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 or not the mercurial remedies employed may act in such cases, owing to peculiarities of constitution or diathesis, in producing and accelerating the suppurative process, is a question not readily admitting of decision; but there can be no doubt that the system will be brought under the full operation of mercury, or that ptyalism will not follow upon the most energetic employment of this substance, when abscess exists, although a slight tenderness of the gums will be produced by it. This circumstance has been proved to us on very many occasions.

"When abscess is formed, the tongue is seldom or never of a natural appearance. At first it is sometimes white, and the papillæ raised or excited: it afterwards becomes of a dusky, brick-coloured redness, or what may be called a beef-steak tongue. At other times it is dry, coated, and of a brown tinge. In the more chronic cases, it is often smooth, chapped, lobulated, and apparently deprived of its papillæ. When great mischief is going on in the liver, without any acute symptoms, the tongue is often an excellent guide, and more to be depended upon than the pulse. In many of the less acute or chronic cases of abscess, the tongue has a peculiar white appearance, with the papillæ raised or excited: it is somewhat dry, but without any coating. This is what we have called an excited tongue, because we have considered it a sign of great vascular excitement going forward in internal structures; and we have often ordered depletions from this symptom alone, the tongue becoming natural as soon as a full depletion was performed. Hence we have considered, that when this state of tongue is observed, depletions may be directed more safely than upon the indication of any other symptom. Care should, however, be had not to confound this appearance with a white and moist condition of the tongue, or with a white, yellow, or brown crusted state of this part. The pulse, at the commencement of the formation of matter, is generally soft and full, is subject to acceleration in the evening, and, as the organic change advances, becomes more irritable, quick, and contracted. The stools are always much disordered through the progress of abscess of the liver: they are generally more or less frequent, are scanty, and usually consist of a greenish, watery fluid, with a greenish froth, or a green, slimy scum, floating on their surface. Frequently there are also straining and tenesmus; and some blood, with mucus, is occasionally voided. The calls to stool are also, in many cases, most frequent during the night. In hepatic disease, terminating in abscess, and complicated with dysentery, both the small and large intestines become diseased, first funtionally, and afterwards organically; and the patient generally dies of the organic change produced chiefly in the large intestines, frequently before the abscess makes its way, either externally or into any other organ. In many cases of hepatitis, complicated with dysentery, more particularly when the hepatitis presents a chronic character, the termination of the inflammation in abscess is accelerated, if it be not altogether produced, by the sudden arrest of the dysenteric disease. In many other cases, as we shall have to show more fully when hepatic dysentery comes before us, the hepatic disease is not apparent until the dysenteric symptoms are subdued; but although the disorder of the liver was not evident, or did not excite notice, while the bowel disease was urgent, we are not on that account to infer that it did not then exist. On the contrary, we believe that in most of of the instances of this description, the liver was the original seat of mischief, which only became more severe and more apparent when the consecutive disorder was abated." 530.

When the abscess is seated posteriorly in the liver, and presses on the diaphragm, anxiety and præcordial oppression are urgent, with occasional dyspnoea or hiccup-when pointing towards the stomach, flatulence

and vomiting are seldom absent. The easiest position is usually on the back sometimes in the sitting posture. Pain is a very uncertain symptom. A prickling sensation is commonly felt where the abscess is pointing. The countenance is indicative of disease-it is sallow, sunk, the eye of a pearly hue--tongue white and excited--spirits depressed, sometimes even to melancholy-progressive emaciation-quickness of pulse in the evening-bowels either relaxed or costive-motions morbid, "and always deficient of healthy bile," resembling soft clay or putty, with a peculiar fetor. In such cases we may infer, that the mischief is not yet very extensive, but that it will be not the less serious in the end.

"When, on the other hand, the symptoms are more acute, when the constitutional derangements are great, the tongue dry and smooth, the fever very considerable, and the functions of the alimentary canal much disturbed, and signs of dysentery present, then immediate danger is to be apprehended." 531.

