peculiar constitution of the patient, and pathological state of the organ, both previously to, and during the inflammatory process; and, indeed, these circumstances will more readily induce the suppurative process than the activity of the pre-existing inflammation.

When the inflammatory action is very acute, and accompanied with the congested state of the organ so often alluded to, abscess then rapidly forms, if the disease be not arrested; but its formation is preceded by signs which ought to lead the practitioner to the adoption of measures which seldom fail of preventing its supervention. It is chiefly owing to some fault in the state of the viscus and constitution of the individual, that it takes place during acute and well-defined hepatitis. Although plethoric and robust young men are very subject to attacks of active hepatitis, characterised by the more acute signs already described; yet, under a judicious and decided plan of cure, abscess very seldom occurs amongst them. But it is chiefly in the more insidious cases of inflammation of the substance of the organ, when the symptoms are but ill defined, and by no means acute, that the supervention of abscess is to be dreaded. Such cases are commonly met with amongst the faircomplexioned, the scrofulous, the relaxed and leucophlegmatic, the enervated, those subject to bowel-complaints, and the sedentary. In such individuals there is often little or no appearance of existing inflammatory action, and the symptoms complained of are often equivocal. In them also, even where inflammation is most evident, it assumes the chronic or even the passive form: there is often no definite sign which will guide the judgment of the practitioner that abscess is forming, although experience will enable him to decide upon the existence of disease of the liver. In cases of this description, patients often neglect themselves, until it is too late to prevent the termination in abscess, if, indeed, abscess be not already formed; and when they come under medical care, some consecutive disease may have made its appearance,-such as dysentery and chronic diarrhoea, which may mask the primary malady, and engage the whole attention of both patient and physician.

Abscess of the liver may be regarded in the same light as abscess of any other part of the body, and the same changes take place in its formation. It is well known that collections of matter sometimes form in external parts of the body without any marked rigors or constitutional disturbance, and even without much fever; and a similar occurrence may supervene with respect to the liver. The symptoms which usher in the formation of abscess in many instances seem to depend more upon the habit and constitution of the indi

vidual, or the magnitude and extent of mischief at the period that the suppurative process is beginning, than upon any invariable change in the system necessary to its commencement, and regularly indicated by certain signs. When the inflammatory action going on in an organ or part is not very acute, and is not attended with great general excitement or high symptomatic fever, and when the constitution is characterised by a scrofulous or tuberculous tendency, then abscess may, and indeed does, supervene in the liver without giving any precise warning, until the very last stage of the suppurative process, when the aggregate of the symptoms may lead us to infer its existence, or its communication with some other viscus renders it manifest. When, on the other hand, the inflammatory action has been acute, the powers of life not materially overwhelmed, and the diathesis and habit of the individual not much in fault, the commencement and progress of abscess of the liver may frequently be detected by the observing practitioner, if his inquiries into symptoms be made with sufficient precision, and understood by the patient. On some occasions, however, symptoms having a stricter reference to the functions and site of the liver, may be so masked from the observation of the practitioner, by some concurrent or consecutive disease, as to mislead his judgment altogether. But in proportion as attention is directed to the subject, and experience respecting it ripens, so will such error very rarely

occur.

When the liver is actively inflamed, it often becomes exceedingly large, from previously existing or concomitant congestion; and sometimes it fills the greater part of the superior abdomen, projecting considerably from under the ribs. This is more particularly the case when the superior surface of the liver is the seat of the disease. When the increase of bulk is chiefly in the concave surface of the liver, it extends more in the direction of the stomach and colon, and is less evident upon examination. Adhesions are then frequently formed with either the stomach, colon, small intestines, or right kidney; and if the inflammation terminate in suppu. ration, the abscess generally breaks in some one of these viscera, or even into more than one of them. When the liver becomes enlarged and congested with blood, at the same time that it is inflamed, although the danger of supervening abscess is greatly heightened, yet the enlargement and tumefaction evident in such cases upon examination, are no sign that the abscess already exists, or even that the suppurative process has actually commenced: on the contrary, when abscess actually forms, the diffused tumefaction

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diminishes, it becomes more concentrated and limited; and at last, unless in the very seat of the tumour, the liver seems, upon examination with the hand, actually lessened in size.

Adhesions to opposite surfaces, it must be remarked, are not always the result of the pointing of an abscess in any particular direction. If it form, and point in the superior and anterior surface of the liver, adhesions to the adjoining parietes frequently are the consequence, and then an operation may be performed with a prospect of advantage in many cases. But it may point in various other directions, and break into the large cavities, or into other viscera, according as adhesions may or may not have formed. When the disease is seated in the superior and anterior part of the organ, with tumefaction, the progress of the suppurative process, and the ripening of the abscess for the operation, may then be very closely and accurately observed. But when tumefaction and subsequent abscess take place in the superior and posterior part of the viscus, or in the concave surface, then the extent and progress of disorganisation can but seldom be accurately followed; and we have no precise information as to the extent of mischief, unless the collection of matter find its way into the lungs, on the one side, or into some part of the abdominal viscera, on the other.

