gall-bladder filled with a great quantity of dark green, inspissated bile. The constriction of the ducts is evidently, in some cases, the result of spasm; in others, of organic change, proceeding from previously existing inflammation. In addition to these appearances, to the production of which the morbid functions and circulation of the liver had doubtless been most conducive, I have noticed considerable inflammatory disorder of the pancreas and duodenum, with tumefaction of the former, and of the mucous coat of the latter, sometimes completely occluding the opening of the common duct. The other morbid appearances sometimes met with in dissections of hepatic diseases, from their being generally more intimately related with abscess of the liver, and with dysentery, will be noticed hereafter.

There is one subject to which I wish particularly to direct the attention of the practitioner in his endeavours to ascertain the nature and seat of hepatic diseases, and this is, an attentive manual and ocular examination of the region of the liver. Even in obvious cases, this means of information should not be neglected, as the

warm climates. When, however, both cystic and hepatic ducts are constricted by spasm, or obstructed by inflammation or any other cause, it may be reasonably supposed that some degree of similar morbid action extends itself to the common duct, or when the common is thus diseased, the cystic and hepatic ducts partake, in some degree, of the derangement. From the evidence, however, which is furnished by the phenomena of disease, as well as from the appearances observed upon dissection, it seems fair to conclude that the cystic duct is often contracted, obstructed, or similarly disordered, when the hepatic and even the common ducts are not materially deranged; hence the hepatic bile readily reaches the duodenum, and the stools afford appearances of its presence, while the flow of the cystic bile is entirely obstructed; and practitioners who do not advert to this circumstance, but too readily infer that the biliary apparatus is free from disease, because yellow or hepatic bile is seen in the stools. The liver itself may be free from disease, yet the bile may not be of that quality requisite to act upon the chyme, to preserve health, or to remove disorder of the alimentary canal. We often observe pale yellow or straw-coloured motions where we have reason to infer that the flow of bile directly from the hepatic ducts is impeded; and yet the body wastes, the tone of the bowels is diminished, and looseness or diarrhoea is present. In such cases there is often evidence of obstruction of the cystic duct, or of accumulation of bile in the gall-bladder; and a healthy state of function is seldom brought about until this disorder is removed. I have, therefore, often thought that the due admixture of cystic bile is essential to the healthy performance of the digestive and assimilating functions, and that, although the recent hepatic bile may have its peculiar qualities and influence, the changes which this secre tion undergoes in the gall-bladder are requisite to a healthy state of the alimentary canal.

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experienced observer may derive more information from this source than from any other, both as to the extent and progress of the disease. In cases where the inflammation has gone on to abscess, this mode of investigation is quite indispensable. It is very justly remarked by Sir George Ballingall, in his valuable work on the diseases of India, that this manner of investigation gives us but little information in the earlier stages of hepatic diseases; yet, it should not even then be neglected. Information, even of a negative kind, is at all times requisite in the disorders of the liver, and more particularly in those which are most acute. Manual examination should be resorted to on every occasion; and the trunk of the body should, in all cases, be exposed to the view of the practitioner, in order to ascertain if fulness or bulging exist in any part of the hypochondrium or in its vicinity. When making manual examination, one hand of the practitioner should be pressed gently upon the part between the base of the right shoulder-blade and the spine, whilst with the other he endeavours with tact and delicacy to detect tenderness, fulness, or distension, either beneath the right false ribs, at the epigastric region, to the left of this region, or between the right hypochondrium and umbilicus. The state of the intercostal spaces should also be examined on the right side; and if pain be complained of in any of these situations, its nature may be inquired into by careful and varied pressure, whilst counterpressure is being made on the back, in the place pointed out. The patient ought also to be made to breathe fully at the time when this examination is going forward, and he may be directed to bend, or move his body in various directions. If fulness, tumefaction, or distinct tumour, be felt, the practitioner should endeavour to ascertain their nature by gentle and varied pressure with the points of the fingers; and the existence of tenderness, the degree of tenderness, the depth at which it seems to be seated, and the presence of fluctuation, whether obscure or palpable, ought to be inquired into with as much dexterity as the practitioner can command.

Causes of Inflammation of the Liver.-The causes, which predispose the liver to inflammation, may be briefly enumerated as follows:- full living, particularly upon animal food, the use of highly-seasoned dishes, and of too little vegetable diet; too great indulgence of appetite,' and living on a variety of dishes; the continued operation of a high temperature combined with moisture and malaria; a neglected state of the bowels; indolence and insufficient exercise; the habitual use of vinous, fermented, or spirituous liquors; exposure to the sun; the sanguine,

sanguineo-melancholic, and irritable temperaments, and scrofulous diathesis; a plethoric habit of body; the use of impure water; a dyspeptic state of the stomach; the depressing passions of the mind; the functional disorders of the liver, already described; attacks of fever, particularly of intermittents and remittents; dysentery and diarrhoea; and a state of irritation long kept up in the mucous surface of the alimentary canal, &c. These, while they dispose the organ to inflammatory action, upon the supervention of the direct and efficient causes, are also, more particularly some of them, occasionally the only sources to which hepatitis, in its various degrees of activity, can be traced. More frequently, however, these causes, when acting singly, are insufficient of themselves to produce inflammation, although they may dispose to it; but when two or more of them are combined, their influence is more certain, and after they have continued for some time to act upon the system, the operation of the usual exciting causes is soon followed by its full effect.

