the other; not, mind you, as a distinction founded in Nature, but brought about by the meddlesomeness of Art! I want you to note that fact; you will have abundant operations and opportunities to observe that shall we call it, in fashionable phrase, "change in the type of disease?" Go into the physicians' wards, and you see abscesses as the result of fever-chronic abscesses; go into the out-patients' department, you see a man who has run a thorn into his hand; he has had pain, heat, redness, swelling, in short, acute abscess. You see this, of course, every day-that is plain sailing: every milk abscess, every whitlow, abscesses after gun-shot wounds, bad fractures, etc., are instances of acute abscess; they make themselves known by the pain involved in the suppurative process, whereas, on the contrary, as I think, all chronic abscesses are without pain. That is a good sign of a chronic abscess. You know what a prominent part "pain" plays in all diseases; now in the absence of pain you must yourselves often find out where the suppurative chronic action is at work. The remote cause of chronic abscess in fever is extreme debility, ending in the formation of pus. (Nothing "pyogenic" here?) We don't know why these abscesses after fever "point" at one side of the leg or "point" at another, we only know the fact as you may observe it now in cases in the hospital. Go into the physicians' wards, as I say, (and I do not now enter on the question whether the lancet and leeches and weakening remedies directly produce exudations that they are believed to prevent,) but ask yourselves honestly what is it that produces after fever, or what is it that is the cause of many cacoplastic deposits so called?

acute.

The chief point to-day to which I wish to draw your attention is the following: All internal abscesses, as a safe practical rule, indicate constitutional debility; all, or nearly all, external or traumatic abscesses are I want you to note this. Isn't psoas abscess an internal abscess pointing externally? Let us take care we do not add to this debility that changes the nature of an abscess. A woman in "Treasurer" ward had her breast enlarged: she came in after having been confined six weeks by it. The pus was probably infiltrated. The orthodox rule would have been more leeches, purgatives, and salines; but I am now certain that where these are used, or abused, according to old routine, we add to the tediousness of the cure! I beg you to mind this in your future practice. We gave her bark and ammonia, wine and meat, and the abscess pointed in a few days, and she got perfectly right again. I say, take care of this in this practice, for such an abscess is often a serious matter; it is now too late in the day to prevent this and other kinds of knowledge spreading.* * Next, let us look at a common case in private practice. A lady, aged twenty-five, lately under my care, suffered intense debility from much hemorrhage, and what may be called "hard

* Sir B. Brodie tells of a surgeon (no doubt a great opponent of caustics) who was about to remove a woman's breast by a heroic amputation. The story went that this surgeon had cured several cases of cancer by the knife; the present case was also pronounced genuine schirrhus, but on Sir B. Brodie looking a little deeper into the matter, it proved to be the "relics" of an old abscess! Many such cases are met in the hospitals in the year.

labor." She was very well tended during her confinement, suckled with both breasts, but all at once a screw is loose-her appetite fails, she has slight fever of an intermittent type, evening exacerbation-all signs of debility, mark you! Next, and only then, came a thickening and painfulness of the outer half of one breast, pus formed, and I opened the abscess. I doubt if this lady would have had a month's illness and the abscess but for the first step in the debilitating descent-the hemorrhage. Well, that is common mammary abscess; dozens of such cases are to be seen every week. Contrast that now with a poor woman recently in "Lucas" ward, who, after her labor, came in with enormous swelling of the entire thigh down even to the ankle, what would be called "thickening and enlargement of the issues" of that part. Her husband was a poor cobbler mending boots on six or seven shillings a week, and she brought him forth, poor fellow, seven children in nine years. She was reduced to the utmost limits of poverty, short of starvation; eating no meat, and drinking some poor mysterious beverage called tea. These few points in her history told me to prepare for an immense abscess. Her pulse was miserably small and quick. The lady, you see, had acute abscess; this poor woman has an immense chronic abscess. Are you justified in Poor-law practice to offer leeches, purgatives, and salines, and all the rest of it, in such cases, or should the conscientious man say, "fiat justitia," order quinine and wine, though it may shock the nerves of the Board of Guardians? What did I do in this case? I endeavored to make the abscess in the poor woman acute, in fact to limit the suppuration; when she got well. Are we justified, then, in laying it down as a maxim of our surgical Moïse, and Persians, that abscess always arises from local irritation and local inflammation, to be met by antiphlogistics and clearing out the alimentary canal? Inflammation, believing, will come in good stead to us as surgeons if we only make its acquaintance honestly-inflammation solemnly, ay, and truthfully, set down for us with pain, heat, redness, and swelling; for I don't at all agree with the new-fangled transcendentalism of the microscope school of savants that inflammation is "altered nutrition" and all the rest of it. Do we observe redness, swelling, heat, or pain, in chronic abscess? No! it's a joke to stick to such a dogma-it's worse, it's untrue! and, in practice, unsound as leading to antiphlogistics, as they are called. I make these observations in no unfriendly spirit; if you are to be educated surgeons, and you should be scattered over one hundred and fifty places of practice in the country, I would conjure you to take advantage, in a manly way, of the growing experience of hospital practice. I want your convictions from having seen cases of abscess and of inflammation in clinical research; do not be led by dicta of mine, or theories of microscopists, or the stereotyped formulæ of books, in upholding venesection by the lancet, antiphlogistics, and clearing out the alimentary canal by means of some mixture. Very well. Now I don't wish to overcharge this as I have been accused of doing; I have taken the trouble to make inquiries of general practitioners; (some men registered?) They will boast of eight, ten, or twelve leeches, then also chloride of mercury in legendary doses, and large senna mixture, blue pill,

