healthy color. The most curious thing, however, was that not only had the saucer-like depression over the seat of the abscess vanished, but the cavity itself seemed to have become filled up with liver tissue! At least, the sensation yielded to the hand in that situation in no way differed from that communicated to it by any other part of the liver. The discharge, too, was now so slight that the boracic solution returned quite clear.

Having to start next day for China, I handed the case over to the care of Dr. Cullimore, and from this point the notes are taken from my father's case-book.

August 4th.-Although it is only the twelfth day since the operation the patient is so well that he returns to the country along with Dr. McEnery to-day. A probe now merely penetrates about half an inch into the liver, if it even does so much as that, for the thickness of the abdominal parietes being in this case an unknown quantity it is impossible to say exactly how far the probe enters the liver substance.

On August 17th the patient came to town looking perfectly well. He says that he eats with a good appetite, has gained a stone in weight, and feels himself every day getting stronger. There is only a drop of discharge from each of the wounds, and that probably comes from the abdominal walls, and not from the liver at all.

September 29th.-The liver is quite normal in size. He has no pain or discomfort whatever, even when he walks, rides, or drives. So he may be said to be perfectly well.

P. S.-April 25th, 1889. Have to-day heard that he is well and strong; stronger, indeed, and in better health than he has ever felt before. The last news I have of him (July 15th) is that he is engaged to be married.

Case 2 is one of another kind, being one of multiple abscess in a strumous patient aged 17. The lad, who is the son of a Lincolnshire farmer, is described as having been suddenly seized with a pain in his liver, associated with sickness and shivering, in June, 1888. On September 3d, after walking twelve miles with a drove of cattle, he felt so ill that he had to be brought home in a carriage and placed under the care of Mr. Heaven, of Colsterworth. The following history of the patient I abridge from Dr. Cooper Key's notes of the case: On September 18th "I saw him in consultation. He was very pale, with a small, weak, and

with Mr. Heaven.

frequent pulse. His temperature was 102°. Tongue coated; bowels irregular, with occasional attacks of diarrhoea and a good deal of pain over the hepatic region. In addition, there was a considerable amount of fluid in the cavity of the peritoneum, and a slight bruit over the left base of the heart."

The patient was subsequently seen by Mr. Newman, of Stamford, who, suspecting hepatic abscess, explored the liver in two places, but found no pus. Early in November the symptoms being urgent, he was sent to London to consult Dr. George Harley. On November 19th, the patient being placed under the influence of A. C. E. mixture, Dr. George Harley, assisted by Mr. Heaven and myself,

Fig. 2.-The dark area represents the extent of liver dullness, from the nipple to two inches below the umbilicus, and four to the left of the mesial line. The dots indicate the points at which the exploring trocar was introduced; a is the seat of the first abscess, evacuated November 25th; b the seat of the second abscess, emptied November 28th.

proceeded to operate, making eight punctures into the liver with his long trocar without obtaining pus. The liver being exceedingly large, measuring four inches to the left of the mesial line, and two beneath the umbilicus, phlebotomy was attempted, but only a very little blood was obtained. During the night, however, profuse

hemorrhage took place through the bile-ducts into the intestines, and at 1 o'clock in the morning I found the patient in a state of collapse. In two hours (after the administration of brandy) he rallied, and, somewhat to our surprise, the bleeding was followed by the most satisfactory results, as within thirty-six hours the liver's dullness had diminished an inch and a half all round.

On November 25th appeared a circumscribed swelling two inches above and slightly to the right of the umbilicus, with a feeling of deep fluctuation; and Dr. George Harley explored it, and was successful in hitting the abscess. It contained very viscid pus. A short length of a silk elastic catheter was then placed in the cyst, and it was washed out twice daily with a 10 grains to the ounce solution of boracic acid. The temperature was 103°, and pulse 120. During the next few days the pus became very offensive, and carbolized tow was placed over the poultice to catch the discharge, which was very profuse.

On November 28th a second abscess appeared in the right lumbar region on a level with the umbilicus. This was opened and found to communicate with the other. A drainage-tube was passed into it, and the boracic acid solution used twice daily to it also. The temperature was now 101°, the pulse 112, and the discharge thin and less fœtid.

November 30th.-Temperature 100°, pulse 108.

December 1st.-A slight rigor. Temperature 101°, pulse 102. December 3d.-Temperature fell to 100°, pulse 100. December 21st.-Temperature 98°, pulse 80. discharge.

