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accomplished practitioners. It is deeply to be regretted that any repulsive encyclopædiacal reading of this kind should have displaced, to the extent it has, the perusal of the instructive and captivating productions of the great writers on medicine and surgery of this and other countries. Well founded as we feel this criticism to be, we are not justified in introducing it in the present article without excepting Mr. Liston's work from its operation. Indeed, its chief fault seems to us, in its possessing scarcely enough of the characters of the manual when we consider it is intended as a guide for young practitioners in surgery. Thus its description both of the precise pathological conditions of parts requiring manual interference and of the modes in which this last is to be rendered, are by no means sufficiently minute and clear to render reference to another work unnecessary; while the book has been expanded and rendered expensive by unnecessarily dwelling upon the general features of the various diseases adverted to, and by the republication of cases which had already appeared long since in the Lancet, and a simple reference to which would have sufficed. Nor do we think the very cursory notices of the various applications of tenotomy, the cure of aneurism by compression, and other interesting topics which have of late excited the attention of the surgical world, by any means sufficient. However, the author of a work which, in so short a space of time has reached its fourth edition, can well afford to disregard more important criticisms than we feel ourselves in a position to offer; and, in fact, we think the popularity which the work has attained is, in the main, fully justified by its great and undoubted merits. As a manual, M. Malgaigne's Operative Surgery has been so long held in esteem on the Continent, that it is very surprising it has not before this been translated. Its descriptions are frequently admirable, and the author's appreciation of the various operative procedures discriminating and sagacious. Treating upon the same department of surgery, it is singular to observe the portions of the subject each has not thought proper to embrace in his plan. Thus, Mr. Liston presents us with no account of the operations upon the teeth or the eye and M. Malgaigne has no description of the treatment required for fractures and dislocations.

Of works of so comprehensive a character, any detailed notice is out of the question. Moreover, with Mr. Liston's former editions most of our readers are familiar; and we have not been able to discover the "considerable additions" advertised as having been made to the present one. We may, however, advert to one or two topics.

Bleeding from the Foot.-We copy M. Malgaigne's account of this simple operation, because we think it is far too seldom had recourse to in this country, seeing the great relief it is capable of affording in many affections of the portal system and generative organs, and the ease with which blood may frequently be so obtained, when its abstraction from a vein in the arm is either difficult or impossible.

"The internal saphena vein may be opened in front of the internal malleolus, or the external saphena in front of the external malleolus: but the latter is seldom large enough to be opened when the internal is not.

"The patient, seated in a chair or at the edge of his bed, first places his feet in hot water, until the veins are very apparent: then the surgeon selects the foot,

wipes it, rests it on his knee, protected by a napkin, and places the ligature two fingers' breadth above the ankle, moderately tightening it, and securing it with a bow on the opposite side. He then explores the vein, puts the foot again in the hot water, prepares his lancet, retakes the foot, and opens the vessel. Care must be taken not to prick the bone and break off the point of the lancet. If the blood flows in a jet it is caught in a basin; if it only dribbles slowly the foot should again be put in the water. We can then only judge of the quantity by the time or redness of water. When the bleeding is supposed to have been enough, the foot is taken out of the water and wiped, and a compress and figure of eight bandage applied. Care must be taken lest the water be too hot, or the foot plunged in too deeply. It is said that the weight of the column of the water tends to coagulate the blood, which stops the mouth of the opening. On this account the foot should be kept only just covered, and the wound wiped from time to time. It is well also to make the patient move his toes."-P. 53.

Opening Abscesses by Incision.—M. Malgaigne lays down the following general rules :

"1. In order to lessen the suffering of the patient, the abscess should, if possible, be incised with one stroke of the knife. 2. It is proper that one extremity of the incision should terminate in the lowest part of the abscess. It has also been recommended to make the incision in the direction of its greatest diameter, and, if possible, parallel to the axis of the body, or well-marked folds of the skin; these two rules are subject to too many exceptions to be strictly preserved. 3. One opening is usually sufficient; it should be large enough to afford a free exit to the pus, if not, it should be enlarged with the bistoury and director. 4. When the abscess is very large, it is better to make several incisions than one of too great extent. 5. When a first incision does not reach the lowest part of the abscess, and when compression will not bring the sides of the sinuses together, recourse must be had to a counter-opening, either by cutting down upon the skin raised upon a director introduced through the first opening, or by retaining the pus at the point where we wish to open it, and incising as for common abscess. 6. When the abscess is prominent and superficial, incision from within outwards is preferred: but when the thickness of the parts prevents this, the incision should be made from without inwards with a straight bistoury. 7. When the abscess is situated under a muscle, it is better to separate its fibres than to cut them; but if this is not compatible with the direction of the incision, they may be cut across."-P. 79.