A

black draught, etc., first to clear out the alimentary canal thoroughly; and all this time the poor patient may have an abscess all but pointing, as in that case of the shoemaker's wife. But if this patient requires a pint bottle of bark or sarsaparilla, why order senna? Do you think Nature requires you to be always setting her work to rights in the chemistry of the alimentary canal? Leave the alimentary tube alone, I pray of you. Why has this lady, whose case I recited, an abscess at all? I'll tell you. It arose overnursing her child, from excessive hemorrhage, and her miserable pulse and want of appetite; and your routine man comes in and orders Mindererus's spirit and antimonial wine, just to act on the skin, colocynth, and the Lord knows what, with calomel, merely to clear out the alimentary canal and improve the appetite! Now, I hold that the vis vitæ of this lady was below par all along; not that the abscess, when we tried to limit its extent and prevent its chronicity, (in which we succeeded by mild measures,) was the cause of want of appetite, etc. What I say to you is this, we are now in a new year, and just observe for yourselves, even if you work amongst the outdoor midwifery cases or others, for one single twelve months, whether you will not have more abscesses in tedious cases with hemorrhage and debility than amongst the better or inflammatory class of patients, if you wish to call them so. You will meet much opposition when you come to entertain my views of things. Give your advice, I pray you, according to your convictions. Doctors differ; of course they do, that above, as a science, one set of men before another set, and that surgery is a progressive art. I do not wish to overcharge this picture of the drugging system; the thing often reacts on itself, and in spite of all the old routine the patient is not cured; and then she goes to a quack perhaps, or a well-read man, and he tells her she ought to have had bark and ammonia, wine, etc., and you lose your patient.

I will go off the subject for a few minutes to tell you of a case of this kind.

A lady, about thirty-five, called to consult me about a somewhat peculiar affection-excessive flow of milk; she was literally deluged with milk, her child seemed starved, and she herself looked wretched.

"You do not take enough of meat and wine, Ma'am," I said.

She was told that "that would feed the disease, and such a thing as touching beer or wine was perdition," and to mend matters she was a water drinker or vegetarian, or some nonsense of that kind!

"Well," I continued, "the remedy is very simple for the disease, beer and wine and no vegetarian diet."

"My physician differs from your opinion, in toto," she replied, and so I afterwards found he did, and what was more he held fast to his opinion and carried the day; so I lost my patient. Some one (Pindar?) says water is the best of things. I agree with that; but it is the water in its right place. The poor lady went back to her vegetarianism, but she got worse and worse, and her child was advancing in marasmus, though she had a perfect ocean of milk! Well, after some days she came back to me and said she would try my plan, and she did try it—the effect was like magic; in less than a month a total revolution was worked in her

system, and the poor infant, like another phoenix, rose from its ashes.

Some years ago another physician asked me to see a mammary abscess in a young lady of twenty-five, situated in the right breast.

"Leeches?" he said.

"Purgatives?"

"No; for I believe suppurative action is never stopped once that it has set in. Bark and ammonia, good diet, and wine, that's what I recommend."

