sign jected. operation with a truss, which he was advised to

Transcription

1 234. PRECIS OP OPERATIONS PERFORMED IN THE WARDS OP THE FIRST SURGEON, MEDICAL COLLEGE HOSPITAL, DURING THE YEAR V which hd fter to be opertion emptied. with wound [Aug., Dischrged 47 dys soundly heled, nd of recurrence. Reducible right Hindu mle, out. 44. By Subgeon-Mjor K. McLEOD, A.M., M.D., F.R.C.S.E., oblique inguinl herni of two months' durtion with double hydrocele; ltter tpped nd inprofessor of Surgery, Clcutt Medicl College. Herni n operted on in usul jected. (Continued from pge 198.) wy. Wound pursuedn septic course,ndheled IX. 4. Opertions for rdicl cure of by first intention. Dischrged 42 dys fter herni.?i. Mhomedn mle, (Bt. 48. Right opertion with truss, which he dvised to wer for sometime, s precution. reducible inguinl herni of one yer's durvii. Mhomedn mle, it. 30. Admitted with tion. Generl helth good. Sc dissected out, trnsfixed, nd tied t neck with ctgut. double oblique inguinl herni of three yers' The right herni irreducible, durtion. Rest of sc removed. Stump reduced into cnl. but returned fter ppliction of ice. Four Pillrs brought toger with double ctgut thred. Counter-opening mde in scrotum; dys fter dmission, both herni} were operted inserted in usul mnner. He tube on simultneously ; nd ntiseptic dressing pplied. "Wound pursued n septic course, nd heled did well until fifth dy, when temperin 15 dys. He remined in hospitl 40 dys. ture rose, nd diffuse cellulitis of left bdothe dischrge from The cnl firmly closed; nd re no minl wll discovered. hernil impulse. He provided with spring side becme putrid. A free incision mde to relieve tension, nd evcute pus. truss, nd dvised to wer it for some time. ii. Mhomedn mle, cet. 30. Right oblique Symptoms of septicsmi incresed, left inguinl herni of 20 yers' durtion. Hd been pleur filled, nd he died of exhustion, from repetedly strngulted; but lwys re- blood-poisoning, eight dys fter opertion. The This hppened on dy of turned by txis. left pleurl cvity found to be distended dmission. Suffering from feverof remittent type. with pus; nd lungs were studded with He detined in hospitl for 40 dys?unpyjemic bscesses. til fever subsided?nd n operted on in viii. Hindu mle, cet. 9. Congenitl inguinl sme mnner s lst cse. Suppur- herni of left side. Sc exposed nd tied t tion took plce in trck of wound nd neck; reminder seprted from cord s fr s testicle, nd removed ; counter-opening repir somewht slow. He bsconded 32 fter when in scrotum, nd dringe tube insertwound lmost mde dys opertion, heled. Some suppurtion took plce, nd ed. iii. Mhomedn mle, cet. 30. Double oblique wound heled by grnultion. Dischrged 25 inguinl herni; right of nine yers', nd left of dys fter opertion, pprently quite cured. two yers' durtion. Both operted on simulix. Mhomedn mle, cet. 45. Reducible left oblique inguinl herni of three yers'durtneously. Right sc removed fter ligture; left, which smller, ligtured t neck, nd retion. Hd hydrocele on sme side. Scrotum in cnl. Wounds remined somewht thickened. Usul opertion performplced septic ; left heled in 16 dys, nd right in 21. Ws ed. Some suppurtion occurred in wound, detined in hospitl for 25 dys, nd provided nd scrotum swelled?with fever (elephnwith double truss. Not herd of since his distisis). This subsided, nd he dischrged 47 dys fter opertion, with wound soundly chrge. i Hindu mle, CEt. 5. Suffering from inguiheled, nd herni rdiclly cured. Ntive Christin mle, cut. 25. nl herni of left side from ge of three Conx. months. The neck of sc exposed, isoherni, right side. Sc exposed ; neck genitl lted nd ligtured in two plces? interveutied, nd reduced into cnl. Reminder of sc The pillrs were dissected off nd removed. Opening mde in imr prt being