not be very strong, as the hand, in using them, would speedily get fatigued. In dissection this instrument is held between the thumb and fore and middle finger of the left hand; but it is often used in the right, in securing arteries during cutting operations, from the greater facility in manipulating with his hand.

A variety of hooks, sharp or blunt at the point, may be used in place of forceps, but the latter is generally preferred. In dissections the chain hooks represented in fig. 7, will often be found of service; but if the parts can be put on the stretch with the thumb and fingers, or between the forceps and little finger of the left hand (the instrument being held between the thumb and forefinger), their use had better be dispensed with, as the fingers often get scratched Fig. 8.

Fig. 7.

with their points. Instead of these a hook fixed in a handle like that of a scalpel, as here exhibited (fig. 8), may be had recourse to; its point, it will be observed, is sharp, and it is often of advantage to have it so, whilst on other occasions a blunt point is to be preferred, such as in fig. 9, and either of them may be single, as they are here represented, or double, as is seen in fig. 10. The hooks set in handles are mostly used during operations, and then they are held by assistants; they are of service in keeping parts out of the way of the surgeon, and very useful in many operations. They take up less room than fingers on the edge of a wound, and generally hold the parts more securely. Slips of copper bent at the points, or flat pieces of wood, are sometimes used for similar purposes, as, for example, in holding asunder the edges of the wounds which are required for ligature of the large arteries at the root of the neck, or in the pelvis.

Fig. 9.

When sufficient familiarity with the different parts of the body has been attained, by frequent dissections, the operations of surgery should then be performed on other subjects. The cutting instruments, above referred to, are now in general to be used in a more free and bold style than in ordinary dissection, and more extensive movements are required in the hand and arm, though occa

sionally the operator has to proceed with as much caution as if making the most minute dissection on the dead subject. There cannot be a greater mistake in a

Fig. 10.

young surgeon's education, than to commence the performance of operations before he has acquired a thorough knowledge of anatomy. If he enters into practice without such knowledge, he can neither operate with safety to his patient nor satisfaction to himself; all must be hap-hazard; whilst on the other hand, in prosecuting his dissections, he takes the surest way of acquiring that dexterity in the use of his hands and instruments, which will be of infinite service to him afterwards in the ordinary performance of his professional avocations. Here I do not so much allude to the performance of capital operations, as to the more common manipulations required in bloodletting, bandaging, dressing sores, opening abscesses, and the numerous little manual proceedings which constitute the routine of surgical practice, which, though seldom named as "operations," should be deemed as characteristic of good practical surgery, as the dexterous removal of a limb, or the rapid and successful extraction of a stone from the bladder.

In the performance of many operations, as well as in certain dissections, a saw is necessary, and as it is difficult to use it in a workmanlike manner, it will be well to practice with it on wood or bones, the latter being preferable when they can be procured in sufficient abundance; for it is not by sawing through the bones of one or two extremities merely that a dexterous use of this instrument can be acquired. The common dove-tail saw is that best fitted for general purposes. One with the blade about nine inches long and two and a half deep, exclusive of the back, will serve on almost all occasions on which a saw is required. I prefer a handle, such as is here exhibited (fig. 11) on a diminished scale,

Fig. 11.

Fig. 12.

similar in shape to that used by the cabinet-maker, made of ebony, and of such a size that, whilst held in the palm, it can be firmly grasped by three fingers, the fore-finger and thumb being placed parallel with its upper margin, to aid in keeping it steady. The blade should be sufficiently firm not to bend on the application of moderate force; the teeth should be about this size (fig. 12), and well set out, so as to make such a breadth of groove as will allow the blade to move in it with facility. In using this instrument, it should be held in the right hand, as above directed, the part of the serrated margin nearest the hand should be placed on the bone, and by drawing it steadily backwards, a slight groove will be made; it should then be pushed forwards, and, by a repetition of such

movements, extending on each occasion nearly the length of the blade, with a moderate degree of force and rapidity, a bone, the femur, for example, may be cut through in a few seconds. In many operations the full sweeps here indicated cannot be effected, and a much shorter blade will suffice; indeed there are great varieties of saws, some of which I shall speak of afterwards, as being better adapted for particular operations, and I shall then also describe the manner in which these, as well as that now alluded to, are to be applied and used for each special purpose.

The cutting forceps (fig. 13) may be substituted with great advantage for the removal of portions of bones, when the saw cannot be readily applied. There is but little skill required in using it, strength of hand being the chief requisite.

Fig. 13.

