with the lung by a perforation through the diaphragm of about the same size as the external fistula, which led into an abscess in the lower lobe of the right lung. This was narrow, elongated upwards, and presented many of the characters of a pneumonic abscess. It had no lining membrane, and communicated with numerous bronchial tubes. Around it the pulmonary tissue was of a greyish-white colour, softened but not granular. The diseased portion did not terminate by any distinct line, and occupied about two-thirds of the lower lobe, which was universally adherent to the diaphragm, and for about three inches to the costal pleura; the remainder of the lung was healthy. The mucous membrane of the stomach was pale and soft, the lower portion of the ileum red, and presenting some aphthous ulcerations; the mucous membrane of the colon was covered with fungous elevations and numerous aphthous ulcerations.*

In this case the diseased action had in all probability a double seat from an early period, namely, the lower portion of the lung and the integuments over the liver; it is remarkable for the double perforation of the diaphragm through its costal and thoracic portions, and for the direct communication made by the latter with the substance of the lung: the pleural and peritoneal adhesions prevented the escape of the matter either into the thoracic or abdominal cavity, a circumstance illustrative of the powers of nature in availing herself of diseased action to promote an ultimate cure.

Some authors have described gangrene as a result of hepatic inflammation; but facts are still wanting for the elucidation of this subject, and there can be but little doubt that, if it ever does occur, it must be a circumstance of extreme rarity. On this subject we shall quote from Mr. Annesley:

"Gangrene has been remarked by many writers and teachers as one of the terminations of acute inflammation of the liver; but although we have observed this disease, and made postmortem examinations of it, the number of which certainly has not been exceeded by any other inter-tropical practitioner, we have never seen a single case of gangrene of this viscus. We are inclined to believe that the appearances that have been taken for gangrene have been merely that black congested and softened state of the organ which is sometimes observed in the more acute attacks of the disease, supervening to congestion, or at least this state of the viscus having speedily run into gangrene after the death of the patient; and therefore, if gangrene had actually existed at the time of dissection, it is to be considered as a consequence of death rather than a termination of the disease."+

In the works of the modern pathological anatomists of Europe, the same infrequency of gangrene of the liver is observed; so that we may conclude that both in warm and temperate climates the termination of hepatitis by gan

Meath's Hospital Reports. Op. cit. vol. i. p. 435.

grene is of extreme rarity. Andral relates one decided case of gangrene of the liver, where the disease surrounded an abscess of the left lobe, and states that this is the only instance he has seen of gangrene of the liver. When we reflect on the vast number of dissections which this great pathologist has made, the fact of his having seen the disease but once is a decided proof of its rarity. Here is another circumstance in which the pathological relations of the liver differ remarkably from those of the lung, as, in the latter viscus, gangrene is a not unfrequent occurrence; but when we consider the greater liability to a stasis or effusion of blood in the pulmonary parenchyma as compared with the hepatic, and also that in the lung the diseased portion is exposed to the action of air, we may find in these circumstances an explanation of the fact.

The effects of chronic inflammation on the liver are exceedingly various, and its results greatly influenced by the constitution or habit of the patient. Among them may be enumerated the different forms of hypertrophy, either partial or general, either of the red or white substance, or of both; induration; scirrhous or tuberculous tumours; and hydatids. We are far from believing that these latter lesions are always the result of an inflammatory process; as there is undoubted evidence that these new tissues may be the result of a lesion of secretion and nutrition, not induced by any previous irritation of the part; while, on the other hand, cases are on record where these different diseases appear to have been first brought about by an acute or chronic hepatitis. The following observations by Andral on this subject are highly philosophic:

"There is scarcely one of the alterations of the liver which have been described which has not been designated by the name of hepatitis. In my opinion there is hardly one of them which may not be the result of an irritation whose first effect was to cause an hyperæmia of the liver. For example, four individuals receive an external injury on the same region of the liver; in one an abscess is developed in the liver; in the second this organ becomes cancerous; in the third it becomes filled with hydatids; and in the fourth it is atrophied. In all these four cases irritation has been manifestly the point of departure: but what has been its mode of action ?-it has deranged the normal nutrition of the organ; there its influence is confined: the predisposition of the individual has done the rest. On the other hand, I do not know an alteration of secretion or nutrition of the liver, not even a collection of pus in its parenchyma, that can be considered as necessarily arising from an antecedent process of irritation. I do not know one of which we can say that its formation has been necessarily preceded by a hyperemia. What, then, does the word hepatitis express? nothing more than the common link by which the different lesions of secretion and nutrition of the liver are often united. But this link is neither constant nor necessary; and if we have seen a case where an hyperemia of the liver by ex

