pain and weight in these situations; the uneasiness and pain about the right shoulder or shoulder-blade; the slight acceleration of the pulse towards evening, with an irritable beat, and considerable heat and restlessness through the night; the burning heat of the palms of the hands and soles of the feet in the evening, and chilliness in the morning; the white, foul, and excited tongue; the bitter or disagreeable taste of the mouth; the hardened state of the gums; the sallow appearance of the countenance, and either yellow or pearly-white colour of the eye; the sickly and leucophlegmatic character of the body generally; and the elevation of the shoulders, -are the principal symptoms by which we are to be guided in determining the existence of chronic inflammation of the internal structure of the liver.

When the surfaces are the seat of disease, the pain is generally then more marked, and as the superior or the inferior surface is chiefly affected, so will more or less disorder be referred to the chest in the one case, or to the stomach and bowels in the other. When the superior and exterior part of the right lobe is the seat of disease, then the patient reclines with most ease on the right side, and feels more or less acute pain, or a dragging sensation, upon turning to the left; but when this sensation is felt, we may generally infer the existence of adhesions between the lobe of the liver and the right side. The back is generally the easiest position to recline upon, and a slightly bent posture is often preferred.

In every case of disorder referrible to the liver, careful examination of the region of the organ should be made, both by the hand and the eye. But in no case should the examination be made roughly, or in such a manner as to excite any pain. It should be recollected, that the liver, when inflamed or congested, is often also softened in its texture, and more liable to suffer from a rough mode of examination. I have known cases wherein much increase of suffering was occasioned by it, and wherein chronic and subacute attacks of disease were converted by it into active inflammation. More precise knowledge will be generally obtained when the examination is made gently and carefully, than when it is made otherwise. We should also take care, when endeavouring to obtain information in this way, that we satisfy our minds distinctly respecting the existence of tumefaction or distinct tumour, or the absence of either. In chronic inflammation of this organ there is generally much loss of flesh; enlargements of the organ, or distinct tumours from abscesses may then be distinctly felt, and many of their relations with the adjoining parts may sometimes even be

detected. This is the case chiefly when tumefaction or abscess takes place on the superior and exterior surface of the liver, or near its anterior edge. When organic changes of the above description are situated in the centre of the liver, or at its superior and posterior aspects, then little more can be detected than tumefaction and fulness in the right hypochondrium and epigastrium, with a descent of the edge of the organ considerably beneath the margin of the ribs. When these changes are situated towards the inferior and posterior surface, then there is neither much fulness nor tumour in the above situations, even when tumour and enlargement actually exist. The stomach and colon give way before tumours or abscesses pointing in this direction; and thus tumefaction is seldom present, and if it be, it is usually of a diffused and undefinable kind. In such cases there is usually much oppression and sense of load at the pit of the stomach, particularly after a meal, with urgent symptoms of dyspepsia, and acrid, acid, and flatulent eructations, sometimes with vomiting, or rejection of the contents of the stomach, sometimes without much retching or exertion, and a disordered state of the biliary organs, with irregularity of the bowels and morbid condition of the stools:

The terminations of chronic inflammation of the liver are various. The greater number of them, however, may be viewed in the light of advanced stages of the inflammatory state; others merely as organic changes to which this state invariably leads in particular habits and constitutions, rather than as actual terminations of chronic inflammatory action, since the vascular disorder may be considered as still existing. As in the more acute forms of disease, those now under consideration may terminate in resolution by a gradual diminution of the morbid symptoms, and a return of the healthy actions of the diseased organ, and of those related to it in function. They may also give rise to a more acute form of disease, or to organic changes of a serious and even fatal tendency. Amongst the former are, active inflammation of the organ, or of the gallbladder and ducts, and dysentery. The latter embraces all the organic changes to which the organ is liable. These are not generally so varied in warm climates as in temperate countries. The chief organic changes met with in the East, consequent upon inflammation of the liver of a more or less chronic kind, are the following:

Collections of matter formed in the substance of the organ consequent upon chronic inflammatory action, as well as from the more active state of disease. When the purulent matter is collected

into one large abscess, it usually approaches the appearance of abscess consequent upon active inflammation. Not unfrequently, however, very minute abscesses are scattered through the substance of the liver, both with and without the appearance of a distinct cyst · the matter collected being of a firm or cheesy consistence, and yellowish white colour. Sometimes this consistent kind of matter does not fill completely the cavity containing it: it seems as if the watery portions of the matter had been removed by absorption, and thus the more consistent part fills imperfectly the cavities in which it is contained: The substance of the organ intervening between the purulent deposits is sometimes more vascular than usual, and of a brick-red colour; and at other times not materially changed from the healthy colour and consistence.

The liver, in many instances of long-continued and slight inflammatory action, becomes much enlarged, particularly its right lobe. This appears to arise from the deposit of lymph in the interstices of the structure, which deposit becomes dense, and closely resembles an organised substance, most probably from the absorption of its watery portions. The enlargement is often accompanied also with. deposits of purulent matter in various parts of the organ, with a friable state of its texture, and a dark-coloured and congested condition of both its internal structure and surfaces: the latter are generally much darker than natural, and often variegated with lighter streaks and small spots.