removed. brought toger, nd wound stitched nd fundus of scrotum, nd dringe tube inserted. Wound remined septic, nd heled, without dressed ntisepticlly. Some swelling of scrotum took plce, nd wound suppurted. suppurtion, in 13 dys. Dischrged 25 dys fter opertion. The ptient hd high fever for few dys. On xi. Hindu mle, cet. 40. Reducible oblique puncturing scrotum, some pus escped from The wht remined of cvity of sc. right inguinl herni of three yers' durtion. Usul opertion. Some bleeding took plce swelling nd fever n subsided, nd wound fter opertion; nd thrombus formed in heled. The result, eventully, stisfctory. Left hospitl 23 dys fter opertion. wound cvity, which suppurted freely. Repir took plce by grnultion. He dischrged Mhomedn mle, ot. 50. Right reducible 51 dys fter opertion with cnl well inguinl herni of 15 months' durtion. Operted on s in cse i. Wound heled kindly. A closed, nd no sign of recurrence. smll collection of pus formed in scrotum, *%* The opertion performed in se cses no sign vi.

2 Aug., 1887.] Dr. McLEOD'S OPERATIONS. hs been fully described in clinicl lecture which I published iu this Journl (September " 1882), nd reproduced in my work on Opertive Surgery " (pge 202). The points which dditionl experience of se cses hs impressed on me re: 1st. To trnsfix ueck of sc twice, t right ngles, in tying it. This gives greter security to ligture nd renders it unnecessry to tighten it so much ; 2nd. The gret dvntge of mking n opening iu fundus of scrotum nd inserting dringe tube ; 3rd. In congenitl cses, dvisbility of cutting off tunic close to testis rr thn tying it; nd 4th. The dnger of performing n opertion on both sides t sme time in double cses. The only ftl cse in this series (vii) double one, nd though septic infection, resulting in pysmi, my occur in single opertions, chnces of its re occurrence greter in double opertions, while vitl resistnce is lowered by shock of more severe nd prolonged procedure. In ddition to se cses rdicl opertion successfully performedfor cure of reducible right inguinl herni which complicted by scrotl elephntisis (see vi B. 1. xiii). Unfortuntely we hve been unble to trce subsequent history of ny of se 12 persons ; but wlieu y left hospitl, result seemed to be quite stisfctory, nd none of m hs since returned. They were ech provided with truss, nd dvised to wer it for t lest yer. 5.? Opertion for rdicl cure of umbilicl herni. Mrs.M.,!Europen,ee?.43. Fiveyersgowhen 235 stisfctory repir,she begn to hve fever, which grdully incresed in severity. On 26th Mrch, n bscess on right brod ligment detected; nd on 30th this sperted, nd 4 oz. of foetid pus removed. Re-ccumultion took plce ; nd, on 1st of April, bscess opened bove pubes, nd dringe tube of inserted. It grdully closed. The fever subsided fter opening of bscess. Her helth improved rpidly; nd she left hospitl on 24th of April, quite cured of both herni nd bscess. A letter received, from her bout yer fter her dischrge reported tht no return of rupture hd n tken plce. %* The ptient stout, unwieldy womn, with very flbby bdomen ; nd suppurtion of wound cused by putrefction which probbly due to slipping of dressings;? se were not t first secured by elstic bndges or strpping ; ltter subsequently employed to retin m, with benefit. Wher pelvic cellulitis of septic origin, it is difficult to sy. No or suppurtion took plce; nd when bscess-cvity emptied nd drined, it heled up kindly. No symptom of peritonitis observed throughout, ud finl result of opertion stisfctory ; though considerble suffering nd prolongtion of convlescence were cused by putrefction nd suppurtion of wound. 