on the deleterious effects of bile circulating in the blood, are very strongly marked, and a tendency to hæmorrhage is very early evinced.

Morbid Appearances.-The condition of the liver differs according to the period at which the disease has proved fatal; but in general, the size of the organ is not materially increased, though, on the contrary, it is not unfrequently perceptibly diminished. There is no accumulation of bile in the minute ducts; and the yellow tinge which pervades certain portions of the structure is scarcely more than other structures of the body have obtained from the bilious impregnation with which the blood is loaded, and bears no analogy to the dark green of the liver gorged with bile from obstruction of the large ducts. On examining the gallbladder, it is found to contain little bile, and sometimes scarcely a trace of that fluid is to be discovered colouring the mucus accumulated by the secretion of its lining membrane. When the disease has terminated early in its course, the whole liver feels rather soft and flaccid, the surface appears variegated, of a light yellow and dark red or purple, in patches; and certain portions project above the rest, which, when cut through, sometimes prove of a softer texture, and even to be undergoing a process of change or disorganization; and portions of the same kind are intermixed throughout the whole substance of the liver; while, at other times, the yellow portions are harder than the surrounding substance. If the disease has not proved fatal at an early period, and while jaundice has been present in a brilliant or intense form, but has gone on for some weeks till the skin has assumed a light lemon-colour tint, which often bespeaks a very general disorganization of the liver, we find the structure extensively altered, and a great many of the acini altogether incapable of receiving such a quantity of blood as is necessary for the secretion

of bile, or for giving the healthy colour to the organ. They are then of a whitish-yellow colour, and rather hard and contracted than enlarged, and these altered acini are seen in groups and clusters which, on careful examination, will generally be found to follow the course of the divisions of the portal vessels, so as to be disposed around them like a sheath, which sometimes extends to the thickness of a quarter of an inch. Any decided marks of suppuration are rare, unless the disease have been complicated with causes of mechanical obstruction and irritation, as the previous deposit of biliary concretion in the ducts.

Exciting Causes.-The chief exciting cause is exposure to atmospheric changes, more particularly when the action of the bowels has been neglected. External violence and injuries will excite it, as probably the incautious use of mercury; and constipated bowels may act not only as a predisposing but as an exciting cause.

Diagnosis. The great mark which distinguishes this form of inflammatory action, is the early appearance of jaundice, with symptoms of inflammation, often very slight, but sometimes more decided, particularly the accelerated pulse and furred tongue, while all evidence of the other ordinary causes of jaundice is wanting.

Prognosis. In the more mild cases, where the inflammatory action is slight, the recovery is almost certain if the disease is treated early; but this is not the case in the more severe attacks; and as the urgent symptoms occasionally supervene upon the milder, the prognosis should be guarded. If, in a few days, it is found that symptoms remain mild, even though little obvious progress is made towards their removal, we may pretty confidently expect recovery. If, on the contrary, the pulse rise in frequency, become sharp or perhaps hard, the tongue assume a red colour, is dry and furred at the base, the jaundice become

very intense, and a drowsy condition take place, alternating with restlessness and occasional wandering of the intellects, the result of the case will be very doubtful; and should these symptoms increase, the prostration, and above all the cerebral depression and disturbance be augmented, the patient will fall into a state resembling low fever, with somewhat of a remitting character, and will in all probability sink.

Treatment. Whether this disease be essentially inflammatory in its very early stages, or whether a state of congestion, in some portion of the hepatic structure, precedes to such a degree as to render it rather a congestive than an inflammatory disease, will admit of doubt; but before its character is so fully developed as to bring it under the eye of the practitioner, more or less of an inflammatory action is extensively spread through the liver, and our treatment must accordingly be decidedly antiphlogistic. It is only. in the more severe cases, marked by considerable vascular excitement, a frequent pulse and some heat of skin, and tenderness on deep pressure, that general bleeding will be required. In the milder cases, cupping, or leeches to the margin of the ribs, will generally be useful, and in many cases quite necessary. In all cases, however slight, the patient should be kept strictly in bed, to favour the more equal distribution of blood on the surface of the body, and a dose of calomel and rhubarb, three grains of the one and fifteen or twenty of the other, should be at once administered, followed after a few hours by castor oil, or the senna and sulphate of magnesia if necessary. Combinations of mercury, antimony, and moderate purgatives are the remedies on which we are chiefly to rely; and for this purpose, two grains of antimonial powder, three of extract of colocynth, and two of blue pill; or the sixth of a grain of ant. potas. tart., with a grain of calomel and a little colocynth, may be given every

six hours; and should the bowels become irritable, the purgative portion of the pills may be omitted, and even a grain or two of the extract of poppy may be substituted, while the bowels are regulated by occasional doses of some simple purgative. If the skin does not become perspirable, doses of the liquor ammon. acetat. may be given three times a day, in the hours intervening between the pills; and the warm bath may be advantageously employed, a large linseed poultice being, during the whole time, kept applied to the right hypochondrium.

By these means, the tenderness of the liver will subside; the jaundice will gradually disappear; the urine become lighter coloured; the stools assume their healthy character; the tongue lose its fur; and the natural taste and appetite for food return: but all this may be an affair of several weeks; and if the means are used negligently or inefficiently, months, years, or the whole life may not suffice to restore the liver to its state of integrity.

CHRONIC HEPATITIS.

There is a still slower process of inflammation to which the liver is subject, one which affects the whole extent of the viscus, gradually rendering it unfit for the discharge of its functions, and reducing it to a state in which it greatly embarrasses the circulation, and gives rise to a succession of diseased actions, under which life is destroyed.

This slow disease is often overlooked for a considerable time, and is only recognised when the destruction of the liver has advanced so far as to give rise to some incurable condition of the system showing itself in confirmed jaundice, destructive hæmorrhage, or unconquerable dropsy. The symptoms are indeed, in the commencement, so obscure, that it is almost impossible to recognise them with certainty. They usually begin by slight indications of

dyspepsia, some wandering pains about the upper part of the abdomen, and some occasional sallow discolouration of the countenance. If careful observation is made, the bowels are found to be irregular, and the stools to be fœtid and ill-digested; while the urine is rather more scanty than usual, and frequently dark-coloured, or loaded with a red and sometimes with a pinkish sediment; and, if disease is suspected, a pretty decided tenderness may be discovered by moderate pressure in the right hypochondrium. After the lapse of many months, during which nothing but dyspepsia has been suspected, emaciation becomes evident, and the fixed though probably slight sallowness of the complexion and conjunctiva, excites the attention of the most casual observer: then, perhaps, is it first seriously suspected that the liver is the seat of chronic inflammation, and medical advice is sought; but by this time the disease has made great progress, it has long possessed itself of the organ, the structure of which is already changed. The attention having been now led to the right channel, the symptoms are at once perceived to be most marked and unequivocal: the sallow, shrunk countenance; the yellow conjunctiva; the unhealthy and flaccid state of the skin over the whole body; the red tongue; the lost appetite; the occasional feeling of loathing and nausea; the obscure wandering and variable pains in the abdomen; the uneasy tenderness on pressure more particularly in the right hypochondrium; the unhealthy yellow or black stools; the loaded urine, of a yellowish tinge, often staining the vessel of a bright pink or lake colour; all bespeak the nature of the mischief which had been long overlooked or only fearfully suspected by the patient or the practitioner. It is now soon found, that towards the evening the ankles begin to swell; an unaccustomed feeling of weight is experienced in the abdomen; flatulent distention is more