Mr. Liston has some interesting remarks likewise upon this important point in minor surgery. He considers a broad-bladed, sharp-pointed bistoury in a folding handle, and fastened when opened by a spring-catch, as a far more workman-like (a vulgar but favourite mode of expression of his) tool than the abscess-lancet in general use. The knife is to be entered steadily, with its blade perpendicular to the surface, and pushed onwards until the lessened degree of resistance allows its point to move freely. The superimposed parts are to be divided by a rapid sawing motion. Sometimes it has to be carried very deeply before the matter can be reached, and which, with due care, may be done safely even in the vicinity of important organs, the vessels and nerves being removed by the morbid accumulations to a much greater distance from the surface than they are wont to be normally. A free and clean opening should at once be made, so as to render squeezing the tender parts, extension of the aperture, or counter-openings

unnecessary.

"It ought to be recollected, that an opening of an inch in length, quickly and

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smoothly made, is attended with no more pain than a course and hazardous plunge of an abscess lancet, which, though the inflamed surface may be partially lacerated to some considerable extent, will be found, perhaps, to have barely penetrated the cavity by an aperture of not more than two lines,-the object being, after all, inefficiently fulfilled. The opening must be uniformly made at that part of the abscess which is most likely to be generally dependent; the state of the patient, and his probable position for some time after his little operation, must, with that view, be carefully considered beforehand."-P. 11.

Occasionally it is better to make more than one opening even at first. Abscesses extending over a large surface can seldom be completely discharged without. This is generally the case with abscess over the ligament of the patella resulting from bruise or inflammation of the bursa. An opening in this case should be at once made upon each side of the limb at the most dependent parts of the abscess. This expedites the cure, and is productive of far less pain than would be produced by subsequent incisions, which the progress of the case might require.

Mr. Abernethy's plan of partially evacuating large chronic abscesses, and temporarily closing the valvular aperture, is now exploded, on account of the violent constitutional irritation it often gave rise to. The opening, on the contrary, should be free and direct, so as to allow of no lodgement of matter, even if a counter-opening be required to prevent this.

"The common and thoughtless practice of squeezing together the sides of suppurating cavities, whether chronic or acute, ought by all means to be discouraged. The patient, it is true, seems to be relieved at the time from a greater load of matter, but in reality much pain and positive injury are thus inflicted. The surfaces so treated are apt, from the mechanical injury, to inflame; the vacuum occasioned is filled by air or by rapid secretions of bloody serous fluid, if not by copious escape of blood from the vessels deprived of their customary support, and torn from their connections. The after discharge is profuse and most offensive, and accompanied by a dangerous excitement of the system, an intense irritative fever, and delirium. Those who have had the opportunity of seeing, under the microscope, the injected lining membrane of the cyst of an abscess, will be little inclined to squeeze together the sides of purulent cavities into which they have made openings. The infinite number of vessels that ramify on the surface, and the layer of lymph by which these are covered, are the means by which the filling up and obliteration of the cavity is effected by nature; by bruising and destroying these, very much pain will be caused to the patient, and the cure will not, in all likelihood, be so rapid.”—Liston, p. 14.

Lithotrity and Lithotomy.-Mr. Liston is one of the few surgeons in this country who have taken much pains to acquaint themselves with the performance and advantages of Lithotrity, and his evidence in its favour is of the more importance, inasmuch as the nearly uniform success which has attended his lithotomy operations might have prejudiced him against other procedures. He says:-

"Until very lately, patients applying to surgeons were constantly recommended to submit to the knife, in order to get rid of stone in the bladder, whatever might be the size of the concretion, or the state of the urinary organs. On the other hand, if he fell into the hands of the professed grinder, no matter what the peculiarities of his case, he was as certain to be subjected to the boring or hammering processes. Now that the merits of both operations are better understood and appreciated-some few surgeons having thought proper to turn their attention to

the matter, and study and understand lithotrity as well as lithotomy-patients have a chance of being treated judiciously and conscientiously, and of having that proceeding resorted to which is adapted to their respective cases. I was not slow to adopt the operation of crushing, have always had a favourable impression of it, and have throughout used the same language regarding it, yet I have the credit of being an opponent to lithotrity. I have all along been, and am certainly still, opposed to the abuse of any one operation, by its indiscriminate employment in all cases, and by its being practised by those alone who know no other. It can be employed safely only by those who understand well the healthy anatomy of the urethra and bladder; who are acquainted with their sympathies, vital actions, and pathological changes; and who both understand, and are in the constant habit of treating, derangement of their functions. The operation of lithotrity is applicable to patients above the age of puberty, when the symptoms have not endured very long, when the foreign body is ascer tained to be about the size of the one sketched two pages back-measuring six or seven lines, or even more perhaps, say as large as a chesnut; when the bladder and urethra are in a tolerably healthy and normal condition—as indicated by the power to retain the urine comfortably for several hours, and to pass it in a tolerably free stream; and when the viscus admits of injection and a careful exploration. "The operation of lithotomy must yet continue to be performed on children, and on those of mature age who are so ill-informed or foolish as to permit the stone to attain an inordinate bulk. The concretions in young subjects are generally composed of a very dense substance, the oxalate of lime, in whole or in part; and the urethra is often so narrow as to preclude the application of instruments strong enough to reduce them to fragments. The reasons for giving a preference to incision over crushing, when the stone is large, have been already given.

