time; and notwithstanding bloodletting was largely performed, followed by leeching, no diminution took place in the secretion of milk, and she was enabled to continue nursing throughout the attack. The treatment was not begun till the 3d day; copious V.S. leeches, moderate purging with neutral salts, effected her recovery. In another case the peritonitis came on after parturition, the patient having suffered much during pregnancy from local pain in the abdomen. It assumed a chronic character, and appeared to occupy principally the hypogastric region micturition was performed with great difficulty; violent vomiting was also a prominent symptom, which yielded to a blister to the epigastrium; the peritoneal inflammation had been controlled for a time by mercurial inunction, but afterwards became complicated with gastro-enteritis, rendering the prognosis extremely unfavourable-in this state she left the hospital at her own request..

Abdominal Tumor.-A case, incomplete in its history, of moveable tumor in the abdomen, may be noticed for some peculiarities attending it. It was of a woman, æt. 44, previously healthy, and who had borne nine children. The tumor first began three years previous to her admission, following her last confinement. At the time of her admission, there was a large and very indurated, but painless tumor, occupying the epigastrium. Subsequently it became very tender, when a severe attack of intermittent fever, of a typhoid type, supervened. The patient would not continue in the hospital. The intermittent was not in the least under the control of quinine.

DISEASES OF Liver.

The entries in the registers of cases of disease of liver, inclusive of jaundice, amount to about 1 per cent on the total admissions during the years 1836-37. The cases, of which the notes have been preserved, are 14; and may be divided, 1st, into those in which jaundice was the principal feature, (4). 2ndly, those in which sanguineous congestion or inflammation of the liver seemed the predominant pathological condition, (5); and, 3rdly, those cases of organic disease of the liver as inferred from the symptoms during life, or ascertained by necroscopical inspection, (5).

Icterus.-The 4 cases of jaundice may serve to show, from the diversity of circumstances under which it originated, its indeterminateness as a basis for a nosological distinction.

In case 1, the patient, an unmarried female, æt. 22, had been subject to attacks of jaundice every Spring and Autumn for four years; during each attack the catamenia were suspended; the alvine excretions were natural, neither was there any abdominal pain or local tenderness; the last attack yielded promptly to purging with pil. hydrarg. and aloes, and the use of decoct. tarax, with supert. of potash.

În case 2, of a female æt. 50, the jaundice appeared to be evidently produced by obstruction to the passage of bile into the intestines, through the biliary ducts, as declared by the character of the stools, and other symptoms. The disorder had lasted two years, and had been attended with repeated attacks of retching and occasional vomiting of colorless fluid. These attacks, accompanied by pain" drawing her double," were followed each time by a deeper hue of the jaundice. Latterly a spontaneous and more violent attack of vomiting, in which bile was rejected, was followed by manifest amendment; after which the disorder was entirely removed by emetics, with small doses of calomel, rhubarb and aloes, and mild mercurial inunction.

In case 3, of a blacksmith, æt. 40, with the same deficient passage of bile into

the intestines, similar disorder of the stomach, as marked by nausea and retching, and the same chronic character of the affection as in the last case; there was an absence of the spasmodic pain in the epigastric or hypochondriac regions, and, in its place, a tensive pain across both hypochondria, with great resistance in the right hypochondrium and dullness on percussion in the lower region of the thorax on the same side. In this case, therefore, the obstruction was probably in the parenchymatous or secretory structure of the organ, rather than in the excretory ducts, as in the last case. In this instance, the general disorder was much mitigated by pil. hydr. hyosc. and calumba; and a further improvement ensued under the trial of hydriodate of potash, but the jaundice was not removed.

The 4th case of jaundice occurred in a shepherd, æt. 21, having malformation of the chest, which projected in front, and in its contour resembled the foetal thorax. The jaundice came on some time after a rheumatic attack, and was attended with cardiac symptoms, especially a loud bellows sound, with the "fremissement cataire." The right hypochondrium was tense and painful, and there was pain in the right shoulder: there was no deficiency of bile in the alvine excretions. But little effect was produced on the disorder by mercurial remedies, and the history of the case remained incomplete.

