3. Operations that can be performed on the
Female Subject only.

The Lateral Operation, as practised by Dr. Buchanan, of Glasgow." The subject being placed in the ordinary position for lithotomy, the operator having first introduced a grooved staff into the bladder and entrusted it to an assistant, should make an incision with a common scalpel on the left side of the vulva, beginning opposite the clitoris, and cutting obliquely across the left labium minus in a line with the ramus of the ischium.

"When the groove in the staff is felt by the finger in the wound the operator should pass a straight bistoury into the groove anterior to the neck of the bladder, and run it along into the vesical mouth. The wound may be enlarged by cutting outwards and downwards towards the left tuber ischii, care being taken not to penetrate the vaginal wall. The finger can now be easily passed into the bladder and the stone extracted."

We strongly recommend this operation, and that of vaginal lithotomy, to the attention of the student, as we are convinced that they are both far superior to dilatation of the urethra when the stone is at all large.

VAGINAL LITHOTOMY.

By vaginal lithotomy we mean the extraction of a stone through an incision into the bladder, through the front wall of the vagina, behind the vesical orifice of the urethra.

Anatomy. The front wall of the vagina is about four inches in length, and has projecting into it above

the neck of the uterus; below this it is in contact with the lower wall of the bladder, and still more anteriorly with the urethra, which is, as it were, embedded in its substance, and can be felt as a rounded cord through the vaginal wall when the finger is introduced into this canal.

The peritoneum, being reflected from the anterior surface of the uterus about half-way down this organ, consequently does not come into contact with the front wall of the vagina. There are likewise no vessels of importance between the vagina and bladder in the middle line.

Instruments. A duck-bill, speculum, forceps, probepointed scissors, and a long-handled scalpel.

Position of the Subject. The subject should be placed in the ordinary position for lithotomy, with the pelvis well raised on a block, so as to better expose the anterior wall of the vagina.

Position of the Operator.-The operator should sit facing the perineum.

Position and Duties of the Assistant.-The assistant should be stationed on the right-hand side of the subject. Having introduced a speculum-should endeavour to thoroughly expose the anterior wall of the vagina by drawing the posterior wall downwards with the speculum.

Operation. The operator should first introduce a small pair of forceps into the bladder through the urethra, and having seized the stone, should hold it so that it may project through the anterior wall of the vagina. He should next make an incision from behind forwards, about

two inches in length, through the vaginal wall, exactly in the mesial line, cutting on the stone. This incision should not encroach upon the urethra in front, and should stop short of the neck of the uterus posteriorly. Ordinary lithotomy forceps should now be introduced into the bladder through the wound, and the stone placed between their blades by the small forceps already grasping it. The smaller forceps being now withdrawn by the urethra, the stone may be extracted by the larger ones through the wound in the vaginal septum.

CHAPTER VI.

OPERATIONS ABOUT THE MOUTH, LARYNX, AND PHARYNX.

Excision of Tongue-Excision of Lower Jaw-Excision of Upper JawTracheotomy-Laryngotomy-Esophagotomy.

EXCISION OF THE TONGUE.

THE tongue may be either partially or completely excised. Partial excision may be accomplished by the knife or écraseur.

By the Knife. As removal by the knife simply consists in cutting off the anterior portion of the organ, we shall make no further comments upon it, than that we do not advise this method of excision, as it is attended on the living with profuse hæmorrhage often very * troublesome to control.

By the Ecraseur.-The operator, seizing the tongue with the artery forceps, passes a thread, by means of a curved needle, through its tip, and then, drawing it forwards by making traction on the thread, he intrusts it to his assistant, who should keep it well drawn out of the mouth. He next carries a strong thread, by means of the same needle, well behind the disease, on the living patient, or as far back as convenient when practising on the dead subject, and, having attached the wire of the écraseur to this thread, he withdraws the thread, leaving the wire in its place. In like manner he passes the wire

of a second écraseur through the tongue at the same spot, and, having well included the diseased portion of the tongue between the two wires, he tightens the écraseurs and begins removing the diseased portion by working the handles of the instruments. A turn of the handle should be made about once every twenty seconds.

2. Complete Excision.-The tongue may be completely excised by one of the following methods :1. Mr. Syme's.

2. Rignoli's.

3. Nunneley's, of Leeds.

4. Paget's.

We shall describe briefly all four methods, but we advise the student to practise the last-named proceeding only.

Syme's Method.-Mr. Syme divides the lower lip down to the bone, and after drilling a hole through each half of the jaw near the symphysis, so as to allow of the parts being held in apposition after the operation by a silver wire suture, he cuts through the symphysis.

The origin of the mylo-hyoid, genio-hyoid, and geniohyo-glossus muscles, are now separated from the jaw; and the tongue is drawn forwards and removed by one sweep of the knife; or the écraseur may be made use of instead of the knife at this stage of the operation.

Rignoli's Method.-Rignoli, of Pavia, makes an incision along the lower border of the inferior maxillary bone stretching nearly as far back as the angle on either side. This incision he bisects by a second, reaching from the chin to the hyoid bone.

The flaps thus formed are reflected on either side, and