Amongst the various influences which more directly occasion the supervention of inflammatory action in the liver, there are few more energetic than the immoderate addiction to the use of spirituous liquors; and the intoxicating drinks which may be so readily obtained by the European soldier in every part of India; exposure to cold or wet when the body is over-heated; draughts of cold fluids when the surface is perspiring; fits of anger or passion; great chagrin, disappointment, and severe grief; injuries received in the vicinity of the organ, or sudden and great exertions of strength; blows or injuries on the head; exposure to a hot sun, and afterwards to the night dews and malaria; great repletions after long fasting; violent exercise; the retropulsion of cutaneous eruptions; the imprudent use of the cold or shower bath; and the neglect of the functions of the bowels. These causes, when acting singly, may not always give rise to the disease, unless the organ has been disposed to undergo it, by the continued influence of one or more of the predisposing causes; and we may often trace the operation of two or more of the occasional or exciting causes in the production of the morbid action. Thus the mental emotions already alluded to, may participate with exposure to the sun, to night dews, or to any other of the exciting causes, in the production of the disease to which the organ had been disposed by the combined action of ano. ther set of influences. And even the exciting or occasional causes, when present in great force, and acting in conjunction, may occasion the malady, without the existence of any predisposing influence

which could have assisted their action, further than the more universally prevalent one of a very high range of a temperature, combined with a moist state of atmosphere and terrestrial exhalations. SECT. II.-On Chronic Inflammation of the Liver, and Organic Diseases of the Organ.

Chronic inflammation may supervene primarily, or the acute forms of the disease may have been so far subdued as to subside into a slow, inactive state. When chronic inflammation takes place primarily, it is generally seated in the internal texture of the organ, and often gives rise to but few local symptoms, and but little constitutional disturbance. But chronic is a term which conveys with it no precise idea, and merely signifies a slow state of inflammatory disorder, presenting every grade, from that state of disease which may be considered as only slightly deviating from the healthy action, and which may continue for a length of time, giving rise to various organic changes. When this form of inflammation remains after the more acute phenomena have been subdued, it is usually seated in the substance of the liver, but not uniformly, as it may be seated in the surfaces; and it should also be recollected, that, although chronic inflammation of the liver may follow upon an acute attack, the latter may also supervene to the former, and actually does so on many occasions, particularly when the patients have been exposed to energetic exciting causes, or to an injudicious regimen and treatment. This should be kept in mind during the treatment of both acute and chronic forms of inflammation of the liver; for it should be an object of importance with the practitioner to prevent active inflammation from degenerating into chronic, and the chronic from being converted into active disease.

Chronic inflammation of the liver usually commences, and is accompanied, with much disorder of its functions. There are appearances of either disordered biliary secretion, or obstruction to the discharge of this fluid into the duodenum. The bile is seldom in due quantity; or, if its quantity be not materially diminished, it is mostly changed from its healthy state. Torpor of the organ, when it accompanies a state of chronic disease of the viscus, may also lead occasionally to attacks of more acute disorder, attended with an increased and vitiated secretion of this fluid; and this effect may proceed from the elements of bile accumulated in the blood, owing to the deficient function of the liver, irritating or exciting it to increased or morbid action. The secretion of bile may, therefore, be various in quantity, according to the particular circumstances

of the case; but it is more generally diminished, and almost always somewhat changed in quality, as far as may be judged from the appearance of the motions and its influence upon the chyme, as shown in the digestive and assimilative functions.

As chronic disease of the liver may present every grade of activity, down from active inflammation of the viscus to the slightest deviation from a healthy function, which may be followed by organic change of the organ,-so the symptoms indicating its existence must vary in severity in particular cases, and assume more or less distinctive characters. When the internal structure of the viscus is the seat of the vascular disorder, and if this be of a slight and inactive character, then the symptoms will be often so slight as not to engage attention until important organic changes may have taken place in the organ, and the concomitant symptoms, such as wasting of the body, with disorder of the digestive organs, lowness of spirits, &c. If the surfaces of the liver become at all involved in the disease, the symptoms are then of a more distinct and acute character.

In the severer cases of chronic inflammation of the liver, the symptoms will be nearly resembling those already described as characterising the more active forms of the disease, only much less acute. The nature, and pathological relations, of the symptoms are, however, the same; they only differ in degree. They also, in some instances, may be correctly considered as indicating the part of the organ diseased; but in the chronic forms of hepatitis, the relations of the symptoms to particular textures or parts of the biliary apparatus are only to be partially relied upon, and are to be distrusted in proportion as the signs become less acute and less distinctly marked.

In the slightest and most chronic forms of inflammatory action of the biliary organs, the symptoms are often indistinct; and it is chiefly in cases of this description, by means of disorder of the digestive and assimilative functions, that we are led, in many instances, to infer the existence of disease of the liver. The loss of flesh, the dyspeptic symptoms, particularly the slow and painful digestion, accompanied with acid and acrid eructations, flatulency, nausea, and sometimes vomiting, torpid state of the bowels, or dark-coloured, offensive, slimy, greenish-coloured, tenacious, or watery and muddy motions; the frequent calls to stool, and the scanty and morbid state of the evacuations; the dark-coloured and disordered condition of the urine; the distension and oppression of the epigastrium and right hypochondrium; the occasional aching