M.

been easy to demonstrate, at the Salpêtrière, the Pitié, and at the Hôtel Dieu, that the liver is susceptible of great increase of volume, and that the dimensions of this gland diminish rapidly after a copious bleeding, and sometimes also by strict regimen, which by itself produces a loss of blood. The diminution of the hepatic organ varies from one to three inches, from above downwards, in the twenty-four hours; this is still greater in proportion as the blood drawn is more considerable. Not only has this fact been observed with old men in whom the venous circulation, embarrassed by disease of the heart, and particularly its weakness, explains the tumefaction of the liver, but also in adults, in cases of plethora and acute fevers. I could easily accumulate twenty observations to support this proposition. Vidal, one of the house pupils connected with my attendance, has just related to me three most remarkable facts taken most carefully. I shall confine myself to the following:A young man discharges a loaded pistol direct against the region of the liver; the ball, however, does not penetrate, which singular fact may be attributed to the presence of air between the muzzle of the piece and the ball, the pistol being applied to his clothes so firmly as to stop up the muzzle: his clothes are, however, torn, and the foreign body, after having violently contused the skin, falls at the feet of the wounded man. The first few days no accident of importance occurred; the circumference of the liver was bounded by a black line. The fourth day there was fever, flushed face, and dyspnoea very intense: this was referred to the liver; this organ above and below exceeded by an inch or more the former line of demarcation. A copious bleeding was tried; the next day the liver had resumed its former dimensions, and the severe symptoms disappeared. The cure was rapid."*

In using the pleximeter we should employ it over the epigastrium and hypochondrium, and also over the lower portion of the chest

State of the liver.

Acute hepatitis
Red softening

both anteriorly, laterally, and posteriorly. By this means the extent of the hepatic tumefaction can be generally determined with ease. In some instances the tumefaction is more evident in the superior, in others in the inferior portions of the liver; when, however, the belly is much distended, this mode of observation is liable to many difficulties: thus, when the intestines contain much solid and fluid matter, we cannot estimate the extent of dulness inferiorly; and on the other hand, when they are distended by flatus, the liver is pushed upwards, under which circumstances the dulness of the lower part of the chest ceases to be a measure of the hepatic tumefaction.

Jaundice has been described as an attendant on hepatitis, but it is not a constant symptom. The patients have generally a slightly yellowish tinge, particularly in the face, similar to what is observed in gastric or bilious fevers, but very different from true icterus. In none of the cases observed by us at the Meath Hospital was there jaundice; and Andral relates numerous cases of hepatitis where this symptom was absent: it may, however, occur in acute hepatitis; but facts are still wanting to explain its absence in some cases, and its presence in others. Of one fact we are certain, that jaundice, when induced by inflammation, is much more frequently the result of a duodenitis than of an inflammation of the liver. From the known effect of a duodenitis, simple or complicated with gastric inflammation, in the production of icterus,* it becomes an interesting question to determine how far the complication of gastro-intestinal inflammation in hepatitis may act in producing the symptom of jaundice. The following table of cases, taken from the writings of Andral, Louis, and from the report of the Meath Hospital, may assist in throwing some light on the subject. The first column states the condition of the liver, the second that of the gastrointestinal apparatus and ducts, and the third that of the skin.

Red induration

Ditto

....

Jaundice.

Jaundice.

Jaundice.

Jaundice.

Jaundice (slight).

Jaundice.

Jaundice.

Jaundice. Jaundice (slight).

Jaundice (deep).

Jaundice.

Piorry, du Procédé Opératoire, etc. Paris,

1831.

* Marsh, on Jaundice, Dublin Hospital Reports. Broussais, Commentaires, &c.