6. Incisions for hcemtocele.?i. Mhomedn, t 60. Hemtocele of right side of three mouth*, durtion ; begn with fever. Tunic lid open ; wound dressed for grnultion. Heled in 35 dys. ii.?mhomedn, cet. 50, Scrotum enlrged by Hd fll fortnight go, followed by incresed swelliug ud pin. Right tunic found distended with grumous blood. It lid freely open. The cvity suppurted nd gruulted; ud wound heled in 40 dys. iii.?mhomedu, cet. 60. Hs suffered from swollen scrotum for eight yers. The swelling incresed periodiclly with ttcks of fever. Both tunics immensely,distended with coffee-coloured umbilicus. The contents return into bdominl cvity when she lies down, or with fluid; skin of scrotum much thickened. The id of mnipultion. On 13th of Februry scrotl skiu removed by n ovl incision. n opertion performed for cure of The tunic} lid open, ud emptied. They were, herni. Au incision mde in middle both, much thickened nd degenerted. The line down to tiie sc which crefully isolted right contined 48 oz. nd left 32 oz. of: nd stitched t neck by 4 or 5 sutures. hjmtocele fluid; 146 oz. of similr mteril ctgut Two dherent omentl processes hd to be tied hd been removed, by tpping, ou previous off cord,nd nd returned. Five strong double ctgut sutures dy. The tuuicj were dissected stitched in nd were plced in ot trimmed nd testes removed tendinous edges ring, tied firmly. The wound n stitched with perinjum, s iu n opertion for scrotl tumour; skin drwn over iron wire nd horse-hir, two dringe tubes nd remins of scrotl were inseited, nd u ntiseptic dressing pplied. m by continuous ctgut suture. On found to be putrid nd There slight fever for few dys; nd free 4th dy wound suppurtion took plce in wound cvity. The sloughy. Dysentery set iu on third dy, ud 7th. Ptient died of lower third of wound heled by first inten- bronchopneumoni on tion, nd rest by grnultion. On 13th exhustion 10 dys fter opertion. of Mrch, while wound undergoing i Mhomedu, t, 40. Hs suffered from stooping down to lift child, she felt something give wy t nvel, nd lump formed, which hs grdully incresed in size. In August 1885, swelling becme tense nd pinful, nd its contents could not be reduced. They were returned fter employment of fomenttions nd purgtives. The tumour is very lrge, nd fills whenever she stnds up. The ring is very wide, dmits three fingers, nd is situted just bove elephntisis.

3 236 hydrocele of right tunic for 24 yers. Hd 8trong ttck ot fever five months go, followed by increse of swelling nd gret pin, which hve continued up to present. The tunic " lid open, nd bout pint of coffee-colour- ed fluid removed. The cvity hed out, nd dressed for grnultion. He dischrged, well, 61 dys fter opertion. *** Hjmtocele in old subjects is generlly sequel of hydrocele. The tunic undergoes gret thickening nd degenertion. A slight injury is n sufficient to cuse bleeding into its cvity. This my lso occur spontneously from degenertive erosion. Ptches of brsion re seen in se cses on interior of tunic, nd it is from se, pprently, tht bleeding tkes plce. The tretment by free incision is most effective nd speedy. I hve tried smll opening nd dringe. If putrefction tkes plce in cvity?nd this is probble contingency? result my be dngerous or ftl. Even if cvity remins septic, process of repir is very slow. With free incision nd complete evcution, it is esier to void putrefction, nd repir is much more rpid. 7. Incision for bubo with removl of inguinl glnds.?i. Est Indin, mle, cot. 18. Acute bubo of 10 dys' durtion following chncroid. A free incision mde, nd some enlrged, softened, nd prtilly isolted gluds were removed by enucletion by finger. The wound dressed ntisepticlly, nd heled soundly in 37 dys. ii.?hindoo mle, cet. 29. Double bubo of 20 dys' durtion following chncroid. Right lid open 20 dys go, nd still dischrging ; glnds much enlrged. A free incision mde ; glnds of left side removed