When the deposition of lymph in the structure of the liver is attended with greater density of its organization, either partially or generally, the change has been ascribed to a specific organic change; and a true scirrhous condition of the organ has been considered as the result. This state seems to be merely the consequence of very slow inflammatory action, with a deposit of organised matter, and an increased consistence of the reticulated or cellular parenchyma of the viscus, and frequently with an effusion of lymph in the granulated tissue composing the greater portion of its internal structure. It seems to me also, that the consistence of the organ met with in cases of chronic disease characterised by enlargement, is more the consequence of the activity of the inflammatory action from which it proceeds, and the habit and constitution of the patient, than any other cause; the organ being more friable and congested, the more acute the previously existing disease,-and more firm and more closely resembling a true scirrhous and semicartilaginous state, the more chronic or slow the inflammatory action which had existed.

Tubercles of various kinds, some apparently encysted, others without any evident cyst or distinct envelop, and, when divided, presenting either a concentric or radiated texture, varying in consistence from a gristly or cartilaginous state to one of semi-fluidity, occasionally filling completely the cavities in which they are contained, particularly when they approach a state of fluidity, and at other times, when their consistence is greatest, leaving vacuities between their circumference and the parts of the liver surrounding them, are often severally detected in examinations of the more chronic forms of hepatic inflammation. In many cases, the substance of the liver containing these tubercular formations presents little or no evidence of much inflammatory action having existed, at least recently, in the organ. The tuberculated liver is often also enlarged, and occasionally it is much firmer in its texture than usual. When signs of co-existent inflammation of the internal structure are present, there is frequently also greater friability; but this is not uniformly the case. Sometimes the substance of the viscus presents a gristly or cartilaginous appearance, and is lacerated with greater difficulty than usual. Such appearances are chiefly remarked in the most chronic cases.

In these cases also, more particularly in those addicted to the use of spirituous and intoxicating liquors, the substance of the liver is obscurely tuberculated, of a cheesy consistence and texture, and of a deep nankeen-like colour: it is generally, at the same time, more or less enlarged. In many chronic cases of diseased liver, arising from the above cause, the internal structure of the organ is of a parboiled and scabrous appearance, drier and more spongy than natural, and, when divided by a scalpel, or torn asunder, presenting a more or less pale colour, and great inequality of consistence, small rough eminences being surrounded by soft, greyish, and spongy matter. In some of these cases, the substance of the viscus is of a greyish-brown colour. Conjoined with this condition, the size of the liver is often diminished, its vessels nearly without blood, the hepatic ducts devoid of bile, and the gall-bladder either empty or containing a small quantity of a pale, straw-coloured, watery fluid, scarcely resembling bile. This state of the hepatic vessels, biliary ducts, and gall-bladder, is often also conjoined with scirrhous enlargements, tuberculous disease, with atrophy, and with many of the other very chronic states of the liver now described.

When the liver, owing to very slow and long-continued inflammatory action, has become tuberculated, or enlarged with scirrhous hardening, then it may generally be felt projecting from under the

margins of the ribs, particularly on the right side. But these forms of organic change are less frequently observed in India than in Europe. The functions of the liver, in cases of tubercular disease, of scirrhous enlargement or hardening of the viscus, and of the other organic changes now described, are always very seriously disordered. There are present a diminished secretion of bile, with change from its healthy state; much disorder of the digestive and assimilating functions; wasting of the body; drowsiness and pain over the eyes; a disagreeable taste of the mouth; unhealthy appearance of countenance; an irregular condition of the bowels, with a pale, morbid, and offensive state of the motions; high-coloured or brown urine; frequently a yeasty, whitish, and clayey condition of the stools; and slight acceleration of the pulse towards evening, with heat and dryness of the palms of the hands, and many of the symptoms formerly enumerated.

In many very chronic cases, the liver becomes smaller than natural; and in some it is very much diminished in size. Such cases cannot often be detected during the life of the patient, otherwise than by the obstinate torpor of the biliary functions, the deficiency of bile in the stools, and the sunk state of the epigastrium and margin of the false ribs, when the patient is examined in a reclining position. Atrophy of the liver may be the consequence of slow inflammatory action; but on this point it is difficult to decide: even although it may evidently result from this source in some cases, it cannot be inferred that it does so always. I have, however, met with several cases in which the wasted state of the organ was attended with a marked cicatrix on its surface, and extending through the greater part of the whole thickness of its substance. In such instances the cause of the diminished size of the organ was manifest; and the evidence of abscess having existed in it many years before was complete. In one case, several cicatrices of the liver accompanied this state of atrophy, and gave the surface of the organ a singularly radiated appearance.

The appearances, then, which are met with on dissection of cases of chronic inflammation of the liver, and which may be considered amongst the terminations and consequences of the more chronic forms of inflammatory disease, are abscess, and small collections of matter; tubercles; enlargement of the organ and softening of its texture; increased density and scirrhous enlargements and tumours; enlargement with friability, or with cartilaginous hardening of its structure; a rough, pale, and parboiled-like appearance; a cheesy tuberculated state of its structure; a spongy and less vascular