4. If prevention is not possible the cavity should be finally thoroughly sponged out and rendered aseptic.

5. Means of temporarily checking hæmorrhage, e.g., forcipressure, will be found very valuable.

6. Not only the intestines, but every part of the patient's person, should be protected from unnecessary exposure and chilling during the operation. This rule includes the use of hot-water cushions, sponges wrung out in warm lotions, &c. It includes also caution in the use of the spray, which may be so misused as to chill thoroughly.

7. When the wound is closed, peritoneal surfaces should be carefully and closely brought into mutual contact.

The discussion on the above subject, opened by Mr. Spencer Wells at the International Medical Congress, London, 1881, may be read with advantage.

Abscess. A circumscribed collection of pus. Two chief kinds, acute and chronic. Term 'cold' is sometimes used as synonymous with chronic, and sometimes means a chronic abscess which has formed without any noticeable signs of inflammation.

ACUTE ABSCESS.-Causes.-Injury, irritation of a foreign body, follicular obstruction, absorption of poison, especially by lymphatics, and some obscure constitutional conditions. Ogston found micro-organisms in all acute abscesses. Symptoms.Chills, rigors; temperature often rises suddenly to 104°. Local symptoms of inflammation. Throbbing pain, which becomes more dull and aching as pus forms. Edema of skin. Fluctuation. The swelling, which is at first hard, gradually softens in centre. Pointing of abscess: the cuticle rises, the skin ulcerates or sloughs, and bursts. Terminations.-1, when opened either surgically or spontaneously, its walls fall together and it closes; 2, a sinus or fistula remains; 3, acute abscesses sometimes cause serious mischief by opening into blood-vessels and serous cavities; 4, blood-poisoning. This is most likely to occur when extensive bone or joint disease is co-existent. See Acute Necrosis. Diagnosis.-An acute abscess can scarcely be mistaken. Treatment.-Local rest very important; general rest in serious cases. Treat cause if possible. Hot moist applications. Ung. belladonna. Quinine internally. Calomel (5 to

10 grains) if the tongue is not clean. Indications for opening.— 1, when in sheath of a tendon; or 2, under strong fibrous membranes; or, 3, anywhere else where pus is likely to burrow instead of coming to the surface; 4, near a joint; 5, under the periosteum; 6, when pressure is likely to be dangerous; 7, when it may cause some direct obstruction to some passage; 8, when caused by some noxious infiltrating fluid, e.g., urine; 9, when a spontaneous opening would produce deformity, e.g., in neck; 10, when near anus. After abscess is open, employ simple forms of antiseptic dressing. Method of opening acute Abscess.-1, By Paget's or Syme's knife or lancet; 2, by Hilton's method when deep and in a dangerous situation. Hilton's Method.'-Incise skin and deep fascia; then push a director on into abscess; lastly, pass a pair of dressing forceps along director, and when they have entered the cavity, open the blades. Opening to be dependent, parallel with any neighbouring important structures, and free.

CHRONIC ABSCESS.-Causes.-Dead bone: all causes of acute abscess, q.v. Tubercle. Signs.-A swelling, at first hard, afterwards soft and fluctuating, usually situated near a lymphatic gland, or in some special situation, e.g., in the psoas muscle, or in loose cellular tissue, e.g., that of buttock. Often a certain amount of pain and tenderness; often evident disease of bone. Pressure on nerves may cause pain or spasm. Abscesses near mucous canals sometimes, but rarely, become emphysematous. Course. Often very tedious, usually tends to burst, either through skin or into some internal cavity, but usually the former. May remain stationary for years; and may contract while its contents partly degenerate, partly are absorbed. Constitutional Effects.-Usually little or none till it opens and its contents are exposed to the air. Then, if antiseptic precautions be neglected, decomposition of its contents tends to occur with high fever. Vide Hectic Fever, Septicæmia, &c. Liability to burrow, to open into important vessels, and to cause injurious pressure effects. Diagnosis.—From, 1, innocent and malignant tumours; 2, aneurisms. 1, in cases of doubt, use trocar, grooved needle, or aspirator. 2, vide ANEURISM. Prognosis depends upon size, position, age of patient, curability

of cause, and upon treatment. Middle age most hopeful. Treatment. Remove cause, vide CARIES, NECROSIS, TUBERCLE, &c. If there is no great tensive pain, or if there is no reason to suspect that burrowing is going on, opening may be delayed. An effort may, in exceptional cases, be made to obtain resolution by counter-irritation, iodine, mercurial plaisters, and rest. Various modes of opening-1, by knife; 2, by trocar and canula; 3, aspirator; 4, caustics. Free openings, counter-openings, drainage tubes, repeated partial evacuations by aspirator, &c. Anti8 ptic Treatment, quod vide. Dangerous septic symptoms, a probable consequence of prematurely opening a chronic abscess.

PUERPERAL ABSCESSES occur after parturition; are probably pyæmic in nature. Locality.-Iliac fossa, orbit, joints, thigh, &c.