by finger ; nd remins of those of right scrped out by Volkmuu's spoon. Eighty-one dys fter opertion, sinuses still remining, se were enlrged, nd three disesed glnds removed from right, nd The wound now one from left side. grnulted, nd heled in 54 dys. iii.?est Indin mle, cut. 24. Hd undergone opertion for right bubo with extirption of glnds five months go. Suppurtion took plce subsequently on left side, which incised without removl of glnds. Sinuses hve recently formed in both cictrices; nd y re found to led down to indurted nd enlrged lid open, nd glnds. The sinuses were glnds removed. The resulting wounds heled by grnultion in 50 dys. i Est Indin mle, it. 40. Enlrged inguinl glnds of both sides following chncroid. Limited fluctution on surfce. Incisions were mde, nd enlrged glnds removed. They were found to be undergoing csetion. Left hospitl, quite recovered, in 53 dys. *%* The removl of prtilly disorgnised ^ [Aug., 1887 cute bubogretly ccelertes recovery. Iu chronic bubo glnds re pt eir to undergo csetion of centre or fibroid thickening of cpsule or both ; nd, in eir cse, incision lone is sure to result in obstinte sinus. In very virulent bubos complete destruction by suppurtion sves trouble of enucletion. In milder forms of perilymphdenitis, when tlie glnd is simply hyperplsi, incision is sufficient ; but, between se two extremes, more stisfctory result is obtined by extirpting disesed glnd or glnds, thn by incising glnds in only. Perinel section.?i. Mhomedn, cet Admitted with retention of urine. Penis nd scrotum cedemtous. Urine dribbling. History of gonorrhoe nd stricture. Some offensive urine removed by No. 8 cter. The perinseum opened; nd urethr divided up to prostte. The bldder n emptied by No. 12 cter. A free incision mde into scrotum, in middle line. A lrge cvity found contining foetid urine nd pus. This lso entered from perinseum nd dringe tube pssed from one opening to or. Syme's S-shped cter tied in Some bleeding took plce fter opertion requiring use of petticot. The scrotl swelling subsided, Urine begn to nd cvity grdully heled. A full-sized flow per urethrm fter 15 dys. pssed into bldder t bougie (Lister's) He improving intervls of three dys. when he bsconded, 43 dys fter rpidly, opertion. ii. Hindu, cet. 28. Admitted with retention of urine; bldder distended..perinseum, scrotum, nd lower prt of bdomen swollen nd (edemtous. History of stricture for six or seven yers. Some urine hd been removed by No. 6 cter, nd some smll punctures mde in The perinseum freely lid open, scrotum. nd membrnous urethr fully divided ; lrge quntity of mmonicl urine thus removed. A free incision mde into swollen penis. Urine continued to pss through perinsel wound, nd extensive sloughing of penis nd scrotum took plce ;? former lmost mputted by gngrene. An ttempt mde to suture corpor cvernos, but filed ; nd it, finlly, thought best The ulcers left by to remove orgn. sloughing cictrised. The perinsel orifice kept open by occsionl pssge of cter, nd micturition Avs performed through it. Ptient hd control over sphincter vesicse. He remined in hospitl 52 dys. iii. Hindu, cet. 38. Admitted with retention of urine, nd pinful swelling of perinseum. Gonorrhoe 12 yers go; stricture for four yers; nd retention for 12 dys. The perinsel bscess lid open; membrnous urethr divided ; nd No. 12 cter pssed into bldder

