as it is, deals with questions of life and death, can scarcely be excused; they can only be lamented and condemned. But as I am convinced that it will do much more good than evil, and I believe I have done my best, I publish the work hopefully. These shortcomings would have been much greater if it had not been for the help in revision which has been given by Messrs. Alfred Street, Mills, Dunn, Alfred Back, Firth, and Charles Paget. Mr. STREET has gone over the whole book. I cannot thank him too warmly. My friend and pupil, Mr. Charles H. Taylor, has made the Index of Names.

Messrs. DORAN, LYONS, and JULER have added contributions on Ovariotomy, Toothache, and Ophthalmic Surgery respectively.

Mr. Juler desires acknowledgment to be made of the help given by Mr. W. Adams Frost and Mr. W. Langdon, in the revision of the article on Ophthalmic Surgery.

Finally, I will express a hope that the practitioner, as well as the student, will occasionally find the book useful as a handy little work of reference.

20 PRINCES STREET, HANOVER SQUARE, W.

September 1881.

INDEX OF SURGERY.

Abdomen, Contusions of.-Always examine patient very
carefully, but gently. Diagnose whether the viscera are injured
or not. Three things protect against injury to the deeper struc-
tures, viz.: 1, thick and muscular abdominal walls; 2, empty
state of the viscera; and 3, the patient's foreseeing and expecting
the blow.

The parietal effects of a blow on the abdomen are, 1, rup-
ture of muscle; 2, mere bruising (which, however, may be
very serious in extent); 3, rupture of the peritoneum, with
consequent extravasation of blood into peritoneal cavity.
Rupture of a muscle causes temporary paralysis, swelling, &c.
Sometimes the separation of the parts may be felt. Abscess
may follow contusion, burrow widely, and cause most trouble-
some sinuses. Hæmorrhage from ruptured peritoneum may be
fatal. The collapse so produced is distinguished from the
effect of ruptured intestine by the absence of great pain and
vomiting, and by positive signs of internal hæmorrhage.

A blow on the abdomen may cause serious and even fatal
collapse without visceral injury, possibly by damaging the ab-
dominal sympathetic system. Treatment.-Attend to collapse,
internal hæmorrhage, inflammation, and suppuration on general
principles. Avoid purgatives. In case of peritonitis, use
leeches, warm moist applications, and a liberal allowance of
opium. Mercury in case of sthenic inflammation. When
there is injury to a viscus, the particular one injured depends
chiefly upon the place where the force is applied. Each viscus

B

presents special symptoms. Liver and stomach most commonly suffer.

RUPTURE OF LIVER.-Symptoms. Pain in hepatic region, signs of internal hæmorrhage, peritonitis, bilious vomitings, white stools. Traumatic saccharine diabetes (Bernard).

RUPTURE OF GALL-BLADDER.-Great pain, collapse, and anxiety. Rapid death.

RUPTURE OF STOMACH.-Bloody vomiting, local pain, and general signs of abdominal injury.

RUPTURE OF INTESTINES.-Bloody stools, and general signs of abdominal injury. Most frequently affects the jejunum. Emphysema.

RUPTURED SPLEEN.-Severe internal hæmorrhage.

RUPTURED KIDNEY.-Pain and bruise in loins. Blood and, if an abscess should form, pus in urine. Vomiting, retraction of testicle, numbness of thigh. Less hopeless than injury of the other viscera.

RUPTURED URETER has occurred, causing a large accumulation of urine on the same side of the abdomen: recovery. RUPTURED BLADDER.-Vide BLADder, Rupture of.

Treatment of Ruptured Viscera.-Perfect rest, warm and moist applications to seat of pain, leeches if pain be severe, opium in small and repeated doses, a minimum diet-starvation if the intestines are believed to be wounded-then give frequent small nutrient enemata. No purgatives. Ice to suck.

Abdomen, Wounds of.-Are either superficial or penetrating. Penetrating are of four classes: 1, without either injury or protrusion of viscera; 2, with protrusion only; 3, with injury and without protrusion; and 4, with both injury and protrusion.

SUPERFICIAL WOUNDS.-Their Treatment.-Keep sides in apposition by sutures and a suitable position of the body, but beware of confining blood or discharge. 1, always secure the bleeding point in severe hæmorrhage, enlarging wound if necessary; 2, in slighter hæmorrhage do not close wound till bleeding stops; 3, open wound freely at least sign of suppuration. Part of abdominal wall which is wounded is liable to become seat of hernia. Foreign bodies of enormous size may be hidden away in these wounds.

SIMPLE PENETRATING WOUNDS.- Sometimes marked by escape of reddish serum. If sutures should be required, place them close to or through peritoneum, give opium, and apply general principles of practice. Prognosis fairly good.

-

WOUNDS WITH PROTRUSION OF UNINJURED VISCERA.Cleanse and return protrusion; if necessary, snick edge of wound to make room. Omentum, if much injured, may be cut off after ligaturing. See that the herniated viscera are fairly and entirely passed into abdominal cavity, and not slipped between muscles. Gangrenous bowel: leave it in sitú to slough, and form artificial anus.

WOUNDS WITH INJURY AND WITHOUT PROTRUSION.-Very serious. Possible escape of urine, fæces, bile, or gas through external wound. Extravasation into peritoneal cavity not invariable. Other symptoms and treatment like those of contusion of abdomen with rupture of viscera. Vide above.

WOUNDS WITH BOTH INJURY AND PROTRUSION.-Treatment. Restrain hæmorrhage by ligature or clamp. Do not be anxious to return solid viscera if they are at all seriously injured. Sew up wounds of intestine with silk or strong catgut. Glover's suture, unless the wound be lacerated or involve much of bowel's calibre; then stitch bowel to edge of external wound to form artificial anus. Allow no food, except ice and barleywater, for three days. See also PERITONITIS (TRAUMATIC), FISTULE (GASTRIC and BILIARY), ARTIFICIAL ANUS.

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. 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