With these general remarks I shall now describe what seems to me to be the most satisfactory mode of operative procedure in cases of hepatic abscess.

So soon as the presence of pus is suspected, its exact situation should be prospected in the following manner: A 6-inch long fine exploring trocar is to be passed up to its hilt obliquely from right to left into the liver, or from left to right, according to which lobe the abscess is supposed to occupy. The pus is then searched for by slowly and gradually withdrawing the instrument so as to allow sufficient time for a drop to appear at its orifice. If pus be found, both its situation and depth in the organ is to be carefully noted. Should blood instead of pus flow from the trocar, the bleeding ought to be encouraged; for in all cases of suspected hepatic abscess the liver tissues are more or less congested, and marked benefit is likely to arise from a free hepatic phlebotomy. The presence of pus having been substantiated before withdrawing the exploring cannula, allow as much as possible to flow from it. As pus, especially thick pus like that usually met with in the liver, does not flow readily through a fine cannula, immediately on its ceasing to flow withdraw the exploring trocar, and introduce, in exactly the same direction and to precisely the same depth, one of the diameter of a No. 8 or 10 sized English catheter, and through it empty the abscess completely by aid of an aspirator. As soon as the cavity is empty, before withdrawing the cannula, wash it out with tepid water, containing 10 grains of boracic acid to the ounce, and continue the washing-out process until the solution returns clear and odorless. Immediately after this insert as large a sized silk elastic cather as will pass through the cannula into the abscess cavity. Now withdraw the cannula, and after having cut off the extruding end of the catheter to within an inch and a half of the opening in the abdominal wall securely fasten it there.

This done, cover the whole over with a large, hot, sloppy linseed poultice. The abscess cavity should be washed out with boracic acid solution night and morning, and poultices constantly applied until the purulent discharge almost entirely ceases. If, however, as occasionally happens, the cavity rapidly refills with pus, another opening is to be made a short distance from the first, and a second drainage-tube introduced into the abscess cavity. This counter

opening, by faciltating the washing-out process, greatly expedites

the cure.

While in Hong Kong I noticed that Dr. Patrick Manson, instead of daily washing out hepatic abscesses with an antiseptic solution, relied for the complete emptying of their cavities on the employment of a yard or more long syphon drainage-tube. This I need not describe, as he is about to publish his mode of treating liver suppurations. The advantages of the mode of treating abscess of the liver now being advocated will be best appreciated, I think, by the narration of its results in two of the most unfavorable cases that it is possible for me to give.

The first case is one in which the patient very nearly died from the effects of blood-poisoning, arising from the absorption into the circulation of toxic matters from the putrid pus in the abscess. The second is one of "multiple abscess," occurring in the greatly enlarged liver of a strumous patient. Both cases, notwithstanding their exceedingly unfavorable nature, as will be seen, made rapid recoveries under the line of treatment just described.

Case 1 was that of a gentleman of delicate constitution, aged 29, who up to the age of 20 repeatedly suffered from occasional attacks of congestion of the liver, as well as from diarrhoea. He had a particularly severe attack of hepatitis while a student at Oxford in 1880-'81, and in 1883 had an empyema of the right side, and, not regaining his strength after it was evacuated, he was sent on a long sea-voyage.

The suppuration of the liver, about which I have now to speak, seems to have begun in the latter part of 1887 and beginning of 1888, while he was residing at Cannes. From notes of his case, kindly furnished to me by Dr. Clemow, it appears he had pleurisy of the right lung associated with the liver disease. In February, 1888, he had three distinct rigors; and Drs. Frank and Clemow, suspecting liver abscess, explored the organ in three places on the 19th of that month, but found no pus. That same night the patient had another very severe rigor, and, as the symptoms did not improve, and still pointed to hepatic suppuration, they again explored with a larger aspirating needle on March 10th, but again with a negative result; so they deemed it advisable to practise hepatic phlebotomy, and drew off between four and five ounces of dark venous blood. This bleeding, small though it was, acted most

advantageously, for after it the symptoms rapidly improved, the temperature becoming and remaining normal, the liver dullness diminishing, and the patient gaining flesh.

In the month of June, after his return to England, the patient again became very ill, complaining of constant hepatic pain, shortness of breath, loss of strength, and exhausting feverishness.

On July 18th Dr. McEnery, of Sherborne, brought him to London, and consulted Sir Andrew Clark and Dr. George Harley. The former, after carefully examining the lungs, pronounced them comparatively healthy; the latter found the liver diseased, its left lobe being not only enlarged and indurated, but conveying to the hand the feeling as if it contained a deeply seated tumor.