4 Aug., 1887.] He begn to mke wter through per urethrm. penis 15 dys fter opertion, nd left hos- pitl 57 dys fter opertion, with perinel wound closed nd fully dilted A No. 12 cter introduced urethr. into bldder every third dy during his sty in hospitl. i? Hindu, it. 30. Sustined rupture of urethr by fll on perineum. Bldder distended ; perineum swollen. A No. 8 cter pssed. Perineum divided, nd urethr slit open up to prostte. A No. 12 cter pssed. Wound closed in 35 dys. A No. 12 cter pssed into bldder every fourth dy. Able to pss wter freely in full strem.?hindu, it. 40. Retention of 24 hours' durtion. History of stricture. Perinel section hd been performed two yers go. Strem lis grdully become nrrowed. Bldder relieved by tpping before dmission. A No. 2 cter pssed with difficulty, nd perithe neum nd urethr were divided on it. stricture lso divided, nd No. 12 cter pssed by urethr. Left hospitl 40 dys fter opertion, with perinel wound closed, nd ble to mke wter in full strem. A No. 12 cter hd been pssed every fourth dy. vi. Eursin, it. 28. Perinel bscess nd fistul consequent on gonorrhoe nd stricture. Perinjeum lid open nd stricture divided on grooved stff. No. 12 cter introduced. Both wound closed within 68 sinuses nd perinel A full-sized cter pssed every fourth dy. vii. Mhomedn, cut. 35. Urinry fistul nd stricture. Hd gonorrhoe 20 yers go, nd perinel bscess 12 yers go. Perineum incised, nd stricture divided on grooved stff. Absconded month fter opertion, before cure completed. The urethr dmitted No. 10 cter. viii. Hindu, it. 35. Six fistule in perineum nd scrotum, lso fistul in no. History of gonorrhoe, bscesses, nd fistul rnging over 22 yers. A No. 2 cter introduced, nd externl urethrotomy performed. No. 12 cter pssed per urethrm ; nl fistul divided. Remined in hospitl 18 dys. The nl fistul cured, nd ll urinry fistule closed. The wound hd not heled ; nd hlf of urine pssed through it. The urethr dmitted No. 12 esily, which pssed every fourth dy. ix. Hindu, it. 40. Hd n ttck of gonorrhoe 20 dys go, followed by hemturi in five dys. Urine begn to issue per num in three dys; nd on dy preceding dmission n opening formed in dischrging urine. There is lrge glutel bscess on right side. The perineum lid freely open ; stricture divided, nd No. 8 cter pssed into bldder. The glutel bscess lso opened. He very low nd dys. 237 Dit. McLEOD'S OPERATIONS. perineum,?lso continued so for three dys. Temperture subnorml. Then, slight rection took plce; but it followed by prostrtion, nd he removed, in moribund stte, six dys fter opertion. x. Hindu, out. 70. Ten urinry fistul; iu perinjum nd scrotum. Hd gonorrhoe five Urethr dmits yers go, followed by bscess. No. 12. Perinjl section performed on guide. A full-sized cter pssed every fourth Left hospitl 70 dys fter opertion, dy. pssing wter in full strem, ud with perineeul wound closed. xi. Est Indin, ct. 28. Admitted with recent fistul on left of perinjum, following gonorrhoe nd stricture. Urethr dmitted No. 12. An ttempt mde to close fistul by lying it open, nd pssing fullsized instrument every third dy. After persevering with this tretment for 45 dys, perinjeum freely lid open nd membrnous urethr divided. The fistul heled ; but perinfel wound remined slightly His helth being bd, lso open fter 65 dys. fistul thretening to reopen, he dvised to tke chnge of ir, which resulted in closure of perin;l wound. lie hs full-sized sound xii. pssed occsionlly. Suffered from gonorrhoe by stricture. A second ttck three yers go succeeded by bscesses of scrotum ud perinjum nd fistul;. There re now four of se, nd urethr is much nrrowed by succession of tight strictures. The perinjum lid open, nd strictures divided. A No. 12 pssed into bldder. He doing well until eight dys fter opertion, when fever nd swelling of scrotum This followed by left pleurisy, occurred. ud erysipels of groins nd flnks. He removed in low condition 55 dys fter opertion. Cock's opertion.?i. Hindu, cut. 30. Admitted with lrge double hydroceles nd generl nsrc. The hydroceles were incised ud drined, nd, while in stisfctory process of cure, 26 dys fter opertion, symptoms pf extrvstion of urine presented