Sanguineous Congestion, or Inflammation of the Liver.-These were cases (5) which differed from the preceding in the absence of jaundice, while they presented a considerable affinity with them in other circumstances, such as-in the condition of the right hypochondrium which, in both classes of patients, for the most part the seat of some morbid sensation, in the present instances was more decidedly tense, painful, and tender—in the occasional occurrence of spasmodic pain in the upper part of the abdomen-in the sympathetic affections of the stomach, viz. nausea and vomiting (in 3 out of the 5 cases). The bowels were more constipated than in the preceding cases, and the constipation more frequently alternated with diarrhoea. The general conditions of the system, under which the disorder originated, were as various as in the cases of icterus. One of the patients was a labourer, æt. 58, who had left India eight years previously, having suffered from "bowel complaints" during the latter part of his residence there, but had since till the last six months enjoyed good health. Tenderness on pressure of the cartilages over the right hypochondrium, nausea, vomiting, spasmodic pain in the epigastrium, constipation alternating with relaxation of the bowels and tormina, formed the principal symptoms, and which yielded to leeches, blisters, and small doses of calomel or pil. hydr. with occasionally ol. ric. A second case occurred in a married woman æt. 27, of a delicate constitution and while suckling an infant eight months old. The symptoms were such as described in the last case with more disturbance of the circulation characterised by hectic. In this case the urine was loaded with the colouring matter of the bile, although the skin was not discoloured. She recovered under the use of the same remedies with the addition of taraxacum and quassia. Two other cases occurred in robust unmarried females of the respective ages of 20 and 24, in which the disorder was attended with less disturbance of the stomach but more torpor of the bowels, the pain and tenderness in the right hypochondrium being the same. The same remedies, including leeches to the hypochondrium, speedily induced recovery. The fifth and remaining case occurred in a robust girl, æt. 12, in whom all the above symptoms existed in a greater degree, with additional disturbance of the brain, producing head-ache, vertigo and drowsiness. In this case V. S. was employed in addition to the other remedies; the vomiting was controlled by a blister to the epigastrium; the patient recovered in about a fortnight.

Enlargement or other Organic Disease of the Liver,-The cases, under this

head, were too various in the nature of the organic disease or too complicated with diseases of other organs, to admit of their being viewed synoptically, but individually possessing some points of interest, may be briefly noticed as distinct histories.

CASE 1.Enlargement and Induration of the Liver, with deficient secretion of bile into the intestinal canal, terminating in recovery under the use of mercurials and iodine.

W. B., ætat. 14, labourer, on his admission, April 19, was much emaeiated, with a harsh dry skin, slightly tinged, as were the conjunctivæ, with yellow; the cheeks and lips, and hands, were of a deep purplish hue; the tongue was white, the appetite gone, and the stools of a light ochry color. The liver was distinctly felt reaching to the level of the umbilicus on the right side, and appeared indurated, with tenderness of its edge. The pulse was 120, thready,

but soft.

He had been ill fifteen weeks, being first taken with pain in the right sidethe jaundice had been deeper.

Mercurial liniment was ordered to be applied twice daily to the right hypochondrium and a grain of calomel with gr. of op. given n. et m. with inf. quass. ter quotidie, and a milk diet. By the 2nd of May, up to which time these remedies were continued, he had much improved, the induration and enlargement of the liver were not easily perceptible; the urine which had been very high-colored was much paler, the stools contained more bile and the gums were slightly swollen and tender. The same remedies were continued at longer intervals and he was allowed meat on alternate days, but which was found not to agree and was discontinued till a later period. During three weeks there was a further slowly progressive improvement with occasional relapses of pain and tenderness in the right hypochondrium. Hydriodate of potash (gr. j. and afterwards gr. ij. ter quotidie) out of camphor mixture was then added to the mercurial remedies, which were still further reduced, and this combined plan was continued till the 17th of June, by which time the liver had become greatly diminished in size, and had nearly retreated to the right hypochondrium, and there was no tenderness although there remained some induration: the stools were natural and the complexion had lost its venous hue. The appetite had long since improved, the stomach tolerated meat, and the boy had become fat— by the 23d of the same month he was discharged apparently well. It may be mentioned that this individual was the brother of the patient whose case was reported in the first part of these Contributions, as a solitary instance, among the cases of phthisis, of the physical and other signs of tuberculization of the lung having entirely disappeared in the course of two years.

