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. Diagnosis. An acute abscess can scarcely be mistaken. Treatment.-Local rest very important; general rest in serious cases. Treat cause if possible. Warm moist applications. 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 pressure, if necessary, to prevent fistula, but poulticing usually suffices as a 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, quod vide. Scrofula. Constitutional debility. 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 the

abscess be of any size, decomposition of its contents tends to occur with high fever. Vide Hectic Fever, Septicemia, &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 trochar, 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. 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 be made to obtain resolution by counter-irritation, iodine, mercurial plaisters, and rest. Various modes of opening-1, by knife; 2, by trochar and cannula; 3, aspirator; 4, caustics. Free openings, counter-openings, drainage tubes, repeated partial evacuations by aspirators, &c. Antiseptic 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.

Adenitis. Vide 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; to save life when nature 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 hæmorrhage.

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, &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 instruments 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 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. Ends 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.— Cut two skin-flaps by dissecting from without inwards. Then finish as in circular amputation.

Hæmorrhage during amputation to be prevented temporarily by digital pressure on main artery, by tourniquet, or by Esmarch's bandage. Afterwards, ligature by silk, hemp, or cat

1

1 For a résumé of the advantages of Esmarch's bandage, see Med. Rec., 1874, p. 271.

gut-torsion or acupressure is to be employed. Sponging with cold or with hot water to stop oozing. Actual cautery to check obstinate bleeding from bone.

Muscles retract greatly in traumatic cases, but very little in limbs affected with old disease. Knife to be used with a free sawing motion. Parts to be relaxed during transfixion. Commence sawing the bone by drawing the saw back to make a groove.

Mortality after Amputation.-Chief causes: 1, shock; 2, secondary hæmorrhage; 3, pyæmia (in nearly half the fatal. cases); 4, erysipelas; 5, phlebitis; 6, congestive pneumonia. Besides which, 7, hospital gangrene, 8, sloughing of stump, and, 9, tetanus, occasionally carry off patient. Pyæmia most common after traumatic, rare after chronic disease cases.

Circumstances affecting Patient's chance of Recovery.-Two classes: 1, constitutional conditions; 2, circumstances of operation itself. Class 1: age, general health, and hygienic conditions. Child's twice as good as a young man's, three times as good as an old man's. Class 2: seat of amputation, structure of bone sawn through; whether amputation is for injury or disease; nature of the affection; time after the injury. Diseased kidneys, town life, amputation high up a limb, amputation for injury, or through much cancellous tissue of bone-all these darken the prognosis. Nature of disease: after chronic disease, prognosis good; malignant or tuberculous disease, bad; acute suppurative disease of joints, very bad; amputation of expediency, very bad. Time after injury: primary or secondary. Primary are such as are done within thirty hours of the injury. Secondary are amputations done after suppuration has occurred. Primary always more dangerous than secondary, except in amputations of the upper extremity done in civil practice. Death after primary amputation usually caused by shock, hæmorrhage, or exhaustion; after secondary, by erysipelas, pyæmia, &c.

AMPUTATION AT ANKLE.-Pirogoff's.-Resembles Syme's. But the lower incision extends from one malleolus to the other across the sole of the foot, and inclines forwards and downwards; while the os calcis is sawn through obliquely, downwards and forwards, just behind the articular surfaces for the astragalus.

1 See Practitioner, Feb. 1879.