When abscess points externally, the circumstance may readily be detected; and in some cases, when it is formed in the body of the liver, and points in the direction of some other important organ, it may be so recognised by the symptoms present, and even, in some few cases, by means of the hand; counter-pressure on the posterior parts of the lower ribs being made at the time of examination. It should, however, be recollected, that abscess may form and point either upon the diaphragm or upon the abdominal viscera, in broken-down constitutions, phlegmatic temperaments, and scrofulous habits, without any evident symptoms being present by which we may judge either of its progress and course, or even of its existence: indeed, in such individual circumstances, unless the disease assumes a very active character, the formation or existence of abscess is not often evident until it is about to terminate fatally, having induced great disorder of more than one of the digestive and assimilative functions; and in some cases, if the attention has not been alive to this consequence of disease, it may pass undetected until disclosed by the post mortem examination of the case.

When acute attacks of hepatitis are not subdued by sufficiently decisive treatment in their early stages, they run rapidly into abscess. This consequence of the disease is chiefly to be dreaded

when considerable enlargement of the viscus is found upon examination. If abscess actually be formed, and is seated in the convex part of the right lobe, the enlargement is evident over the whole hypochondriac region, the liver extending considerably below the ribs towards the umbilicus, and sometimes across the epigastrium to the left side. When the abscess is likely to point below the ribs, there are generally great tumefaction and increased heat of the surface of the part and its vicinity: frequently there is found a distinct enlargement, particularly in the more advanced progress of the abscess, immediately under the margin of the right ribs. If, however, abscess form on the superior surface of the liver, and point upon the diaphragm, although the enlargement of the organ will be very perceptible, yet there will seldom be felt any great increase of temperature on the surface of the hypochondrium. The abscess may point between the ribs ; in this case, a bulging of the false ribs will be observed, and more than usual fulness of the intercostal spaces, and increased heat in this situation, with considerable enlargement, the liver being felt below the right hypochondriac region in the epigastrium, and sometimes in the left hypochondrium. This enlargement may exist for a considerable time before matter forms; but in this case there will be no distinct tumour nor increase of heat: when the abscess has advanced considerably to maturity, the undefined enlargement and tumefaction become even diminished, and distinct tumour is more observable, according to the situation of the abscess and the direction which it may take.

When the abscess is completely formed, and is seated in the superior and posterior part of the liver, the enlargement and tumefaction felt beneath the ribs, previous to, and during the formation of matter, become considerably diminished; but if it be in the inferior and anterior part of the organ, the enlargement becomes more and more reduced and circumscribed, until it assumes the character of a distinct tumour: and the pain which was often considerable during the period of general enlargement or tumefaction, either altogether ceases, or is now but little felt.

The supervention of abscess of the liver is often not manifested. by symptoms of a decided nature, particularly when it is the consequence of a chronic inflammatory action, complicated with dysentery in such cases especially, the formation of matter may com. mence and terminate without the appearance of any of those signs upon which the inexperienced are taught to rely. The presence of rigors can seldom be expected; but slight shudderings and formi

cations are more frequently observed. Even when rigors are complained of, they are not diagnostic of the formation of matter in this disease; for the practitioner must remember, that hepatic disease is often complicated with ague, and the rigors may belong to the febrile paroxysm. Rigors may proceed also from that state of stomach induced by irritation and spasm of the gall-ducts, and by the irruption of bile into the duodenum. When rigors or horripilations supervene to the more active forms of hepatic disease, then more dependance is to be placed upon them, as characterising the formation of matter in the liver; but it is chiefly by the manner of their supervening to the antecedent symptoms, and by the relation which they bear to the phenomena succeeding them, that we should be guided in our judgment respecting them.

Sometimes an internal sense of throbbing and fluttering has been felt in the region of the liver, and has been followed by a broad, soft pulse, and night perspirations. The supervention of night perspirations, with a clamminess of the skin of the extremities, is one of the most certain signs of the formation of internal abscess which we possess: but even this ought not to be relied upon alone, but should be viewed always in connexion with the other symptoms characterising the case. The next in importance are frequent cold sweats, but these are chiefly met with in the advanced stage of abscess. Frequent fainting sensations are deserving of considerable reliance on the part of the practitioner. There are also generally much anxiety and oppression at the præcordia, and restlessness. If, during the treatment of hepatitis, we find it a matter of difficulty to affect the system with mercury, vascular depletions having been previously practised with the requisite decision, we may then dread the existence of abscess. Whether the mercurial remedies employed may act in such cases, owing to peculiarities of constitution or diathesis, in producing and accelerating the suppurative process, has been questioned. Mercurial action in this state will, in my opinion, accelerate the suppurative process; the system will not be brought under the full operation of mercury; ptyalism will not be produced; the gums, however, will be swollen, become very red and irritable, and sometimes ulceration will even be occasioned. These denote the general irritation of the system caused by this agent, which it is evident must necessarily accelerate the formation of pus.

When abscess is formed, the tongue is seldom or ever of a natural appearance. At first it is sometimes white, and the papillæ raised or excited it afterwards becomes of a dusky, brick-coloured red