CASE 2. Enlargement of Liver, with jaundice and absence of bile in the alvine secretions--subsequent contraction and induration of the organ with growth of a large cartilaginiform cyst, attended with ascites and general dropsy, terminating in two years from the commencement of the disorder in death.

The heading of this case comprises the principal points of interest in its history, which was principally remarkable from having afforded the opportunity of noticing the conversion of an enlarged liver into one of normal dimensions but greatly indurated texture. The period of the commencement of the growth of the cyst could not be clearly assigned, nor the question decided whether it preceded or followed the other hepatic disease. The patient was a girl, æt. 12, at the time of her decease. The liver, when she first came under observation (Aug. 17, 1836), reached as far as the umbilicus; she had then been ill 12 months, and was jaundiced and had very light coloured evacuations from the bowels. Mercurials and iodine did not increase the secretion of bile into the intestinal canal ; but for a time this was effected by a repetition of emetics: no further amend

ment ensued and the patient left the hospital Sept. 10, and the case was lost sight of by the author till he was invited to attend the post-mortem examination on the 20th of Aug. 1837. She had for many months been labouring under ascites to a vast amount with infiltration of the lower extremities, and extreme emaciation of the upper portion of the body,

Post-mortem Examination.-The liver was not larger than natural, and its peritoneal surface pale; its substance was rigid, and its section mottled with deep red points; the gall-bladder was full of bile-under its inferior surface and opposite the longitudinal fissure and attached to the liver, was found a cyst of the size of two fists, having firm cartilaginous parietes of the thickness of a halfcrown piece, containing perfectly clear and colorless fluid, and which were lined with a soft membraniform white deposit, apparently not organically connected with the cyst, as it readily collapsed into its cavity on the escape of the fluid contents. The internal surface of the cyst, on the removal of the membranous deposit, was rough and of a deep saffron-color, interspersed with spots of a still darker color, The mucous membrane of the intestinal canal presented a glairy mucilaginous deposit on its surface. A thymus gland was found of the size met with in the infant. The heart was very small but healthy, as were the lungs, but the cavity of the thorax was surprisingly contracted.

CASE 3.-Hypertrophy of Liver, with large hydatid cyst imbedded beneath its convex surface. Insidious attack of central pneumonia of the right lung, reaching the suppurative stage, and producing a fistulous opening into the pleura, with pneumothorax, and causing death by inflammation of that membrane.

C. W., æt. 43, labourer, was admitted I. P. Aug. 11, 1837. He had been ill six months, and during that time had emaciated. He had cough and three or four times had had slight hæmoptysis, but his principal complaint was of pain under the right hypochondrium and extending to the right shoulder. The pulse was small but not accelerated, but he had frequent chills and sweats. The appetite was impaired and digestion difficult, but stools were stated to be natural, while the urine was of the color of porter. The thorax was observed to bulge externally in the inferior part of the right side, where percussion was dull and the respiratory sound absent. A moderate mercurial treatment was adopted without any material effect for a week, when on the 18th he was suddenly seized with rigors and became slightly delirious; subsequently the breathing became very laborious and distressing, from acute pain in the right hypochondrium, increased by pressure of the cartilages and with much tension and heat of that region. He had likewise vomiting and the pulse had become quick and sharp and hard; by the evening of the following day the space over which the respiratory sound was absent and percussion dull in the right side of the chest had much increased. During this period antiphlogistic means by blood-letting, general and local, had been largely employed, and afterwards acetate of morphia given. The pain and suffering from laborious respiration had then entirely and rather suddenly subsided. The next day (the 20th), the chest was observed to be unusually sonorous where previously it had been quite dull on percussion, the respiration continuing inaudible in the same situation. In this state he continued two days, free from pain or much suffering, but with symptoms of gradual collapse and died on the 22nd.

