cision. Operator should stand beside the hand or forearm, not in front of it; otherwise his own left hand will get in his way. Beware of locking knife under sesamoid bones; and keep close to metacarpal bone, to avoid wounding radial artery. Arteries: dorsales and arteria magna pollicis.

2. Thumb at Metacarpo-phalangeal Joint.- Oval amputation. TOE, GREAT.-At Tarso-metatarsal Joint.-Two methods, flap and oval.

1. Flap. Cut a flap from whole length of inner side of metacarpal bone. Better not transfix for this. Then transfix between first and second metacarpals, and cut downwards right through web of toes. If possible, save base of metacarpal bone; otherwise divide tendon of peroneus longus and disarticulate. Beware of sesamoid bones, and of dividing communicating branch between dorsalis pedis and external plantar artery at base of interosseous space. Artery divided always: first digital.

2. Oval Amputation.-Commence incision half-an-inch posterior to where the bone is to be divided or disarticulated.

TOES.-Amputated in same way as fingers.

Anæsthesia. The term usually applied to the production of insensibility to pain for surgical or medical reasons. This state is induced for five purposes. 1, To relieve the pain of operations or examinations; 2, to facilitate such proceedings as the reduction of dislocations and herniæ; 3, where spasm interferes with diagnosis; 4, where hysteria or malingering is suspected; 5, as a curative agent, e.g., in puerperal convulsions.

Anaesthetics are either general or local. General anaesthetics in ordinary use: 1, chloroform; 2, ether; 3, a mixture of chloroform, ether, and alcohol; 4, bichloride of methylene; 5, nitrous oxide gas.

Their physiological action consists in paralysing temporarily almost all the nerve centres, except those necessary to maintain life.

Advantages and Disadvantages peculiar to each.-Nitrous oxide is the least dangerous, but it is inconvenient for long operations. It is, par excellence, the anaesthetic for short operations. Bichloride of methylene has a quick action and causes

little vomiting. Recovery is rapid; but it is more dangerous than ether, and perhaps as dangerous as chloroform. It is used in ophthalmic surgery and for ovariotomy. Chloroform has a quick and powerful action, is comparatively agreeable to take, and seems safe enough for children; but for adults is more dangerous than ether. It frequently causes vomiting. Ether is safe and powerful, and not much slower than chloroform when properly given. On the other hand, the patients sometimes require strong assistants to manage them in the stage of excitement; and in old bronchitics bronchial irritation is produced. As air should not be mixed with ether, it is not adapted for operations about the mouth. The mixture of alcohol, chloroform, and ether is much liked at Guy's Hospital. (Chloroform has been said to be quite safe for parturient women, but several deaths have been recorded.)

Modes of Administration.-Always see that all buttons. and braces about neck and chest are loose. In bloody operations about the mouth the patient should sometimes be turned on his side. Prone position permissible if required. Carefully watch respirations and pulse, especially the former.

1. Chloroform. Recumbent position. Clover's inhaler. Other inhalers. Piece of lint. Towel. Allow free access of air. Commence gently. Pour 3ss. upon the towel to begin with.

2. Ether. Best administered in a towel folded conically with a sponge at the bottom, or in a cone of mackintosh lined with felt. Two ounces are not too much to begin with, and the drug should be administered boldly, especially in the stage of excitement. If the drug be pushed vigorously then, complete anathesia usually follows immediately; if indecision or timidity be displayed the patient's struggles last a long time. No air should be allowed to get under the apparatus, which should be held firmly down over mouth and nose. Patient may pull it off, unless assistants are arranged before commencing so that they may be ready to restrain the patient the moment restraint is necessary. 3j. of ether is to be put into the cone from time to time. The patient's face is red and congested, and his breathing apt to be stertorous. Much saliva is secreted.

2A. It is an excellent plan to administer successively, nitrous oxide and ether, a mixture of the two, and lastly ether alone. Mr. Clover has contrived an apparatus which answers this purpose admirably. No stimulant should be given before administering ether. Pure anhydrous, washed ether always to be used. Robbins' ether for local anesthesia is dangerous.

3. The Mixture, of alcohol 1 part, chloroform 2 parts, and ether 3 parts, is to be given like chloroform; but the air should not be allowed to mix quite so freely with the vapour (?).

4. Bichloride of Methylene.-3j. is placed in Rendle's apparatus. This is a cone of leather lined with flannel, has small perforations at the apex, and is held close over the mouth and nose, as in giving ether. If a second drachm is afterwards used to prolong the anesthesia, the effects resemble those of chloroform.

5. Nitrous Oxide Gas.-Is given perfectly pure, from a bag, which is replenished from an iron bottle, which contains the gas compressed to a liquid state. The appearances produced are somewhat alarming; for the blood is temporarily 'unoxygenated,' like venous blood. But this is not really dangerous.