The cutting edges are brought together by compressing the handles betwixt the palm and fingers. The pressure should be forcible and steady, and on no account should there be any shaking or twisting of the handles. În partial amputations of the fingers or toes, hand or foot, it may on all occasions be used in preference to the saw. I have even divided the femur with it on the young subject. The saw, however, ought to be preferred for the large bones in amputations of the extremities.

For the removal of diseased or dead portions of bone, when the neighbouring healthy bone requires to be cut, it may, unless the tissue be exceedingly hard, entirely supersede the common saw, or any other which the surgeon might be disposed to select. Indeed, though this is a somewhat ancient surgical instrument (for it was figured by Scultetus nearly two hundred years ago), and though it had become in a manner obsolete till within these thirty years, I know of no single instrument whose reintroduction to practice in modern times has conferred a greater boon on the operating surgeon; and for this we are solely indebted to Mr. Liston, whose example in using it has been most extensively followed by a large proportion of the present race of operating surgeons.

The usual length of the instrument is from eight to nine inches; but various sizes may be used, according to circumstances. The blades behind the joint should be very strong, so that they shall neither bend nor break with the strength of the surgeon's hand; the cutting edges should be sharp, and come exactly in contact when the handles are shut; and they should be finely tempered also, so as not to be readily turned or broken. When used, the blades being open and made to grasp the object to be divided, the flat surface being nearest the healthy parts, the handles should be squeezed towards each other, when, if sufficient force be exerted, the cut surface will look as level as if made with a saw. In a hard bone, such as the lower jaw, or in the tibia when it is necessary to remove a portion of the hard part of the shaft, as in compound fractures, I believe this instrument breaks the textures at the part where it is applied; in softer bones, besides cutting, it partly bruises, and some theorists have objected to its use from the latter circumstance; but on no occasion, so far as I have observed, has this instrument produced more serious consequences on the remaining portion of bone, than the saw might have done, had it been used instead.

Besides the shape of cutting forceps represented in the sketch above, I have for many years been in the habit of using others more conveniently

adapted for particular purposes: sometimes I have found that when the blades were curved in this manner (fig. 14) at the point, I could effect with them what

Fig. 14.

Fig. 15.

Fig. 16.

Fig. 17.

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I could not with the straight ones; and in other instances I have had reason to be much satisfied with the bend exhibited in figure 15. But now I seldom use any other kind than that represented by figure 16, which I prefer to the others on almost every occasion. There are other shapes, too, nearly all of them being derived from the same "Armamentarium," but these (especially 14 and 16) I have found most generally useful in the ordinary operations on bones.

The gouge (fig. 17) is an instrument which has been in a great measure overlooked by the modern surgeon; but I cannot here omit giving it a full measure of praise. It was used by the Moreaus in their operations on carious joints, and has been recommended by various authorities; yet it is seldom seen in the surgeon's hand. In operations for necrosis and caries, I deem it indispensable, more particularly for the latter; and the amount of good which I have seen accrue from its use in my own practice, leads me to give it the strongest approbation as a most useful surgical instrument. Cases will be referred to in after parts of the work, when its efficacy in operations for caries of the tarsal bones, of the shaft of the tibia, and of the articular surfaces of several of the

Fig. 18.

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large bones, will be fully exemplified. The instrument which I generally use is about four or five inches long, including handle; the blade is about half an inch broad, and sharpened at the point like a turner's gouge. Both handle and blade are short, to enable me to rest a finger on the surface near where the instrument is applied, and so prevent any sudden plunge, such as might happen

were it of greater length. The round handle is kept in the palm, whilst the point of the fore-finger directs the scooping movements.

Perhaps there is no department of modern surgery so characteristic of improvement as that connected with the removal of dead or diseased portions of bone. Even after the saw or forceps has been used to perfection, the isolated part may not be easily taken away. If the fingers or common forceps (fig. 6) will not suffice for this, then such an instrument as is depicted in figure 18 may be very useful. This will be recognised by the seniors of the present race of surgeons, as the usual accompaniment of the others which formed the ordinary pocket dressing-case. In modern times such a case is rarely made so comprehensive in its contents, and this instrument is generally laid aside for special purposes, although it is often yet used for removing soiled dressings or other purposes, for which the fingers or common dissecting forceps are generally applied. In my opinion the common forceps will do all that may be required of them, as regards dressing a sore or wound, but when it is necessary to dip deep into a narrow space they may be of service, especially in removing objects which may be somewhat firmly fixed. This instrument is about six inches in length, with blades in proportion, but for the removal of portions of bone when some force is required, if these seem slender, I use an instrument of greater strength, of similar shape and construction. In certain instances the elevator (fig. 19), which figured in the old trepanning cases, is of service in loosening