It is obvious, from the inspection of this table, that we cannot arrive at any explanation of the presence or absence of jaundice in cases of hepatic inflammation, from the consideration of the circumstance of gastro-intestinal complication. We see here cases of hepatitis with jaundice, in which the digestive tube was free from disease, and the same symptom with gastro-intestinal inflammation; and, in the cases of hepatitis without jaundice, the tube was healthy in some, and diseased in others.

We may remark, while on this subject, that in hepatitis the biliary secretion is variously affected. In some it appears to be suspended, while in others, even after extensive suppuration of the liver, the gall-bladder has been found filled with healthy bile. We have observed these facts repeatedly in the Meath Hospital. Thus, in a case where a great number of abscesses were formed, the gall-bladder contained a perfectly transparent viscid fluid which did not coagulate by heat or the addition of nitric acid; the fluid was perfectly colourless, and in short presented all the characters of pure mucus. Notwithstanding this appearance of the contents of the gall-bladder, it is most remarkable that the intestines contained a quantity of yellow mucous and fœcal matter. In this case the mucous membrane presented indications of inflammation.

In two other cases, where the most extensive destruction of the liver had taken place, the gall-bladder was found to contain a bile healthy to all appearance. In the first of these a chronic abscess existed in the right, and a recent abscess in the left lobe. In the second, the organ was completely burrowed by numerous abscesses. In the different cases of hepatic abscess recorded by Louis, the greatest variety in the contents of the gall-bladder occurred. From these facts we seem justified in concluding that in acute hepatitis, and probably also in the chronic disease, we cannot form any exact diagnosis of the state of the liver from the appearance of the biliary secretions in the stools, inasmuch as in one case it is altered in its quality in a variety of ways, while in another, apparently the same condition of the organ, no perceptible change is observable. The truth is, that neither its presence, absence, nor alterations, give us any data to enable us to conclude as to the stage, extent, progress, or termination of the inflammation; and it is plain that under these cir

cumstances the state of the stools will but little assist our prognosis. It is probable, however, that a very copious secretion of bile is more favourable than the contrary, as the inflammation of secerning organs is generally more inveterate when their secretion is arrested.

When hepatitis is once formed, it may terminate by resolution or by suppuration; or the irritation may continue in a modified manner, so as to be classed among chronic diseases of the liver. The indications of resolution are, in the first instance, the subsidence of the fever, the gastric symptoms, and the pain: this is followed by the disappearance of the tumefaction, which, though generally the last in the order of symptoms, often occurs with great rapidity. The infra-mammary and postero-inferior portions of the chest recover their clearness of sound on percussion; the dilatation of the side is no longer observed; the right hypochondrium and epigastric region lose the tension and fulness which occurred during the acuity of the disease. Although a few cases of suppuration without perceptible tumefaction of the organ have been met with, yet from our own experience we would say that the subsidence of the swelling is one of the most certain indications of the resolution of the disease, certainly more so than the disappearance of the fever and pain.

But when suppuration is to occur, we often find that the tumefaction, so far from diminishing, becomes increased, and this at a time when the fever is frequently changed in character and assumes a hectic type. Shiverings, more or less severe, are observed, with or without perspirations; the pulse becomes small and rapid; the countenance is pale, and a sour smell of the surface is perceptible. In one case we have observed a miliary eruption. There is generally a constant sense of weight and uneasiness in the right hypochondrium, and the pain has in some instances been found as it were to concentrate itself on a particular spot, probably corresponding to the principal collection of pus. After some time a fluctuating tumour may appear generally in the epigastrium or some part of the right hypochondrium, which is followed by discoloration of the integuments; but in other cases no such occurrence takes place, and we must be guided by the history of the case and the constitutional symptoms in forming the diagnosis of suppuration. Should the tumefaction persist,

with a fever either of the continued or remittent type, we may suspect the formation of matter. When, however, the abscess forms so as to be perceptible by manual examination, we may observe the following conditions:— 1. a generally enlarged state of the organ, in which, though no perceptible fluctuation exists, a doughy or boggy feel is communicated over a greater or less portion of the tumour; 2. distinct tumefaction below the margin of the rib; 3. a tumour in the epigastrium; and, 4. a bulging of the false ribs, with more than usual fulness of the intercostal spaces.