Causes of Danger from Anæsthetics.—1, sudden stoppage of respiration, either from paralysis of nerve-centre, or from mechanical obstruction, e.g., falling back of the tongue, or passage of blood into larynx; 2, sudden paralysis of the heart. But it would appear that heart-disease does not contra-indicate anæsthetics; and ether is a powerful cardiac stimulant; 3, shock.

Precautions.-1, Do not push the anaesthetic too much at first. Be careful about the quantities used; 2, allow plenty of air with chloroform; 3, recumbent position, especially with chloroform, though not required with gas; 4, loosen all tight coverings on chest and neck; 5, have ether of the right quality; 6, it should be possible to let a free supply of fresh air into the room if necessary; 7, administrator should confine his attention to the administration only; 8, he should carefully watch the pulse and respiration-the former most closely with chloroform, and the latter with ether.

1reatment of Dangerous Symptoms.-Pull the tongue out

of the mouth. Clear the throat out if there be any suspicion that blood or vomited food is obstructing the larynx. This failing, tracheotomy may be found justifiable. Artificial respiration. Galvanism: one pole on the throat near the phrenic nerve; the other in pit of stomach. Hot affusion to head. Perpendicular position, with head downwards. As much fresh air as possible.

LOCAL ANESTHETICS.-Extreme cold produced.—1, ice and salt; or, 2, ether spray. Use twice as much powdered ice as salt, in a gauze bag. Useful for small operations on the skin or about the nails: excision of small epitheliomata, &c.

Aneurism.-A considerable dilatation of an artery, or any hollow tumour communicating with the interior of an artery.

Classification. According to the relation of its sac to the wall of the artery, into-1, true; 2, false; and, 3, dissecting aneurism. According to its shape, into fusiform and sacculated. And, according to its apparent cause, into spontaneous and traumatic. Cirsoid aneurism and varicose aneurism not usually included in this classification.

A true aneurism used to always mean one whose sac consisted of all three arterial coats. The term, rarely now used at all, often means merely that the sac is formed chiefly by the wall of the artery. False, in the same way, may mean either that the sac is wholly, or that it is chiefly, formed of tissues outside the artery. Dissecting aneurisms are formed when the blood burrows between the coats of an artery.

Causes.-Dilated arteries are almost always found to be atheromatous (Vide Atheroma of Arteries.)-1, occupation : soldiers, sailors, employments where severe and prolonged efforts are required irregularly. Soldiers are chiefly liable to thoracic, sailors to subclavian and axillary aneurisms (probably from climbing, &c.); 2, abuse of alcohol; 3 syphilis: the liability of soldiers is partly attributed to the latter two causes, and partly to the strain on the thoracic organs, caused by the old-fashioned stock and knapsack; 4, strains; 5, age: very rare in childhood, commonest between thirty and forty; 6, traumatic aneurisms are caused by direct wounds.

Pathology. An idiopathic aneurism begins by the dilatation

C

of a diseased part of the wall of some artery. The whole wall may be so softened as to dilate; but usually the inner coat is ulcerated, and then, from the first, the aneurismal sac consists only of the outer and part of the middle arterial coat. But always, before the tumour reaches the size of an average orange, all trace of distinction between the arterial walls and the surrounding tissues is lost in its sac. In the meantime, wherever the inner coat of the artery is absent, the blood tends to deposit layer after layer of fibrin: the outer layers, after a time, have become organised and pale, while the inner are still soft and dark-coloured. Fusiform aneurisms have the inner coat of the artery most sound, and only a few shreds of fibrin adhere to their walls. The wall of an aneurism itself tends to thicken and strengthen. Adjacent parts are pressed upon, nerves are irritated or paralysed, ducts obstructed, bones absorbed.

Symptoms.-Patient generally applies for advice either because of the swelling, or of the pain caused by the pressure of the tumour; but the earliest symptoms are generally those of slight muscular weakness of the limb. Tumour, in the course of some artery, soft at first, harder as it progresses. Pulsation, expansive. Bruit, loud and rasping, or soft, or altogether absent. Pulse below aneurism weak. Often oedema, neuralgia, spasm or paralysis from pressure on veins or nerves. Compress artery above, tumour less tense or smaller; compress artery below, tumour may become larger or more tense. tumour can often be partially emptied by pressure.

The

Diagnosis. May be confounded with-tumours, or abscesses in the course of large arteries; malignant tumours of bone; or mere enlargement and relaxation of the artery. It is always to be borne in mind that the pulsation of an aneurism is heaving, while that of a vascular tumour is usually sudden and more abrupt; also, that aneurisms do not always pulsate,' and that when an aneurism is emptied by pressure, it gradually returns to its full size. Diagnosis from Tumours and Abscesses pressing on the Artery.-1, such swellings mostly have no bruit ;

1 For Diagnoses, &c., of aneurisms which do not pulsate, see Holmes, in Brit. Med. Journ., Jan. 1880, and Morrant Baker, in St. Barth.'s Hosp. Rep., 1879. Auscultate and observe the effect of pressure on the main artery.