thetically, we ourselves are perfectly satisfied. The complicated systems of nosology, and those artificial arrangements that attempt to usurp the very throne of nature, and delude the mind by their shadowy forms, are fast sinking before the increased intelligence of the age. The following, without further preface, is the classification of Dr. Thomson. Errhines. B.-Influencing the body solely by their action on the part to which they are applied. Epistastics. a. Rubefacients. b. Vesicants. c. Actual Cauterants. II-CHEMICAL Agents: -Influencing the state of the body, or its contents, by their chemical properties; acting on the surface. on the contents of cavities. Escharotics. a. Potential Cauterants. Antalkalies. a. Antiseptics. Antilithics. III.-MECHANICAL AGENTS. Demulcents. We never pretended to offer a review of Dr. Thomson's work. Comprising much new matter with more that is merely elementary, it is too much to expect that a reviewer can peruse such a work sufficiently to point out all that is new, or all that is deserving of particular attention. Yet he may satisfy himself of its general tenor, and may be able to determine its general merits or defects. In this manner we have judged the present volume, and we think we may safely pronounce it creditable to the author, creditable to the school of which he is no inconsiderable ornament, and creditable to the character of British Medicine. Need we say more, need we add the hackneyed recommendation to our students to buy? Most assuredly a good elementary work is certain of being successful in the end, and such a work we consider the present. III. ELEMENTS OF SURGERY. By Robert Liston, Surgeon to the Royal London and Two parts of Mr. Liston's work have been already published, and were introduced at the time of their publication to the notice of our readers. Being of an elementary character, we cannot pretend to review it, but we think we may venture to give a general idea of its merits by a glance at one or two chapters. AFFECTIONS OF THE RECTUM. The following short and accurate account of the anatomical structure of hæmorrhoidal tumours is not unworthy of notice. After stating that branches of the hæmorrhoidal veins become varicose, probably from their superior trunks being compressed, Mr. L. proceeds to observe : "The varix protrudes the superimposed mucous membrane; and at first the excrescence is composed of the dilated venous trunks containing fluid blood, and invested by the membrane, which inflames, thickens, loses its villous character, and discharges a vitiated secretion. In this stage the tumour is easily compressible, and by pressure may be made to disappear almost entirely, the communications between the varicose vessels and the trunks above being still unobstructed. But inflammatory action is soon kindled in the incommoded veins, as frequently happens in varix of the lower extremities; their coats become changed, are thickened, effuse lymph externally and internally, adhere to one another, and are ultimately matted into one confused and solid mass; the contained blood coagulates, becomes fibrinous, the whole tumour feels hard and firm, and often is painful. At length all traces of venous structure disappear; the tumour seems to consist chiefly of effused lymph, condensed cellular tissue, and coagula. In not a few instances, however, the contents of the veins remain partially fluid, and a communication exists betwen the vessels of the tumour and those of the surrounding parts. That such is the usual structure of piles, I am convinced from repeated and careful dissection of the tumours." 64. Mr. Liston's treatment of piles is no novelty, but evinces judgment. In slight cases he employs astringent ointments or decoctions, with sedulous attention to cleanliness-for inflamed tumours, abstraction of blood by leeches or punctures, and subsequently fomentations-when constriction by the sphincter has occurred, replacement of the tumour, if possible-for irritability of the spincter, a bougie or incision-for internal piles, when an operation is required, the ligature, and for external, excision. Inflammation of the Rectum. This may follow hæmorrhoids, or the operation for them, or may be occasioned by ascarides, or by hardened fæcal collections or biliary concretions in the cavity of the bowel, or foreign substances, as bones of small animals, needles, pins, &c. irritating or wounding Mr. Liston describes the symptoms of inflammation of the rec its coats. tum thus: "It is attended with excruciating pain, burning heat, and a feeling of contraction increased very much when the parts are thrown into action by evacuation of the contents of the bowel, or of the bladder. The heat may be felt on introducing the finger, with the view of examination; by doing so, dreadful torture is produced, and such manipulation should not be had recourse to unless there is a suspicion of foreign matter lodging in the part, by removal of which the action might be cut short. The bladder is often