effected either in the dilated cutaneous capillaries or after extravasation of blood into the tissues. The last three groups all presuppose increased destruction of red corpuscles, and with a view to elucidate this question Knoepfelmacher has investigated the blood of infants during the first seven days of life in three directions-the number of red corpuscles, their resistance to sodium chloride solutions, and their histological character. The research was carried out upon twelve children, all of whom developed a greater or less degree of jaundice. The cord was tied as soon as it ceased to pulsate, the first estimation was made as soon after birth. as possible, and the succeeding ones at the same time on the following days. The resistance was measured by the strength of sodium chloride. solution required to break up the red corpuscles within a given time. The author finds that the number of red corpuscles either falls steadily from birth, or else rises a little immediately after birth and then falls again; these changes are, as regards the corpuscles, only apparent, being really due to alterations in the volume of the plasma. They also bear absolutely no relation to the development or disappearance of jaundice. The resisting power of the red corpuscles is found to be the same at birth as in adult life, nor is it increased in icterus neonatorum, although Von Limbeck has shown it to be much above the normal in the jaundice of adults. The most intense jaundice during the first week of life does not affect the resisting power. Histologically Knoepfelmacher was able to detect considerable variation in the size of the erythrocytes, some of which were pale throughout, and others pale in the center; deformed and "shadow" corpuscles were absent. There was hence evidence of rapid production of red corpuscles without any indication of increased destruction. The author hence concludes that the red blood corpuscles play no part in the etiology of icterus neonatorum.-Ibid.

EFFECT OF DIPHTHERIA ANTITOXIN ON THE KIDNEY.-Siegert (Virchow's Archiv, November, 1896,) records some clinical and experimental observations upon the effect of the subcutaneous injection of Behring's diphtheria antitoxin on the kidney. He finds that after the injections there occurs generally a slight transitory albuminuria and albumosuria; this was found, not only in patients already suffering from diphtheria, but also in healthy children in whom the antitoxin was injected as a prophylactic measure. In animals the injection produced similar change in the urine and also a diminution in its quantity and specific gravity. It was suggested that the albuminuria was due to the small amount of carbolic acid in the serum, but this was easily disproved. In some cases acute parenchymatous and hemorrhagic nephritis occurred in patients treated with the serum, but there was no evidence that this occurred unless some change had taken place in the serum used. Occasionally anuria occurred after the injection, and the same phenomenon was observed in animals. If albuminuria be already present in a case of diphtheria the injection of

antitoxin generally causes the albuminura to disappear without evil consequences. That the alterations in the urine are generally due to mere functional disturbance in the kidney seems to be shown by the fact that even with 10 c. cm. of Behring's serum no organic lesion of the kidney could be produced in a rabbit. Siegert concludes that if it can be shown that antitoxin is a specific against diphtheria the usually slight disturbance of the function of the kidney can not be urged against its use.-Ibid.

PERFECTED X-RAYS.-A sixteen-inch spark in a twenty-inch tube, giving an intensity two hundred per cent greater than that possible with the four-inch spark in a twelve-inch tube, formerly used, is said to do the work in thirty seconds and do away with the long exposures.

Special Notices.

A PHYSICIAN AND HIS PATIENT IMPOSED UPON BY A Druggist's SUBSTITUTION.— I gave Sanmetto to Mrs. H., aged twenty-eight years, for frequent micturition and tenderness in region of kidneys. Patient was compelled to rise four or five times during the night, passing nearly a half gallon of urine during this time. After using a bottle of Sanmetto she was greatly relieved, but instead of getting more Sanmetto, as I directed, patient was induced by her druggist to get a preparation of palmetto ; this had no appreciable effect whatever. Patient is now using Sanmetto, and is not likely to be imposed upon again.

W. OCELLUS HARTSHORNE, M. D., Cross, Okla. T.

I HAVE used Celerina quite largely both in private and hospital practice, and with gratifying results. It is void of repugnant taste and is readily retained by the stomach. My experience with Celerina has been confined chiefly to its use in nervous diseases, particularly loss of nerve power and the opium habit, in which conditions it has served me well, and I shall continue to prescribe it both in private and hospital practice. W. IRVING HYslop, M. D., 4408 Chestnut St., West Philadelphia, Pa.

We call the attention of our readers to the advertisement of the Robinson-Pettet Co., Louisville, Ky., which will be found on another page of this issue. This house was established fifty years ago, and enjoys a widespread reputation as manufacturers of high character. We do not hesitate to indorse their preparations as being all they

claim for them.

LABOR SAVING: The American Medical Publishers' Association is prepared to furnish carefully revised lists, set by the Mergenthaler Linotype Machine, as follows: List No. I contains the name and address of all reputable advertisers in the United States who use medical and pharmaceutical publications, including many new customers just entering the field. In book form, 50 cents.

List No. 2 contains the address of all publications devoted to Medicine, Surgery, Pharmacy, Microscopy, and allied sciences, throughout the United States and Canada, revised and corrected to date. Price, $1.25 per dozen gummed sheets.

List No. 2 is furnished in gummed sheets, for use on your mailer, and will be found a great convenience in sending out reprints and exchanges. If you do not use a mailing machine, these lists can readily be cut apart and applied as quickly as postage stamps, insuring accuracy in delivery and saving your office help valuable time.

These lists are furnished free of charge to members of the Association. Address CHARLES WOOD FASSETT, Secretary, cor. Sixth and Charles streets, St. Joseph, Mo.

