condition of its internal texture; atrophy, with or without the marks of cicatrices; various colorations of its surface or substance; and adhesions of various kinds to adjoining parts. The above organic changes are very frequently met with in fatal cases of dysentery, particularly that form of the disease which is called hepatic dysentery, and in bilious remittent fevers and obstinate intermittents. Indeed, they are more often observed, in India, thus complicated than as simple diseases of the biliary organs, and generally they are variously conjoined the one with the other.

In addition to these organic changes, which are to be referred chiefly to the substance of the liver, there are others which belong more especially to the gall-ducts. These are collections of very viscid and thickened bile in the hepatic ducts; and biliary calculi in the same situations. I have seldom observed, however, biliary calculi lodged in the hepatic ducts. It is very probable, that, when they form in this situation, they become a source of irritation and, acting as a foreign substance, produce inflammatory action, which soon terminates in abscess. Biliary calculi frequently form, in warm climates, in the gall-bladder, and often produce inflammatory action, in this receptacle, or in the cystic or common duct, not unfrequently attended with spasm, which often extends to adjoining organs.

The symptoms indicating inflammatory action of the gall-bladder or ducts cannot always be distinguished from those accompanying inflammation of the concave surface of the liver;-the same irritability of the stomach and irritable beat of the pulse, pain at the pit of the stomach, and disordered state of the bowels, accompany both the one and the other. When, however, the ducts and gallbladder are inflamed, there is, more generally, a marked deficiency of the biliary secretion, or an entire absence of it from the stools, and jaundice is more constantly present. Frequently also, and particularly if the inflammatory action be attended with spasm, or arise from the irritation of biliary calculi, there is an irregular action of the diaphragm, sometimes hiccup, and occasionally short paroxysms of dyspnoea.

When inflammation attacks the pancreas, it not unfrequently extends to the common duct, occasioning occlusion of its canal, and enlargement of the pancreas itself. When this is the case, jaundice becomes complete, and the patient generally sinks under the disorder of the biliary and pancreatic apparatus, and the imperfect state of the assimilating process; marked disease generally supervening also in the small and large intestines, from the absence

of bile, and the insufficient changes produced upon matters taken into the stomach in the course of their passage along the alimentary canal.

When inflammation commences in the duodenum and extends to the ducts, the symptoms very closely resemble those already noticed as characterising inflammation of the concave surface of the right lobe of the liver; and there generally is present, in addition, considerable pain in the region of the duodenum, proceeding from beneath the right scapula to the right hypochondrium, with a sense of dragging or drawing together of the parts in the vicinity. Owing to the tumid state of the mucous tissue accompanying the inflamed state, and particularly if the inflammatory action extend to the common duct, the opening of this duct into the duodenum will be considerably obstructed, if not entirely occluded, and jaundice will thus supervene as a necessary consequence. Inflammation of the duodenum extending to the ducts, is, moreover, attended with sickness at stomach and vomiting, which generally come on about two or three hours after a meal, and with a relaxed or irregular state of the bowels, and a light, cream-coloured, and frothy state of the motions.

Jaundice can scarcely be considered in any other light than in that of a symptom of a functional or an organic disease affecting some part of the biliary apparatus. It varies in degree from a slight yellowness to a deep green, or even olive colour; the latter of which has been commonly called black jaundice, and is comparatively rarely met with. A slight form of jaundice is often seen accompany. ing bilious inflammatory fever and bilious remittents; but in such cases this symptom seems to arise rather from an increased secre. tion of bile than from any obstruction to its discharge into the duodenum. It may also arise from the absorption of bile and morbid secretions from the internal surface of the alimentary canal, especially when active purging has not been instituted sufficiently early in the disease.

It is unnecessary to add any thing respecting the causes of chronic inflammation of the liver, in addition to what has been already stated respecting the causes of the more active forms of the disease. When chronic inflammation supervenes primarily, it generally springs from the sources already pointed out, and is more frequently met with in the nervous and melancholic temperaments, and as a sequela of long-continued disorder of the digestive organs, particularly of the stomach and large intestines. It is also frequently found as a consequence of more active disease, and of organic

changes produced in some part of the biliary apparatus. Morbid states of the functions of the liver, and of the constitution of the bile itself, owing to the continued irritation thereby kept up, are also conducive to slow inflammatory action in the substance of the organ; chronic inflammation frequently thus originating, as the more active inflammation often does, in functional derangements, and in congestion of the viscus. Indeed, on many occasions, such derangements not only introduce the inflammatory state, but also accompany it in a more or less marked manner during its progress, and even often continue for some time after its decline.

Those cases of hepatitis which differ from the more acute forms of the disease merely in degree, becoming on this account only more chronic or slow than those already detailed, require no further illustration. They seldom terminate otherwise than favourably, when treated with judgment and decision; and when they end unfavourably, it is generally by inducing organic change, either in the biliary organs or in the large bowels, owing to the morbid condition of the biliary and intestinal secretions.

SECT. III.-On Abscess of the Liver.