affected sympathetically; there may be frequent desire to empty it, or else retention of its contents; this latter occurrence not unfrequently follows operations on the bowel, as for the removal of hæmorrhoids. The inflammation extends to the cellular tissue round the rectum, with swelling and increased pain; the pain is aggravated by pressure, and the patient is unable to sit erect. As the painful symptoms abate, puriform discharge from the membrane of the gut takes place, and often is very profuse. The morbid action sometimes extends to the other intestines, attended after a time with mucous or even bloody evacuations. When the affection is confined to the rectum, the fæces and vitiated secretion are distinct from each other, and the former are usually of their natural appearance; but when the other intestines participate, to a greater or less extent, the fæces are fluid, and intimately mixed with the morbid secretion. Ulceration of the mucous coat, with continued discharge, often supervenes. Sometimes the peritoneal coat of the bowel is affected secondarily, and then the pain is much more acate and more aggravated by pressure." 67. Effusion, succeeded by suppuration, takes place in the cellular membrane round the gut, attended with fever of greater or less severity, according to circumstances. In persons of bad habit, or under unfavourable circumstances, the collection of matter may be most extensive, and productive of the worst form of typhus. Several cases of this kind have been recorded. A patient, for instance, has all the symptoms of typhus gravior without'apparent cause, when by accident, or by careful examination, an abscess is discovered in the neighbourhood of the anus; it is punctured, and a fish bone escapes. Mr. Liston also describes a carbuncular affection of the skin and cellular tissue in the vicinity of the anus. There is partial suppuration and extensive sloughing of cellular tissue, and the symptoms of depression soon become severe, and often fatal. Free and early incisions and stimulants alone can save the patient. For inflammation of the rectum Mr. Liston recommends antiphlogistic treatment, local or general, according to circumstances-leeches and fomentations to the perinæum-and if suppuration occur here, an early opening. We recollect a remarkab case. A woman had a small circular ulcer of the rectum, just above the external sphincter. After an examination of it fever set in, and some tenderness of the abdomen, with sickness, succeeded. The case appeared to be one of muco-enteritis. At the end of five or six days the woman died. On examination of the body the ulcer of the rectum was found not to have passed quite through the muscular tunic Inflammation and deposition of lymph had taken place between the muscular and mucous coats, and had extended up between the same tunics throughout the intestinal canal; there was comparatively little peritoneal inflammation. "It has been recommended that, in abscess extending along the gut, the cavities of the bowel and abscess should be at once laid into one by incision. I have done so, but always found the cure to be tedious. It is better that the matter should first be evacuated through an external opening, that the painful symptoms and constitutional disturbance should be allowed to subside; and that after the cavity has contracted, and the extent of the sinus been ascertained, the operation should be performed." 81. In considering fistula ani, Mr. Liston adverts to the means of detecting an internal fistula, that is, one which opens into the intestine, but does not open externally. He remarks that we may suspect its existence, when we observe puriform discharge from the bowel, increased on going to stool, and then accompanied with tenesmus; pressure on the side of the anus causing pain, and sometimes an augmentation of discharge; and in many instances hardness, deeply seated. On introducing the finger into the rectum, the aperture in the coats of the bowel is perceived, or a part of the bowel feels more boggy and tender than the rest; through this point a curved probe, introduced along the finger, may be passed into the sinus, and being then directed downwards, reaches the outer extremity of the canal, causes the integuments to project, or is readily felt from the surface. The internal opening is usually immediately within the sphincter, seldom higher. The discharge, in general, is rather profuse, the bowel is very irritable, desire to evacuate it is frequent, and the fæces are often tinged with blood. There is a sensation of itching about the fundament, the heat of the parts is felt by the patient to be increased, he is unable to bear pressure there, and sits on one hip: in most cases the bladder sympathises considerably. Mr. Liston strongly recommends the use of the speculum in these cases, as an adjuvant to the sense of touch. By these means, the surface of the bowel, for five or six inches above the anus, can be examined "as accurately as if it were an