mselves ;? Mvollen, boggy perinjeum, oedemtous scrotum, nd tender swelling bove pubes. There stricture ner metus which divided, nd perinsum lid freely open, floor of urethr incised, bldder emptied, nd No. 12 cter pssed. Urine escped freely through wound, nd ptient seemed to do well for three dys, when supr pubic swelliug becme boggy. It freely incised in middle line, nd dringe tube pssed through wound, beneth pubic rch, to perinel wound. The symptoms of septicoemi becme more severe; nd this disese proved ftl five dys fter Hindu, 24 yers go, ct. 40. followed ^ opertion. 32

5 238 ii. Hindu, ture for t. 33.?Hs suffered from stric- eight yers, nd from retention for three dys. Instruments hve been used forcibly, nd urethr is bdly lcerted; bldder is gretly distended. A cter cn be pssed; but nothing issues through it, except smll quntity of snious fluid. The perineum divided, nd urethr incised in front of prostte. The bldder fouud to be full of clots, which were removed by lithotomy scoop nd injection. A stricture of penile urethr divided, nd No. 12pssed frombehind forwrds. After week full-sized instrument introduced into bldder per urethrm nd this He left hospitl repeted every fourth dy. 31 dys fter opertion with perinel wound closed, nd ble to mke wter in full strem. iii. Hindu, oet. 30.?Stricture nd perinel bscess. Gonorrhoe six mouths go. Abscess opened, nd stricture divided. A No. 12 pssed per urethrm. Secondry hsmorrhge took plce on 5th nd 7th dys, nd stopped by ligture nd pressure. A full-sized cter introduced 25 dys fter opertion, nd every fourth dy refter. He left hospitl 87 dys fter opertion, with perinel wound still unclosed, but pssing bout three-fourths of his urine through penis in good strem. i Mhomedn, ct. 55.?Retention for 48 hours. History of gonorrhoe nd stricture. The bldder hd been tpped per rectum, nd cnul retined. Perineum nd scrotum much swollen. Ptient very low. Perineum lid open, nd urethr incised in front of prostte by Cock's method. Syme's cter tied in. Incisions were lso mde on swollen penis nd scrotum. Ptient died of septicoetni four dys fter opertion. Hindu, oet. 50.?Gonorrhoe ten yers o-o followed by succession of fistuls, which re situted on perineum, scrotum, nd penis, nd through which urine is pssed with gret difficulty. No instrument could be pssed into bldder. The perineum divided nd, strictured urethr lid open. A No. 12 cter This repeted every fourth introduced. left hospitl 57 dys fter operptient dy. cure completed. tion before vi. Mhomedn, cet. 35.?Fell on perihs not been ble to mke neum six dys go. Pssed some blood fter wter since n. ccident. Perineum swollen nd boggy. Cterism tried to no purpose. Bldder distended to umbilicus. Cock's opertion performed; 6 pints nd 2 oz. of bloody urine withdrwn. Considerble deep bleeding which stopped byplugging. He got violent ttck of dysentery next dy, which proved ftl in twelve dys. Pyemic bscesses were found in liver. *#* The cuses for which se 18 opertions [Aug., of periucel section were performed were vrious. Two were rendered necessry by rupture of urethr?one recent, nd one of six dys' stnding ; recent cse did well; or got pyemi nd died. Two were cses of externl utlie thotory for strictures with retention. In oue of se urethr hd been bdly lcerted by violent cterism, nd bldder distended with clots. These cses re not uucoinmon ; nd it is often impossible to introduce n instrument into bldder. If retention is urgent, Cock's opertion is best nd sfest course in such cses ; stricture being sought for nd divided t sme time tht bldder is opened by incising prosttic urethr. Both se cses did well. In three cses perinel bscess ssocited with stricture nd retention; nd by sme opertion bscess evcuted, bldder emptied, nd stricture