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"This favorable opinion of lithotrity was published in 1840; since when it has been confirmed and much strengthened by ample experience. Of late years, in point of fact, I have scarcely been obliged to have recourse to lithotomy at all in private practice. At the hospital, patients yet present themselves with large stones and bad bladders. Then lithotomy is both a less painful and much more safe operation, as already propounded. During the above period twenty-four patients have been cut, and all have recovered without accident; these patients have been of all ages from two to eighty years of age, and some of them not over favourable subjects. So that, after all, there is not much to find fault with as regards this cruel and bloody' operation' when carefully set about.”—P. 500–5. .

It is satisfactory to know that Mr. Liston's great success as a lithotomist has been obtained by the use of the simplest apparatus, his incisions being commenced and completed by the same straight knife. He makes his external incision very free, but the internal one is very limited. “It should certainly not extend beyond six or seven lines from the urethra outwards and downwards," which in all ordinary cases will allow the requisite dilatation to be safely made. "The object in following this method, is to avoid all interference with the reflexion of the ileo-vesical fascia from the sides of the pelvic cavity over the base of the prostate gland and side of the bladder. If this natural boundary betwixt the external and internal cellular tissue is broken up, there is scarcely a possibility of preventing infiltration of urine, which must almost certainly prove fatal." An opening of this extent, owing to the elastic and yielding character of the parts, will readily admit the finger, and allow of the extraction of a stone of considerable dimensions. In cases in which, from the corpulence or unmanageableness of the patient, or the size and rigidity of the pros

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tate, the inner opening is executed with difficulty, the blunt gorget may be employed for enlarging the opening into the bladder, but Mr. Liston has never had occasion to use it. The exact position of the stone must be carefully ascertained before using the forceps, and its favourable adjustment within these carefully adjusted by the finger. The use of the forceps is in fact the most difficult part of the operation; "and it is equally the duty of the pupil to practise the seizing and extraction of the stone, as it is for him to study the relative anatomy, so that he may be enabled to cut into the bladder with precision and safety." An important piece of advice this, which is much needed, as students invariably occupy themselves with the cutting part of the operation alone. If the surgeon finds upon examination with his finger that the stone is a very large one, he must convert his operation into a bilateral one before attempting to remove it. If his external incision has been sufficiently free and low enough in the perineum it will require no enlargement, and he has only to pass a narrow-bladed, blunt-pointed bistoury along the finger, and make a similar incision on the opposite side of the neck of the bladder, directing the edge of the knife towards the right tuberosity of the ischium. In nineteen cases out of twenty the single lateral incision suffices. When the incisions are placed low, and the deeper ones performed cautiously, there is no danger of hæmorrhage; and of considerably more than 100 operations performed by Mr. Liston, only one old man suffered from hæmorrhage, and that because the diseased condition of the branches of the hæmorrhoidals prevented their contracting when divided. Mr. Liston attributes much of the success of his operations to his practice of introducing through the track of the wound, and securing in the bladder, a gumelastic tube, which, by facilitating the flow of urine, much lessens the danger of infiltration and its dreadful consequences, and affords an easy means of suppressing any excess of arterial or venous oozing. It need not be retained in children for more than 20 hours, but in old persons of lax fibre it should be kept in for 40 or 50 hours at least.

"The operation of lithotomy, about which so much dread has lately been excited and fomented by interested persons, and which certainly, according to the complicated methods, and more especially with the great apparatus delineated at p. 506, was formidable and not over-successful-if performed in the very simple and easy method recommended, is effected with much less pain than is supposed; it is completed with perfect safety, in a short space of time, and offers very favourable results. It is, however, an operation that never ought to be undertaken without due consideration of all the circumstances that may arise; and the surgeon who undertakes it must have resources within himself sufficient to encounter and overcome difficulties in all the various stages of the proceeding. Were the circumstances of all cases precisely similar as regards the depth and resistance of the parts, the size and consistence of the prostate and of the foreign body, the capacity of the bladder, and the width of the outlet of the pelves, then the operation might always be completed in a given time with certainty, and in the same manner. But it is not so: unforeseen obstacles occur, from first to last, and the operator must make up his mind to proceed in all cases with the greatest caution and deliberation: he must commence with a determination to finish his task safely and well: and he will also accomplish this quickly, when the state of parts is favourable, and nothing unusual intervenes."-Liston, p. 518.

The practice of making so small an internal incision is a controverted