external part." Mr. Liston relates a case, in which a portion of bougie remained for a length of time at the bottom of a fistula, and produced very troublesome consequences. As the case is brief, we will extract it. Case. "A middle-aged man, when in Holland, laboured under a very deep and extensive fistula in ano. Sinuses were divided in all directions, and some healed; one, however, remained open, leading towards the gut from near the tuberosity of the ischium on the left side. He was desired to keep this open by means of bougies, which, as many were used, he manufactured himself out of cloth and plaster. On one occasion, a portion passed deeply, and could not be extracted; but his alarm at this occurrence was appeased on being told that the foreign body would be absorbed. His condition at that time was very miserable; and inflammation was often excited in the parts, with fresh collections of matter. At the same time, he laboured under stricture of the rectum and urethra. He applied to me fifteen years after the commencement of the disease. Then the most troublesome symptom was a constant itching in the perineum, and round the anus, preventing sleep, and causing much excoriation from involuntary scratching; besides, he was annoyed by seminal emissions, and frequent desire to make water. I first divided a small internal fistula, and some time afterwards operated on a large com plete one; in the latter instance, a foreign body was felt deep in the wound, the ineision was extended, and a large portion of bougie, firmly impacted, was with some diffieulty withdrawn. Some days after, other portions of bougie were extracted along with hairs; and these continued to be discharged for many weeks. The symptoms were much relieved. An occasional itching remained, but disappeared after the cure of a very bad stricture in the urethra. He recovered perfectly from the complication of dis eases." 75. Whilst adverting to the treatment of malignant diseases of the rectum, Mr. Liston makes a remark which is calculated to excite no small share of surprise and disgust. Female patients, says he, have by some been cruelly treated; the vagina and diseased bowel have been laid into one loathsome cavity, and though the patients have continued to pass excrement and discharge through this cloaca, with the symptoms undiminished, themselves miserable, and obnoxious to others, still such cases have been reported as cures ! Can such things be? Is it possible that Mr. Liston has witnessed such daring charlatanerie ? We will now take the liberty of passing to another subject-stone in the bladder. Mr. Liston is well known to be a most dexterous, and a very successful operator; his opinions on lithotomy are, therefore, entitled to some attention. Mr. L. observes that he has, on several occasions, removed from children concretions of considerable size through the urethra, by means of properly constructed forceps. He prefers Weiss's. He has experienced no difficulty in operating with it in many cases, and at all periods of life. Mr. Liston appears to be no great friend to lithotrity or the lithotritists. He employs rather sharp expressions. In turning, says he, to the records of Lithotrity—and under this term we shall include all attempts to break down stones within the bladder, whether by drilling, or filing, or hammering-it will be found that many patients have died from the mere exploration; and altogether, nearly a half of those who had fallen into the hands of the experimenters and adventurers have perished in consequence. Every successful case is well advertised; the dead men rest in peace. Mr. L. recommends all surgeons to make themselves sufficiently acquainted with the lithotritic instruments to be able to employ them if necessary. He prefers the three-branched lithotrite of Civiale. "Various forms of drill have been contrived for acting on a large surface of the stone; others for scooping it out, the shell to be afterwards broken into fragments and triturated; they are unsafe and ineffectual. The instrument is also so constructed that a drillbow may be used, and the apparatus may be fixed by what mechanics call a bench, or it may be attached, by complicated machinery, to the table on which the patient is laid, and be there secured in a proper position. But all this implies an intention of attacking large and dense stones, and a repetition of the attempts. So far as my experience goes, and besides having seen Civiale and others operate, I have myself employed the instruments in a good many cases, and in some successfully,—I should dissuade from all endeavours to rid the patient of stone by such means, unless its size and consistence were such, that it would yield to one or two attacks, and to the drill set in motion by the fingers." 193. Mr. Liston criticises severely M. Heurteloup's plan of breaking the stone by the stroke of a hammer. It certainly does appear to be a dangerous experiment. In point of fact, Mr. Liston does not believe that lithotrity will |