No longer any

January 2d, 1889, that is to say, on the 28th day after the first abscess was opened, the patient returned to his home in Lincolnshire, a distance of 120 miles, without a single bad symptom.

In a letter from Mr. Heaven, dated may 12th, he says: "G. is gaining flesh and strength rapidly, and going about as usual. There is no pain or tenderness about the liver, except a little on pressure over the seat of the abscesses."

Not only do I consider the rapidity of the recovery in this case remarkable, but that any recovery should have taken place at all, in such a weakly constitutional strumous patient, seems to me surprising; all the more so when I mention that so great is the tendency to suppurations in the lad that Mr. Heaven says, in a letter

dated August 1st, that he had a few days before drawn "off a large saucerful of thick pus" from his left side-the exact seat of the suppuration not being specified.

When all the foregoing facts are taken into consideration, I scarcely think that anyone who has had much experience in treating abscesses of the liver can fail to be struck with the satisfactory results in the above cited cases, as two more unfavorable ones for any line of treatment whatever it would be difficult to find. It is, indeed, on this very account they were selected to illustrate the advantage of treating liver suppurations in the manner I have described, and which may be briefly summed up in the three following sentences: First, by the employment of boracic acid we have not only the assistance of a thoroughly safe antiseptic agent, but the great advantage which accrues from the use of one free from the objection of coagulating the albuminoids in the pus, and thereby inducing a fouling of the instruments, such as is unfortunately the case with carbolic acid and most other antiseptic preparations. Secondly, the daily washing out of the abscess with boracic acid solution not only expedites the healing process by keeping it clean, but has the further advantage of rendering it quite unnecessary to take any precautions against the intrusion of air into the cavity, no matter how large it is. Thirdly, the washing out of the abscess with boracic acid solution, from its enabling us to get rid of all the purulent matter, thick as well as thin, does entirely away with the necessity of making a large opening either in the abdominal walls or liver tissues with a knife or other instrument—a point of no mean moment, seeing that it is a well recognized axiom that the smaller the breach of coutinuity in any animal tissue, no matter whether it has been made accidentally or intentionally (other things being equal), proportionally quicker is the healing process.

Dr. George Harley, in reply to the question of the danger from hemorrhages arising after exploring the liver, said that no doubt there did exist danger, but only when the explorations were improperly performed; for, as he had explained at the meeting at Brighton, when Professor Boyes Smith related his case of hemor rhage into the abdominal cavity after exploring the liver for abscess the danger only arose when the instrument was thrust into the liver at a point of the organ where pressure could not be applied by bandaging the abdominal walls sufficiently tightly to make them

close up the opening of the puncture into the liver. He need not repeat his remarks on the subject, as the whole matter had been fully gone into in a paper published in the Journal in reply to Dr. Boyes Smith's criticisms upon his paper on Hepatic Phlebotomy, read at the Brighton meeting.-British Medical Journal.

TREATMENT OF MEDICAL EMERGENCIES-SYNCOPEAPOPLECTIC SEIZURE-CONVULSIONS-LUNG HÆMORRHAGE—NASAL HÆMORRHAGE-GASTRIC AND

INTESTINAL HÆMORRHAGE—ASPHYXIA.

By JAMES TYSON, M.D., Professor of Clinical Medicine, University Pennsylvania, Visiting Physician to the Hospital, etc.

The surgical emergency has been the subject of numerous addresses and papers, but the medical emergency has rarely, if ever, received systematic consideration. Yet the instances in which it demands treatment are scarcely less numerous than in the case of the former. By medical emergencies I mean (1) syncope or fainting, (2) the apoplectic seizure, (3) the convulsion, whether caused by epilepsy, Bright's disease, peripheral irritation, or hysteria; (4) the lung hemorrhage, (5) the nasal hemorrhage, (6) the gastric and intestinal hemorrhage, and, (7) asphyxia or suffocation.

Beginning with the simplest of these emergencies, the fainting fit, it may be defined as a state of sudden unconsciousness, accompanied by extreme feebleness in the heart's action. It is the result of some profound impressions upon the heart, either directly or through the nervous system. The former has its illustration in the effects of embarrassment of the heart's action from diseased muscle or valves, and is by far the most serious form of syncope. Similar is the effect, too, in certain drugs, as aconite. The latter, or indirect (through nervous influence), is seen in the effect of fright, extreme pain, fatigue or mental emotion, excited in various ways, as by the sight of blood during an operation, or by witnessing suffering in another; excessive heat operates similarly to produce fainting. As an intermediate cause, operating either directly on the heart or through the nervous system, or both, is hemorrhage.