Post-mortem Examination 5 hours after Death.-The bulging on the right side of the chest was very perceptible. On incising the intercostal spaces on that side a large quantity of fetid gas escaped with a slight explosion, On removing the sternum the right lung was found greatly contracted and pushed back against the vertebral column, the surface of the lung was concealed by a thick layer of soft yellowish-white membranous coagulum; the same description of deposit lined the whole of the left pleura; the cavity of the pleura was intersected by soft bands of the same material, and contained about a quart of opaque fluid,

slightly colored. On exposing the lung and separating the cleft between the upper and middle lobes, a fistulous opening was discovered, from which a large quantity of semi-fluid matter escaped, of a chocolate colour; this opening led to a large irregular cavity in the center of the lung, in which the pulmonary tissue was softened down to the consistence of pulp: the parts of the lung forming the boundaries of the cavity, though not diffluent, were dark, half-decomposed and easily reducible into pulp by pressure between the fingers-the cavity was intersected by bands of pulmonary tissue in the same state. The rest of the lung appeared condensed by pressure, being tough but pliant. A small insulated mass of cretaceous matter was found in the upper lobe in front-the left lung and the heart were healthy.

On exposing the abdominal viscera the anterior surface of the liver reached below the umbilicus and filled up the epigastric region. Its enlargement had also pushed up the diaphragm into the thorax and caused the bulging-the right lobe was altered in form superiorly, its convexity being much increased (bombée). In this situation was found a large cyst imbedded in the lobe, of the size of two fists and filled with hydatids (acephalocysts), some collapsed and a few entire, and of the size of pigeon's eggs or walnuts. The walls of the cyst were in some portions cartilaginous. The surrounding tissue of the liver seemed healthy; the gall-bladder was full of a greenish-yellow viscid bile.

CASE 4.-Vomiting and purging with brief intermissions for thirteen weeks; stupor the last few days preceding death. Gangrenous and carcinomataus tumor enveloping the gall-bladder, and communicating by two distinct ulcerated apertures with the duodenum and transverse arch of the colon-disease of the mucous membrane of the duodenum and colon—exemption from disease of the jejunum and ilium, but contraction of their calibre (the aliment having probably passed directly from the duodenum into the colon)-copious effusion under the arachnoid.

M. G. æt. 64, nurse, was admitted Nov. 22, 1837, having had diarrhoea with frequent vomiting for nine weeks. The tongue was dryish and cracked, and the appetite bad. The matter vomited often green and the stools dark-the pulse small and very irregular-features sunken. A defined, roundish, indurated, but painless tumor was detected below and extending beneath the right hypochondrium. From the period of her admission to the 18th of the following month the same symptoms continued with occasional intermissions and but little controlled by the remedies, viz. mild mercurials with small doses of opium, opiate enemata and tonics. The tumor had latterly become very tender. On the 18th drowsiness came on; the diarrhoea had increased and she appeared sinking, but again rallied during the day, with roaming at night, till the 25th, when she fell into a stupor from which she could be only momentarily roused-this state continued till the 29th when she died.

Post-mortem examination nine hours after death. No emaciation.

Head. The brain was small and firm; the arachnoid was raised up in the form of a bladder from the convolutions and was slightly opaque-from 6 to 8 ounces of fluid escaped from beneath it-the convolutions were separated by the interposition of the fluid. The surface was rather exsanguine.

Abdomen. Accumulation of fat in the omentum. The liver in its general aspect presented the ordinary nutmeg appearance; at the lower margin of its right lobe, under the concave surface at the great longitudinal fissure, and extending to the corresponding portion of the transverse arch of colon and the first and second portions of the duodenum, was found a dark, friable, mass of disease, which was ruptured by a slight accidental violence in examining the part, and displayed a fetid, dark gangrenous substance, presenting the appearance of grumous blood being intermixed with the disorganized structure of the liver and with portions resembling soft carcinoma; the gall-bladder was enveloped in this