divided. Six were cses of urinry fistul. Owing to neglect se cses re often of severe nd intrctble If perinsl section does not confer comnture. plete cure in such cses, it gives gret relief by exchnging one direct nd centrl opening for severl tortuous ones, nd swelling surrounding ltter lso disppers. By persevering use of instruments perfect cure cu be obtined in such cses if loss of substnce in perinceum hs not been gret. Five were cses of extrvstion of urine. Two of se did well, two died, nd one removed moribund. The importnce of pssing full-sized instruments frequently in such cses need hrdly be pointed out. In ll cses of stricture occsionl instrumenttion is dvisble; how much more so when urethr is divided by opertion or dmged by injury or disese. Unfortuntely in hospitl prctice it is very difficult to persude ptients to undergo this very necessry prt of tretment. 9. Incision for nl nicer.?eursin femle, A lrge ulcer of rectum of eight ct. 22. months'durtion; constntly pssing blood nd mucus, with pin nd strining. Sphincter nd floor of ulcer divided, nd wound dressed with The ulcer iodoform nd borcic ointment. heled by grnultion : nd she left hospitl, in 56 dys, with prts lmost heled, ud quite relieved of her former sufferings. 10. Tenotomy for tlipes vrus.?i. Mhomedn mle, <xt. 3. Tlipes vrus of right foot, The nd enlrged burs over outer nkle. tendo chillis nd tendons of tibilis posticus nd flexor longus digitorum divided nd burs dissected out. Removed 17 dys fter opertion with foot gretly improved. 11. Europen child, cet. 12 mouths. Right tlipes equino-vrus. Hd been operted on shortly fter birth, but deformity persisted. The tendons of tibiles nd flexor longus

6 Dr. McLEOD'S OPERATIONS. Aug., 1887.] digitorum nd tendo ud, under greter cre d?8- Hindu mle, cct. 42. b. Heptic bscess. Hd fever one yer go, followed by enlrgement of liver. Fever subsided in three months, leving liver enlrged. A relpse of fever occurred seven months go, ttended with hrd swelling in right hypochondrium. Fever left fter month ; but swelling remined, nd during lst four months hs been incresing in size. It is situted over epigstric nd right hypochondric regions, is dull on percussion nd fluctutes. The right lobe of liver is of norml dimensions. An incision mde on 2nd of December 1886 under ntiseptic precutions t most prominent prt of tumour, nd 3 oz. of reddishbrown pus removed, sinus found leding deeply into left lobe of liver. A dringe tube inserted. The swelling subsided, no fever ensued, nd dischrge continued to flow through tube in considerble quntities. It remined sweet. The tube removed On 17th Jnury sinus on 18th December. being contrcted, but ptent nd still dischrging, it enlrged, nd tube reintroduced. On 19th of Februry dischrge continuing, chloroform dministered, nd sinus lid freely open. He remined in hospitl till 14th of My. The orifice hd gin undergone contrction, nd smll mount of dischrge continued to issue from it. He free of ll unesiness, his generl helth good, nd, tiring of tretment, lie insisted on leving hospitl. c. Ilic bscess.?i. A Hindu, cet. 16. Pyjmic bscess of left side in cse of resection of elbow joint for compound frcture (vide III. 3..) opened nd drined..ptient died of py3mi. ii. Mhomedn mle, >t. 30. Left ilic bscess of one month's durtion, opened by Hilton's method below Poupm-t's ligment nd drined. Heled in 28 dys.? Hindu, it. 11. An ilic bscess hd opened ten dys go on right side bove Pouprt's ligment. This being imperfectly iii. chillis were divided, in fter-tretment, been better result obtined. iii. A precisely similr cse. i Europen child, 2 months old, with double tlipes vrus. The tendons were divided, nd under creful fter-tretment deformity thoroughly corrected. The three lst cses were not detined in hospitl; in two of m tendons hd been previously cut,but necessry fter-tretment neglected. To ensure thorough section, tendons were exposed by smll longitudinl incision, rised by strbismus hook, nd divided. Cse iv complete success owing to intelligent id of prents. 