At this time the patient was exceedingly weak, both in body and mind; his intellect, indeed, was so perturbed and his memory so defective that he could give no intelligible account either of his past history or present symptoms. He had even forgotten the

names of his doctors, or that he had ever had either shiverings or sweatings; notwithstanding that both had been very marked. The cause of this great mental confusion was afterwards found to be due to the toxic effects on the brain of blood-poisoning.

The result of the consultation having led to the conclusion that the tumor in the left lobe of the liver was probably an abscess, it was aaranged that an exploration should be had recourse to. Accordingly, on July 23d, Dr. George Harley, in the presence of Dr. McEnery and myself, performed the operation. The patient's temperature at the time was 102° F., his pulse 108, and he had profuse sweatings, without, however, any diarrhoea. His face was of a cachectic yellowish livid color, and wore a most anxious expression. The liver dullness reached, as shown in diagram (Fig. 1) from the right nipple to the navel, and projected at least two inches and a half to the left of the mesial line.

The effect of the poultices, which had been assiduously applied since the consultation on the 18th, had proved most favorable, for now there appeared to be an indistinct fluctuating area surrounded by a hard rim about one inch and a half directly above the navel (Fig. 1, a).

On a large-sized aspirating needle being introduced into the centre of this doubtfully fluctuating area, a quantity of extremely fætid, blood-stained, putrid pus made its appearance. So offensive

was its odor that not only was it almost intolerable to us three med. ical men, but even the patient, ill though he was, held his own nose, a very unusual thing, as Dr. George Harley remarked, seeing that people can in general tolerate the bad smells emanating from their own bodies much better than anyone else. Even the silver cannula, although it was not twenty minutes in the abscess cavity, was rendered jet black by the sulphuretted hydrogen the pus contained.

Fig. 1.-The dark area denotes the liver dullness extending from the nipple to the umbilicus, and three inches to the left of the mesial line; a is the point at which pus was suspected, and afterwards ascertained to exist, and through which it was subsequently evacuated with a trocar.

After about 18 ounces of pus had been removed, the abscess cavity, appearing to be pretty well emptied, was washed out with a tepid water solution of 10 grains of boracic acid to the ounce until the solution returned clear and almost odorless.

A drainage-tube was then inserted into the cavity, which measured in a direct line backwards 5 inches in depth, and a hot poultice applied. It was noticed that immediately after the abscess was emptied the abdominal walls receded, and left a saucer-shaped depression round the seat of the wound. The pus, on standing,

ABSCESS OF THE LIVER -TREATMENT.

11

separated into three distinct layers: an upper one of a dirty yellow color, a middle one of a pale green tint, and a lower stratum of a decidedly pink hue. Under the microscope, besides pus and blood cells, I found a great many large exudation corpuscles.

By the following morning a marked improvement had taken place in the condition of the patient. The pulse, instead of being 108, was only 99, and his temperature had fallen two degrees, that is to say, to 100°. The discharge was, however, still very fœtid, so that the cavity had not only to be washed out night and morning with boracic acid solution, but an antiseptic mixture of sulphate of iron and quinine given to the patient.

The next day a still more decided change for the better was observed, his temperature being only 99°, although the pulse remained about the same, namely, 99 per minute. On the fourth day, in spite of the drainage-tube acting well, the abscess cavity had refilled with putrid pus; so Dr. George Harley made a second opening with a No. 10 sized trocar, about two inches from the first, and introduced another drainage-tube into it. These two openings enabled the cavity to be thoroughly washed out; for, while the boracic acid solution was pumped in at one, it flowed freely out by the other opening. From the second being also a somewhat larger drainage-tube than the first, it more readily permitted the numerous small blood-clots and pus-flakes to come away. On the fifth day the temperature was normal and the appearance of the patient greatly improved. The exhausting sweatings had ceased. The pus, though now thin and only slightly fœtid, was still so copiously discharged that the poultices were discontinued and absorbing wool used in their stead.

On the 29th, that is to say, six days after the first operation, the discharge ceased to be fœtid, and the abscess cavity was so greatly diminished in size as only to admit the probe one inch and a half, the patient being, at the same time, able to leave his bed and recline on the sofa. The following day he was well enough to get up to breakfast and to eat with an appetite a couple of eggs along with bread and butter. He said he now tasted the flavor of his food, everything previously having tasted as if it was fœtid. Moreover, the confusion of ideas no longer existed, and he had regained his memory. The appearance of his face, too, was entirely changed; the cachectic hue had disappeared, and was replaced by a