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than any thing else.-RUSKIN.

Original Articles.

ABSCESS OF THE LIVER.*

BY JOHN G. CECIL, A. M., M. D.

Professor of the Principles and Practice of Medicine in the Louisville Medical College.

Suppurative inflammations of the liver are divided into two classes, the solitary or tropical abscess, and the septic or pyemic abscesses. This division is convenient; it also has an etiological basis in the character of the micro-organisms which produce these abscesses. The solitary abscess in hot climates commonly follows dysentery, and is doubtless caused by the ameba coli. The septic and pyemic abscesses, whether associated with traumatism, embolism, suppurative. cholangitis, foreign bodies or parasites, are caused by the various forms of pyogenic cocci.

The relation existing between the solitary or tropical abscess and amebic dysentery, as demonstrated by the investigations of Kartulis, Councilman, Lafleur, Dock, and others, is most convincing. By these observers it is proven that the solitary abscess and amebic dysentery are due to the ameba coli; the relation ordinarily existing between them is that the dysentery precedes the abscess, in other instances they coexist, in still others the patient may have ameba in the actions, decided symptoms of liver abscess without symptoms of dysentery, the feces being well formed.

The mode of ingress into the liver is yet undecided, the most probable channel being through the portal circulation, though in

* Read before the Louisville Medico-Chirurgical Society, April 25, 1897. For discussion see page 303.

other instances it is not improbable that the entrances are by way of the bile ducts. In this variety the abscess cavity is usually single; there may, however, be two or more large cavities. In about 70 per cent the abscess occupies the right lobe and is situated more toward the upper surface of the liver. In chronic cases there is frequently a well-defined limiting membrane; in others the abscess wall is made up of necrotic liver tissue. "The pus is often reddish-brown in color, closely resembling anchovy sauce." (Osler.)

The septic or pyemic abscesses of the liver are always multiple. Many small cavities may, however, break into each other, forming one large collection of pus. The micro-organisms reach the liver by means of the hepatic artery, the lymphatics, or the portal vein. Unless induced by direct injury or foreign bodies and parasites, they are always secondary to inflammatory process in some other part of the body, this process being most often within the limits of the portal circulation.

Antedating pyemic abscesses we have dysentery, other ulcerations of the bowels, hemorrhoids, strictures, appendiceal inflammations, pelvic abscesses, rarely after typhoid fever; suppurative cholangitis, caused by gall-stones and parasites. It is well to remember that injuries to the head and bone diseases are occasionally followed by liver abscess. The infective agents sometimes reach the liver after passing through the respiratory capillaries without producing pulmonary abscess; the more sluggish circulation through the portal system favoring the arrest of these germs is the probable explanation of this. The suppuration is generally within the branches of the portal veina suppurative pylephlebitis. The liver is uniformly enlarged, the surface may be smooth and normal in appearance, or yellowish points of suppuration may be visible. "These abscesses are either round in outline or distinctly dendritic, having the appearance of small isolated abscesses; but on closer examination they are found to communicate with the portal vein and to represent its branches, distended and suppurating."

Symptoms and Diagnosis. When it is remembered that the liver and the regions and organs in its immediate vicinity are the seat of so many obscure affections, it is not surprising that the diagnosis of liver abscess should be beset with manifold obstacles. Not rarely does it happen that the disease runs a latent course, to be discovered by post-mortem examination, or by rupture into adjacent cavities.

Of the ordinary symptoms, pain in the region of the liver is one of the most constant. This, however, is extremely variable. When the abscess is deep-seated, the liver being a rather insensitive organ, pain is either entirely absent or amounts only to a sense of uneasiness and heaviness. When the abscess reaches the investing capsule the pain becomes both constant and great; if located toward the convex surface the pain is referred to the back and right shoulder; when on the under surface the pain is deflected downward, and the gastric symptoms are more exaggerated. Jaundice is another uncertain sign. Cases resulting from suppurative cholangitis, with obstruction to the common bile ducts, generally have pronounced jaundice, with fecal discharges showing absence of bile. In by far the greater proportion of cases there is not distinct jaundice, the skin showing an icteroid tint, the complexion being muddy or dirty-looking. When abscesses have attained any considerable size, the right side will be enlarged and the area of liver dullness increased. Should the abscess grow downward, fluctuation may be found; this, however, is not available in many cases. Recalling the fact established by the statistics of Waring, Murchison, and others, that the majority of hepatic abscesses are located in the right lobe, posteriorly and near the upper surface, we may look for the increase in area of liver dullness to be upward. Nausea, loss of appetite, vomiting, and progressive emaciation are quite constant and confirmatory symptoms. Tenderness upon pressure over the liver and a board-like resistance in the abdominal muscles, especially the rectus, as it is found in appendicitis, are corroborative signs. A dry, hacking cough and dyspnea are frequent symptoms, particularly when the pressure is upward on the diaphragm. There is always more or less febrile action, chills followed by fever and sweats, frequently assuming a distinctly periodical intermission or remission closely resembling malarial fevers. Ascites, enlargement of the superficial veins, and edema of the lower extremities seldom occur in connection with hepatic abscess, differing in this respect from many other diseases of the liver. It is said that persons suffering from dysentery and abscess of the liver can not take the classic ipecac treatment for the former. It must not be forgotten that the aspirator may be used in any case to clear up a doubt. If used at all it should be used boldly, fearlessly. It does not add materially to the danger. The patient should be anesthetized, the needle large, and the punctures deep and in different directions until the pus is located.