There is some pain,

occurs in ninety per cent. of all the cases. some tenderness on pressure. You may be able, in some cases, to detect fluctuation by palpation. It is exceedingly difficult to recognize with certainty deep-seated fluctuation in the liver. Nearly always, where I have attempted to determine precisely the presence or absence of pus, I have been deceived with regard to fluctuation, and have reached the conclusion that a patient may have a quart of pus in his liver and we may not get fluctuation. On the other hand, a patient may have no pus and we get fluctuation with excellent satisfaction. I knew of a physician who submitted himself for examination to other physicians, after the diagnosis had already been made, and asked them if he did not have hepatic abscess; and those physicians, after a short consultation, came to the conclusion that there was no trace of the existence of hepatic abscess, and yet within forty-eight hours an enormous abscess opened into the bronchial tubes, and the patient died. Exhaustion occurs early, and is a prominent and characteristic symptom in these cases. In the process of exulceration, the patient may experience a sudden stitch in the side, associated with a dry, hacking cough. In obscure cases, when suppuration is suspected, and the stitch in the side makes its appearance, it is a sort of warning to the physician that pus exists, and that it is gradually burrowing its way onward, and has already caused diaphragmatic pleurisy; and later along, as the disease extends, escape of pus into the peritoneal cavity, pleural cavity, or bronchial tubes may take place.

A case of abscess of the liver recently came under my observation, in which I was called to examine the patient for diagnosis, and on reaching the residence of the patient I was informed that some of the most eminent physicians of the city of Chicago had examined him. After examining the case myself, I came to the conclusion that the patient had some malignant disease, the nature of which could only be ascertained after a thoroughly protracted examination, if then; and on making this frank acknowledgment, I received information to the effect that the other physicians had reached precisely the same conclusion. Some attempted to locate the trouble in the pancreas, but the general trend of opinion was that the patient had a malignant disease which could not be definitely located. There was one physician among the many, however, who suggested abscess of the liver, and in the course of a week or so the patient passed a quart of pus from his bowels, the abscess,

in other words, having opened into the intestinal canal. The patient died. Post-mortem examination revealed an enormous abscess of the liver. You can readily understand how errors in diagnosis may occur when you consider the symptomatology of the chronic form of this disease. So far as my own knowledge goes, chronic hepatic abscesses are more common than those of an acute character.

To recapitulate: The skin in this disease is muddy, rarely jaundiced; the expression of the patient is melancholic; there is anorexia and vomiting; the bowels are constipated; the tongue quoted; urine high colored; there may or may not be pain; there is usually a low, irregular type of fever, in which the pulse rarely exceeds one hundred beats in the minute; the temperature may not exceed 100°. There is general impairment

of health, progressive emaciation, some degree of exhaustion, and when the disease has pursued a somewhat indefinite course -a course such as I have mapped out-the patient may be seized with a stitch in the side, accompanied with more or less cough; he may suddenly be thrown into a condition of violent shock from rupture of the abscess into the peritoneal cavity, or the abscess may break externally between the ribs; this, however does not very commonly occur. Sudden death may occur under circumstances where such a termination had not been suspected, resulting from the breaking down of the abscess and exulceration of the pus. Cases of abscess of the liver occur sometimes in which there are few symptoms of any kind to direct the attention of even the most observant physician to the condition of the liver.

Professor Hammond directed the attention of the profession very prominently to obscure cases of this kind, and adopted, I believe, a rule in practice, which I have imitated somewhat myself. It is to this effect: That when a patient is found to be running down in health; if there be progressive emaciation; a low grade of fever that cannot be explained by the discovery of the local lesion somewhere; if the patient be melancholic in disposition, the melancholia be associated with symptoms of pain and discomfort, attention should be turned in the direction of the liver. I believe in resorting to aspiration in all obscure cases for purely diagnostic purposes, informing my patients that aspiration is not, strictly speaking, an operation at all, but a method pursued for the express purpose of finding out, if possible, what is the matter with him.

The prognosis in cases of hepatic abscess is, as a rule, grave.

The mortality ranges from seventy-five to ninety per cent. of all the cases that have been recorded; but happily this rate has been very much lessened by resorting to aspiration in dubious cases. The duration of abscess of the liver varies from two weeks to six months, the termination depending somewhat upon the course the abscess pursues. If the abscess bursts upwards into the lungs, it may be regarded as a most favorable indication for recovery of the patient, for fifty per cent. of all the cases that result in exulceration of the pus in this direction terminate in recovery.

TRANSLATIONS.

FRENCH LITERATURE.

SELECT EXCERPTA.

TRANSLATED BY C. J. MINER, ANN ARBOR, MICHIGAN.

PHYSIOLOGICAL ALBUMINURIA.