Acupressure.-Four chief modes; 1, a long needle is thrust right through flap and made to bridge over artery; 2, a short needle, with a twisted wire through eye to extract it by, is thrust into soft tissues on each side of and made to bridge over artery; 3, the vessel is compressed between a needle and a loop of wire, like the common hare-lip suture; 4, needle is thrust through soft tissues beside artery, then twisted down upon the artery through an arc of a circle, and thrust into the neighbouring soft tissues again. Advantages of acupressure.-No foreign body is left in wound more than a day or two, as, after that time, the needles are removed. A few hours suffice for small arteries. Acupressure does capitally in scalp-wounds and when varicose veins burst. Vide Pirrie's and Sir James Simpson's writings. Only under very special circumstances is acupressure now ever used.

Adams' and Alexander's Operation.-This ingenious procedure, devised independently by the Glasgow and the Liverpool surgeon, consists in drawing each round ligament about an inch and a quarter out of the external abdominal ring, and fixing it by suture to the tissues in front of the pubes. The object is to hold a prolapsed and retroverted uterus upwards and forwards. (See Glasgow Med. Journ., vol. i., 1882, and Liverpool Med.-Chir. Journ., 1882.)

Adenitis.-Vile GLANDS, DISEASES OF.

Adenocele. Adenoma.-Glandular Tumour. A growth, the whole or part of whose structure resembles that of some gland. (But the term 'Lymphoma' is usually applied to any tumour resembling lymphatic gland.) When not pure these tumours are called Adeno-sarcoma, Adeno-myxoma, &c. Occurrence.In the mucous polypi' of the nose, rectum, and uterus: vide Polypi; in thyroid gland: vide Bronchocele; in parotid, lips, tonsils, and skin. Physical Character: movable, rounded, ovoid, or lobulated. Growth, variable in rapidity. Treatment.Divide capsule and enucleate in suitable cases. Also refer to articles Polypi, Bronchocele, Breast Tumour, &c.

Amputation (when through a joint it is termed Disarticu tion.)-When required.-For incurable and disabling disease, deformity, or injury of the part; for disease which would take too long time in recovery (now an indication of rare occurrence, but formerly commoner because of tediousness of expectant treatment of joint disease); to save life when nature, however assisted, would find it easier to heal the amputation wound than to cure the disease or injury; for aneurism below or even above the site of operation; for secondary hemorrhage.

General Principles.-1, Remove no more of a limb than is necessary; 2, obtain sufficient coverings for the stump; 3, arrange that the cicatrix shall not lie on the end of the bone; 4, do not take hopelessly unsound tissue into the flaps; 5, take every precaution to check hæmorrhage and to prevent its recurrence; 6, cut the large blood-vessels transversely; 7, remember the paramount importance of dressings and after

treatment.

Instruments.-1, Knives appropriate to each case; 2, saw; 3, bone-forceps; 4, lion-forceps; 5, common scalpels; 6, arteryforceps; 7, dissecting-forceps; 8, ligatures; 9, needles and sutures; 10, dressings, sponges, retractors, towels, water, either spray or arrangement for antiseptic irrigation, &c.

Assistants.-1, Chief, who sponges, secures arteries, &c., usually stands opposite operator; 2, holds part to be removed; 3, secures main artery, unless tourniquet be used; 4, hands intruments when wanted; 5, chloroformist. Number of assistants of course depends greatly on supply accessible.

Methods.-1, Circular; 2, oval; 3, flap; 4, mixed of skinflaps and circular cut through muscles.

Steps.-1, Divide soft parts; 2, saw bone (avoid splintering, cut off spicule); 3, tie vessels and trim soft tissue; 4, adjust flaps and insert drains and sutures; 5, apply first dressings.

CIRCULAR AMPUTATION.-1, Sweep through skin and fat and dissect up for half diameter of limb, turning edge of knife slightly away from skin to avoid scoring the vessels which supply the skin-flap; 2, sweep through muscles, retracting' all the time; 3, still having the muscles well retracted, one or two inches, and having divided the periosteum by a sweep of the knife, saw through bone. Finish as directed above.

OVAL AMPUTATION.-See amputation of finger at metacarpophalangeal joint.

FLAP AMPUTATION.-Three varieties: 1, Double Flap; 2, Rectangular (Teale's); 3, One Long Flap.

Double Flap, may be lateral, antero-posterior, or oblique. Cut thin flaps from without inwards, but thick and fleshy ones by transfixion. Flap containing vessels to be cut last, and vessels cut long.

Rectangular Flaps (Teale's).-All the soft tissues down to the bone included in the flaps. Main artery to be in short flap. End of flaps square. Long flap its length and breadth each equal half the circumference of the limb. Short flap its length equals one-fourth that of long flap. Bones sawn exactly at angle of union of flaps, without any retraction.

Spence's Operation (a modification of Teale's).-No posterior flap; retraction instead. Anterior flap simply hangs down

over bone.

Lister cuts an anterior rounded flap two-thirds diameter of limb in length; skin and enough muscle to cover bone. Posterior rounded flap (one-third limb's diameter), all skin. Posterior muscles cut as short as possible (to free flaps from effects of their contraction). Retract soft parts for two inches, and saw bone.

Single Flap amputation. Vide amputation at phalangeal joints of fingers.

SKIN FLAPS AND CIRCULAR INCISION THROUGH MUSCLES.—