11. Lrge bscesses.?. Axillry bscess.? Hindu, cct. 14?. 15 dys durtion, opened nd drined ntisepticlly ; heling delyed by n enlrged glnd. Dischrged quite recovered in drined. Anor ilic bscess existed on left side. Getting high fever nd suffering from dysentery. Both bscesses lid open below Pouprt's ligment. Dischrged well in 31 dys. i Eursin child, it. 4. Right ilic bscess opened beneth Pouprt's ligment. Removed convlescent five dys fterwrds. Hindu, ct. 5. Left ilic bscess of 5 dys' durtion, result of fll, opened ntisepticlly below Pouprt's ligment, heled in 16 dys. Abscess of Mhomedn mle, it. 16. ilic foss nd right thigh (periostel) Both opened on sme result of fever. dy by Hilton's method under ntiseptic precutions. The ilic bscess heled in 10, nd thigh bscess in 28 dys. %* The dvntges of opening se bscesses below Pouprt's ligments re: (1) tht bdominl wll is not wekened; nd (2) tht dringe is more thorough, nd repir more rpid. The spot t which opeuing is mde is hlf-wy between rtery ud nterior superior spinous process of ileum. The skin, superficil nd deep fsci re divided by short longitudinl (verticl) incision. A director finds its wy very esily long under surfce of ilic fsci. The opening is enlrged by forceps ud good-sized dringe tube inserted. Repir tkes plce in 10 to 15 dys. bscess.?this cse hs been le. Pelvic redy described under hed of rdicl cure of umbilicl herni (IX 5). The collection situted in right brod ligment of uterus, nd evcuted by spirtion in first instnce, nd n by incision bove pubes nd dringe. d. Glutel bscess.?i. Est Indin child, it. 4. Deep bscess of right glutel region of 10 dys' durtion, opened ntisepticlly by Hilton's pln. Heled iu 12 dys, ii. Europen mle, ct. 30. Five weeks go he jumped into wter. This followed by fever nd pin over left buttock, which becme prominent few dys go. A lrge nd deep bscess opened, nd portion of ileum found to be bre. A sinus resulted opposite brebone which continued to dischrge fter He d bscess cvity hd filled up. vised to return to Scotlnd, nd left hospitl 63 vi. right dys fter opertion. Est Indin child nine fll dys go, resulting in ct. 9. Sustined of left thigh. An bscess swelling pinful detected beneth qudriceps muscle, nd by Hilton's pln. It opened ntisepticlly heled completely in 19 dys. ii. Hindu mle, t. 20. Admitted for cute e. Thigh bscesses.?i.

7 240 of right knee-joint. A lrge collection of pus detected in lower prt of thigh 13 dys fter dmission. It opened ntisepticlly, nd heled in two months. The joint underwent simultneous recovery. iiij i There were two cses of children dmitted with sinus of leg leding to brebone, bscess of thigh nd disesed knee-joint; bscess opened nd sinus drined. One child removed before recovery complete, or got fever of hectic type, nd died of convulsions. Hindu, cet. 25. Lrge nd deep bscess of thigh of 15 dys' durtion, resulting from fever, opened ntisepticlly ; heled in 19 dys. *#* These bscesses were opened nd subsequently dressed, under irrigtion, by bichloride lotion. In no cse did putrefction occur. Severl of cses illustrte dvntge of opening periostel bscesses erly ; nd few of m indicte trouble which is pt to rise if this is not done ;? periosteum is destroyed, osteitis ensues, nd necrosis vrying in depth ccording to severity nd extent of osteitis is consequence. This is often ssocited with sclerosis or ltter occurs lone. In eir cnse very protrcted nd intrctble sinus results. {To be concluded.) synovitis [Aog, 1887.