When inflammation of the liver, especially of its internal structure, is not treated with sufficient decision in its early stages, the formation of one or more abscesses is a very frequent consequence. Abscess is very frequently a consequence of the forms of inflammation of the liver, which are, as already shown, of a more or less active nature, although often not manifested by many acute or painful symptoms. It also supervenes to inflammatory action of a less questionably chronic form; and it often follows upon that state of increased vascular action of the substance of the organ which seems to be intermediate to acute and chronic disease. When suppuration takes place, there is either something favourable to its supervention in the state of constitution or diathesis of the individual, or in the vascular condition of the organ, or in the concurrent circumstances and phenomena of the case. In illustration of this position, it may be observed, that the sanguine and scrofulous habits are particularly liable to this termination of hepatic inflammation ;-that it may be dreaded by the practitioner, when he finds, upon examination, considerable tumefaction of the organ accompanying the early stages of the disease;-and that it frequently supervenes to the insidious inflammation of the substance of the liver, which often accompanies, if it does not actually occa

sion, a particular variety of dysentery, and which, although not generally manifested by acute symptoms referrible to the region of this organ, is not the less active as respects its progress and termination. Indeed, in many instances, the practitioner in India will find, when the early stage of inflammation of the liver is accompanied with much fever, a heavy aching pain, and great tumefaction in the region of the organ, that it is very difficult to prevent the supervention of suppuration even by the most prompt and copious depletions, and by the most active employment of mercurial remedies. It frequently happens also that considerable enlargement of the liver is observed as a sequela of active disease of the viscus, even although much decision may have been evinced in the treatment, and the most urgent symptoms have been subdued. But, in such cases, enlargement of the organ is the result of some degree of effusion of lymph in the interstices of the inflamed tissue, and denotes a similar state of parts to that marking the previous existence of inflammatory action in more superficial and more tangible glands. Indeed, inflammation of the liver, especially of its internal structure, may be considered as resembling that of any other glandular body: when inflamed, it is generally tumid; and this tumidity arises from similar causes, in conjunction frequently with congestion of blood in the portal and hepatic veins, and accumulations of bile in the ducts. As in other glandular parts also, and in the cellular tissue especially, so is there a disposition inherent in tumefaction of the liver to terminate in abscess, in proportion to the extent to which it is present, and the powers of the constitution impaired; and even when this particular state is so far subdued as to prevent the accession of this unfavourable consequence of vascular disorder, it will still remain to a considerable extent, owing to the effusion of lymph in the affected part. It is owing to this circumstance that tumefaction, with evident soreness of the organ upon pressure, is so often remarked during the decline of the disease; and it is chiefly in 'promoting the quick removal of this effect of the morbid vascular action, that a short mercurial course is so beneficial in the treatment of hepatitis after depletions have been sufficiently practised. When tumefaction remains for any time as a consequence of inflammation, or when inefficient means are made use of in order to remove it, or when the patient is exposed to hurtful influences and causes, and allowed to indulge in stimulants, or to experience mental or physical excitants, before it be entirely removed, and the functions of the bowels restored to the healthy state, it becomes the centre of vascular disorder, in

which abscess rapidly supervenes, owing to the predisposition of the vessels of the part to undergo the suppurative process derived from their previous state of disease.

In cases of this description, and in debilitated individuals of a scrofulous diathesis and sanguine temperament, abscess very frequently forms both suddenly and unexpectedly, and often without any very prominent symptoms preceding or marking its supervention. In the strong, plethoric, and unimpaired constitution, the inflammatory action preceding suppuration is generally active, and productive of more or less symptomatic fever, and local signs, by means of which approaching mischief may be suspected and guarded against.

It has been stated in a former part of this work, that there may exist two states of congestion of the liver, the one differing very much from the other; namely, congestion of the portal system of vessels and of the hepatic veins, and engorgement of bile in the hepatic ducts. These, although often existing separately, frequently also are present at the same time, and are not uncommonly, either collectively or individually, connected with accumulation of bile in the gall-bladder. This state often produces great disturbance of the system, according to the degree in which it exists, and the constitutional peculiarities of the patient, and often induces inflammatory action, with great tendency to the suppurative process; this tendency being in proportion to the degree of congestion of the vessels, and consequent tumefaction of the organ. When the habit and constitution of the patient are unimpaired, and the vital energy of the organ has not been overpowered, the congestive state above enumerated is generally relieved by means of a healthy reaction of the circulation of the organ, and a free secretion of bile; and if the reaction thus induced should run to inflammation, it will readily subside under a depletory plan of cure, and the functions and circulation of the organ return to their healthy condition, but when, owing either to a scrofulous diathesis, deficient tone of the organ, or obstruction to a free circulation in any part of the viscus, or irritation of its vessels in a particular part, or impediment in the way of a free discharge of bile into the duodenum, great tumefaction of the organ supervenes to, or accompanies, the inflammatory state, the formation of one or more abscesses is much to be dreaded; and when tumefaction of the organ is detected, the most active means are required to prevent this consequence, although they cannot always succeed in averting it. Thus it will be seen, that the supervention of abscess of the liver will depend much upon the