The question of so-called physiological albuminuria has in the last few years seriously occupied the attention of pathologists. It was quite generally admitted, not long since, that in case the presence of albumen in the urine were positively made out, the prognosis should be adverse, whatever be the apparent state of health of the patient. New researches have meantime contributed to soften the rigor of this prognosis, and it has been established that there are cases characterized by a transitory albuminuria, acute or accidental, without fixed duration, disappearing sometimes at the end of some months, sometimes at the end of years, and very often intermittent in their course. Pushing further their conclusions, certain authors, of high authority withal, have even affirmed that many cases of albuminuria have shown themselves in healthy persons, indicating absolutely no danger; that the albuminuria was purely physiological, and therefore of no account.

To what extent are these optimistic views justified by the facts? We will not undertake to discuss this. In an article in the Revue de Medecine, of last April, Dr. Dubreuille, of Bordeaux, leaving aside the cases where the amount of albumin was really infinitesimal, studied those where an albuminuria existed, clearly appreciable by heat and nitric acid, and particularly the cases of intermittent albuminuria. He distinguished three groups of cases, three types of albuminuria, in persons in good

health: transitory albuminuria, acute or accidental; chronic albuminuria without clear periodicity; and, periodically intermittent albuminuria. To these three types of cases he applied the name "essential albuminure," and admitted that, though the subjects were not ill in the ordinary sense of the word, they were nearly all in delicate health; some presented the characteristics of the lymphatic temperament, but more often they were nervous or bilious; they also presented digestive troubles.

It would seem evident from what precedes, that, though these subjects were free from any clearly characterized affection, there was a predisposition, of which it is impossible not to take account. Then what would be the prognosis? "In general," says Dr. Dubreuille, "the prognosis has no other gravity than that of the concomitant symptoms, which may be troublesome enough; but there remains a black point on the horizon. The albuminuria may indicate a feebleness of the kidney, which cannot resist the slightest of the causes of nephritis. The experiments of Semmola seem to show that the secretion of albumen itself is a sufficient source of irritation to the kidney to cause grave lesions."

This "black point on the horizon" indicates sufficiently that the prognosis should be reserved in any event. Though we may not believe the case serious, we should be guarded, and not affect an assurance to which the event may cruelly give the lie. The life insurance companies are very particular on this point, and will not take any risk with albuminuria, whatever the robustness of the subject otherwise. Johnson, finally, says that all socalled physiological albuminuriæ are latent nephritis.

Professor Semmola, of Naples, cited above by Dr. Dubreuille, drew attention to the subject of albuminuria at the Congress at Washington last September, and gave the following conclusions which for him resumed the subject in question:

(1) So-called physiological albuminuria cannot be considered as such, since in the normal state, the albuminoid principles are not eliminated from the organism. It ought then to be a question of a pathological state, or, if you wish, it is always an abnormal condition. This perhaps may be light, the subject may be thought to be in perfect health, but the elimination of albumen by the kidneys always indicates a lack of equilibrium between the ingestion and excretion of albuminoid matters.

(2) The facts established up to this time concerning the increase of blood-pressure cannot be regarded as conclusive,

because they are based on grave functional disorders seated in organs other than the kidneys.

(3) The gravest diseases of the heart, at their period of noncompensation, are always accompanied by stasis of the blood in the kidney, but are not invariably complicated with albuminuria. Could this not, then, come from another cause?

(4) By augmenting the general blood-pressure by means of transfusion, one can cause hæmoglobinuria, sometimes even hæmaturia, but never albuminuria. The increase of the bloodpressure cannot then, of itself, produce albuminuria.

(5) The increase of blood-pressure produced by injecting into the jugular vein a certain quantity of defibrinated blood, and by transfusing the same quantity of pure blood, produces at the same time hæmoglobinuria and albuminuria, the latter in considerable quantity. It is then evident that the dyscrasic state of the albuminoids constitutes, in the etiology of albuminuria, the true cause of the filtration of albumin through the kidneys, which are forced to eliminate from the organism all that is useless or dangerous in maintaining the other functions.

This is where the question is at this time. Surely it deserves study in all its aspects. The cases of so-called physiological albuminuria are far from rare, and it is important, if necessary, to establish the diagnosis and prognosis in a positive manner.L'Union Medicale.

ACUTE PNEUMONIA.

BY PROFESSOR JACCOUD, PARIS, FRANCE,
Academie des Sciences.

The paper that I have the honor to submit to the Academy is regarding the causes of acute pneumonia, and one of the origins of the microbes that characterize it. It was some time since established that pneumonia is a germ-disease, cultivatable and inoculable, and the following conclusions have been deduced from this discovery: (1) Exposure is not a sufficient cause for pneumonia; (2) pneumonia has a unique cause, namely, the accidental penetration into the organism of specific microbes coming from without. Therefore I have noted two cases, the study of which has enabled me to establish the real value of these propositions. The first observation was that of the case of a robust laborer, fifty-one years old, who slept well covered. During the night the window opened, and thence came a draught which caused an acute pneumonia. Twelve hours after, the