"That's new to me, quite new," said he in rather an apocryphal mood.

"It's not quite new to me," I replied; but he was a sensible man, and he adopted a plan now almost invariably adopted more or less, that is to give force to the circulation in such cases of debility. Don't be afraid of it, I say; take the slow suppurative mischief by storm, and you'll cure it; the capillaries want power, and there is nothing equal to bark, ammonia, and wine.

In conclusion, I say purulent matter will form in less than forty-eight hours; I can give you fifty cases to prove this. Do not encourage it, then, by depleting measures. Look at the men with big ridges of suppurating tissues, half-formed buboes, in the out-patients' department; will all that smearing with mercurial ointment, all the leeches and purgatives stop that ridge of hardened tissue coming to an abscess? No, you must improve the health of many of these men in the manner I have set forth to-day; improve the health and you hasten the crisis; if you take blood from such a man, you will leave him farther off than ever from the abscess coming to a "point." Fortunately the hospital is rich, and I have for a series of years given the plan of treatment I now recommend a fair trial. I can see at every turn cases treated on the old plan, but I am every day more and more convinced of its fallaciousness. I would not if sick myself wish to be bled and leeched without sufficient cause; the mere fancies of old times will not do, nor can I conscientiously recommend them to you.

From the American Journal of the Medical Sciences.

ON THE ALLEGED SUGAR-FORMING FUNCTION OF THE LIVER, AND THE INFLUENCE OF DIET ON THE LIVER. By F. W. Pavy, M. D., London.

THIS Communication is one of exceeding interest and importance, certainly in these respects not second to any in the whole volume. The experiments detailed by Dr. Pavy, and the deductions he draws from them, will aid materially in the solution of the problems that now occupy most the attention of physiologists. From the care and skill with which

the experiments were evidently made, and the great number of times they were repeated, we must rely upon the results uniformly obtained by them. The deductions drawn from them are fully warranted, indeed forced upon us. A little reflection, too, will show clearly that they are not only not opposed to the facts obtained by Bernard and others, in their experiments, but entirely in accordance with these facts, and only opposed to the interpretation hitherto given to them.

Experiment has proved, beyond a doubt, that a large quantity of sugar is met with in the liver, and in the blood of the hepatic veins, and of the right side of the heart of an animal that has been for some time previously restricted from the ingestion of saccharine materials, after the death of the animal. The question Dr. Pavy desires to solve is, whether sugar is natural to the right-ventricular blood of the living animal and to the living liver, for to find sugar on examining the blood or the liver after death is no proof that it was also present during life. The results he has obtained in endeavoring to solve this question are very striking, and lead one irresistibly to the conclusion that during life sugar does not exist in the liver, but a substance which happens to be with extreme facility, by a process allied to fermentation, convertible into sugar, and which has the power to resist transformation into sugar, whilst located in the tissue of the living and healthy liver. With the destruction of life this power of resistance is at an end, and the organ then becomes speedily charged with the saccharine principle.

When blood was removed by Dr. Pavy during life from the right ventricle by means of a catheter passed into the right jugular vein, it was found to contain only the merest trace of sugar, the reaction with the Barresvil solution being sometimes so slight as to be liable to be overlooked altogether. Dr. Pavy made upwards of sixty observations to establish this fact. When in these cases the animal was killed, the blood collected after death from the right ventricle occasioned with the same reagent an abundant orange-yellow precipitate of suboxide of copper.

When an animal is pithed, and a minute or two is allowed to elapse before the chest is opened, the blood flowing from an incision into the right side of the heart will be found strongly saccharine. When the chest was instantly opened by Dr. Pavy after the pithing was effected, and a ligature placed around the base of the heart, the contents of the right ventricle were found to be free from sugar.

Having discovered that the sugar-forming substance of the liver was not transformed into sugar, whilst in contact with a ferment, when an alkali was present, Dr. Pavy immediately after death injected a strong solution of potash into the liver of a dog. The presence of sugar was in vain sought for, either in the liver or the contents of the circulatory system. Again, injecting only half of a liver, in the same manner, this half contained no sugar, while the other gave the ordinary amount. When the organ was allowed to remain a few moments after death before the injection was practiced, so as to give time for the post-mortem transformation of liver material into sugar to take place, the presence of sugar was as easily shown as if the potash had not been made use of.

Knowing how much changes partaking of the character of fermenta