bed and administer an opiate, when it may become coated with mucus, and may be expectorated during coughing or vomiting, or when the patient is narcotized he may be quickly turned upside down, when the foreign substance may suddenly be ejected; these devices failing, the surgeon must resort to:

Laryngotomy, if the substance is arrested sufficiently high up. This operation is performed by cutting longitudinally through the skin, then horizontally through the crico-thyroid membrane, which may be felt as a soft depression, an inch below the Pomum Adami.

Tracheotomy is performed by the surgeon standing on the left of the patient, whose head being thrown back, an incision an inch and a half or two inches long is made exactly in the middle line, from near the top of the