stances so compatible with a diagnosis of malaria, all contribute to this mistake. So common is the error that Osier says he hardly ever meets with a case of liver abscess which has not been drenched with quinine. My experience is the same. I have seen medical men make this mistake not only in their patients but in their own persons. If carefully considered, there are several circumstances which should obviate so serious an error. (1) No uncomplicated ague resists quinine in full doses. (2) In malaria, if the liver be enlarged the spleen is still more so; the reverse is the case in liver abscess. (3) The malaria parasite cannot be found in the blood in non-malarial hepatitis. (4) In liver abscess the fever is almost invariably an evening one; in malaria it most frequently comes on earlier in the day. (5) Quotidian periodicity, contrary to what is the case with tertian or quartan periodicity, is by no means pathognomonic of, or peculiar to, malaria. (6) The almost invariable history of antecedent dysentery, or, at least, of bowel complaint, in liver abscess. (7) Polymorphonuclear leucocytosis in liver abscess: relative mononuclear leucocytosis in malaria, kala- azar, and trypanosomiasis.
To mistake other forms of suppuration for liver abscess is of no great moment, because in many of the suppurative diseases just enumerated the treatment is the same as for liver abscess, and no bad result need be looked for if diagnosis is not quite accurate. A more serious error, however, is to overlook the presence of leucocythæmia, pernicious anæmia, or scurvy, and to proceed to aspirate an enlarged liver on the supposition that the symptoms arise from abscess. Fatal intraperitoneal hæmorrhage from the puncture has been known to ensue in such circumstances. If any doubt is possible on this point, a microscopical examination of the blood should be made before proceeding to explore.
A point to note in exploring is that, when the instrument enters the liver, an up-and-down pendulum-like movement will be communicated to the outer extremity of the needle, in harmony with the rising
