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XXXIV] even where no pus is discovered, is not infrequently followed by rapid improvement in all the symptoms. Many such cases are on record. Hepatic phlebotomy, as Harley designated the removal from the liver of a few ounces of blood by the aspirator needle, is a measure of proved value in hepatitis. With due care, risk from hæmorrhage is small; it is very small indeed in comparison with the risk of allowing an hepatic abscess to remain undiscovered and unopened.

Some surgeons, in order to obviate the small risk from hæmorrhage attending aspiration through the abdominal or chest wall, prefer to expose the surface of the liver by a short incision and then explore. It is hardly necessary to add that strict aseptic precautions, in the way of purifying the patient's skin, the surgeon's hands, and all instruments, must be carefully observed.

Operation for abscess of the liver.— The following is the operation usually practised by English surgeons. It is substantially that described by Godlee in the British Medical Journal of January 11, 1890, to which the reader is referred for many valuable details and practical hints.

If pus is struck below the costal border, the aspirator needle being left in situ as a guide, the abdominal wall is incised down to the peritoneum. A 3-in. incision will give plenty of room. If firm adhesions be discovered, a sinus forceps is at once run along the needle, and pushed through the intervening liver tissue and into the abscess. The aspirator cannula is now removed, and the blades of the forceps are opened sufficiently, as it is being withdrawn, to make a wound in the liver big enough to admit the forefinger, which must now be inserted and moved about so as to enlarge the wound and to gain some idea as to the size and direction of the cavity of the abscess. A rubber drainage-tube, about as large as the finger, and provided with a flange, is cut to a suitable length, and carried by means of the forceps to the back of the abscess. The abscess is then allowed to empty itself. When pus no longer flows freely, a