massive antiseptic dressing is applied and firmly secured by a broad binder or many-tailed bandage.
If, after division of the abdominal wall, no reliable adhesions be discovered between this and the liver, the capsule of the latter must be securely attached to the former by a double circle of stitches. The abscess is then to be opened, as above described, with sinus forceps. After stitching, some surgeons prefer, before opening the abscess, first to stuff the wound in the abdominal wall with iodoform gauze, and to wait for a day or two for adhesions to form. Others stuff the wound with gauze without previous stitching.
Should the abscess be struck through an inter-costal space, and if the latter be not deemed sufficiently wide to admit of manipulation and free drainage, a couple of inches of rib had better be excised. The diaphragm may then be stitched to the thoracic wall or, better, to the skin as well, when the abscess may be opened with forceps. To stitch the capsule of the liver to the diaphragm is a somewhat difficult proceeding; but if there are no reliable adhesions it had better be attempted, especially if the opening is to be made through a part of the liver covered by the peritoneum. If by any chance the pleura is opened during the operation, pneumothorax will result— an unfortunate but not necessarily a serious contingency. In this case the hole in the pleura must be carefully stitched in such a way that the pleural cavity is completely cut off before the diaphragm is divided and the abscess opened. Pus must not on any account be allowed to enter the pleural cavity; this, owing to the aspirating influence of inspiration, it would readily do if the smallest hole should remain patent. The young surgeon would do well to practise these operations on the dead body, and familiarize himself with the relations of the various structures involved.
Some operators of experience completely ignore the absence of peritoneal adhesions, and, even in these circumstances, open the abscess without previous stitching of peritoneal surfaces. The risk and danger of escape of pus into the peritoneal cavity,