But it must be always borne in mind that, although the constitutional symptoms frequently undergo a remarkable change at the moment of suppuration, yet there are abundance of cases in which the change is scarcely if at all perceptible. To this we shall recur in speaking of the difficulties in the diagnosis of this disease.

The constitutional symptoms which are of most value are, the supervention of night perspirations, shiverings, cold sweats, clamminess of the skin, and frequent fainting sensations. If this state has arisen in a case where it has been found impossible to affect the system with mercury, the diagnosis of abscess may be made with a great degree of certainty. In this last and most important statement, the best East-India practitioners agree, and we have heard one gentleman, who occupies a high rank in the service, declare that he never yet knew a case of abscess of the liver in which ptyalism was induced, even although the largest quantities of mercury had been exhibited. Mr. Annesley says, that there can be no doubt that the system will not be brought under the full operation of mercury, or that ptylism will not follow on the most energetic employment of this substance, when abscess exists, although a slight tenderness of the gums will be produced by it." As far as our experience in the Meath Hospital has gone, we should say that the same circumstance holds good in the case of hepatic suppuration in these countries; but it is not peculiar to inflammation of the liver, as it is observed in other cases of intense visceral inflammation, in which, when ptyalism is induced, it is obviously the effect and not the cause of the reduction of the visceral disease; and we have no doubt that, from not properly estimating this circumstance, practitioners have erred with respect to the curative powers of mercury, and have done injury by the introduction of enormous quantities of this mineral into the system at a time when the violence of the local action prevents its specific and sanative effects on the economy.

The terminations of these cases of hepatic abscess are various. We have already alluded to the internal openings of the abscess in describing the pathological anatomy of the liver in a state of inflammation. In these cases the diagnosis is to be made on the same principles which Louis has laid down in speaking of peritonitis from perforation of the intestine: there is a sudden appearance of a new train

of symptoms, accompanied in almost all cases by subsidence of the hepatic tumour. Thus, when the matter makes its way into the lungs by the mechanism which we have before described, a sudden and copious expectoration of puriform matter has been commonly observed; this is accompanied by a remarkable diminution in the hepatic tumour. Should these symptoms arise in a case where previously there had been no evidence of disease in the pulmonary parenchyma, the diagnosis may be still more certain. We had once an opportunity of making a stethoscopic observation of this most interesting lesion: the patient had recovered from an attack of that violent gastric fever accompanied by yellowness of the skin which we have described in the article ENTERITIS, when he again came under our care, labouring under symptoms of hectic fever, which proved ultimately to proceed from hepatic suppuration. This patient had a constant dry cough, which led us to make repeated stethoscopic examinations without our being able to detect any disease whatsoever in either lung: in less than twelve hours after the last stethoscopic observation the patient was suddenly seized with a feeling of suffocation, and began to expectorate large quantities of perfectly formed pus, of which in the course of the night he discharged upwards of a pint and a half. On the following morning the left lung, which the day previously had presented no morbid sign whatever either by the stethoscope or percussion, was found completely dull over the whole region of the lower lobe, with complete extinction of the respiratory murmur: there was no bronchial respiration, no resonance of the voice, dilatation of the side, nor displacement of the heart; nor was there any constitutional symptom indicative of either pleuritic or pneumonic inflammation. The patient continued to expectorate copiously for some days, and after the second day the morbid phenomena of the chest began to subside. We had, first, a mucous rattle audible at the root of the lung, which gradually extended over the dull portion, and was followed by a return of the respiratory murmur and resonance of the voice.

This stethoscopic observation, for the accuracy of which we pledge ourselves, is explicable only by the sudden filling of all the bronchial tubes with purulent matter. Let us observe, first, the sudden supervention of dulness and absence of respiration in a patient whose chest a few hours before presented no morbid phenomenon; this is accompanied by a copious expectoration of purulent matter, and there are no constitutional symptoms of pleurisy or of pneumonia. The absence of these symptoms is of great importance, because if the disease had proceeded from either of these lesions, it must have been of extraordinary violence, and would have certainly been accompanied by high constitutional and local symptoms. There was no dilatation of the side, or displacement of the heart, so that the diagnosis lay between hepatization of the lung and the sudden filling of the tubes with pus;