Abscess of the liver may wear out the constitution before it breaks externally or internally-generally through the medium of a bowel-complaint. The appearances on dissection are very various, not only as regards the situation and extent of the abscess, but the colour, consistence, &c. of the purulent formation. The state of the surrounding parenchymatous structure is also very various. These varieties we need not dwell upon. Neither can we afford space for any of the numerous cases which are detailed by the author.

TREATMENT OF CHRONIC HEPATIC INFLAMMATION.

In our second analytical article on Mr. Annesley's work (No. 18. p. 344.) we took up the treatment of acute hepatitis, and, therefore, need not again go over that ground.

Mr. Annesley observes, that the chronic forms of hepatitis differ only from the more acute, in the duration of the disorder," and in the texture of the organ, more generally the seat of the inflammatory action." In fact, he considers the division into acute and chronic as entirely arbitrary, and only to be adhered to as far as respects the duration of disease." The therapeutical agents are ranged under the following heads.

I. Vascular depletion. Whether chronic hepatitis has resulted from the acute form, or been primary in itself, more or less vascular depletion will be necessary--chiefly local. The extent must be left to the judgment of the practitioner. The vigour of the patient's constitution, the fulness or pain in the side, the febrile action in the system, and the length of residence in a hot climate, will afford the necessary indications. There are few cases, however, where repeated, though moderate leechings will not be beneficial. After each leeching Mr. A. recommends a poultice to the side, and an aperient, consisting of calomel at night, and black draught in the morning. When the morbid action of the liver is lessened by these means, and the morbid secretions carried off, the calomel may be changed for a milder preparation, as blue-pill, or the hydrargyrum cum creta, with saline and antimonial aperients. Bowel-complaints are very common attendants on chro, nic hepatitis.

"When such is the case, enemata, either of a purging or of an emollient nature, should be a dministered, and the pulvis ipecacuanha comp. given in combination with the blue-pill at VOL. X. No. 20. 43

bed-time, and be followed by a dose of castor oil in the morning. In many of these cases, much advantage will be derived from the use of a flannel bandage kept constantly applied round the abdomen; and the local depletions which have been practised may be followed by blisters on the epigastric or hypochondriac regions, and these by the nitro-muriatic wash, until a healthy state of the secretions be brought about." 627.

II. Nitro-muriatic Solution. After the removal of acute symptoms by the means already pointed out, Mr. Annesley strongly advocates the use of this remedy, which English practitioners have strangely neglected--or rather rejected, without cause. We are in the habit of prescribing it frequently-and we are as certain of its effects on the system as we are of jalap or calomel. The following is Mr. A.'s formula for the solution.

"The nitro-muriatic solution, lotion, or bath, may be made in the following manner:Into a common quart bottle put about eight ounces of pure water, to which add four ounces of the nitric acid, and four of the muriatic acid, of the strength of the London Pharmacopoeia. The Nitro-muriatic Solution' is thus formed, and the bottle containing it ought to be labelled accordingly. If it be intended to use this solution in the form of a bath, from 2 ounces of it to 5, according to the strength of the patient, may be mixed with from two ayd a half to three gallons of warm water, of a temparature nearly approaching that of the blood, in a high and narrow vessel, and the feet and legs kept immersed in it for about twenty minutes or half an hour, every night before retiring to rest. If the bath does not occasion a pricking or itching sensation in the parts immersed, after twenty minutes have elapsed, the next bath should be increased in strength. Although we have frequently employed this bath, and generally with advantage, we prefer, in many respects, the practice of sponging the trunk of the body, particularly the abdomen, with the nitro-muriatic wash.

"When the nitro-muriatic solution is to be employed in the form of a wash, from two to three drachms of the Solution, prepared as just stated, should be added to a pint of warm water, and the trunk of the body, insides of the thighs, &c. assiduously sponged with it, by means of a large sponge, for about a quarter of an hour daily, or, occasionally, night and morning. We have found great advantage from employing this solution also in the form of poultice, in torpor of the liver and in chronic affections of the organ, attended with enlargement and a deficient and morbid state of the biliary secretion. Occasionally much benefit will arise from employing this wash in the form of fomentation; the water having been made as hot as 130 or 140° of Fahrenheit, when the acid solution is added. When this is practised, the flannels soaked with the wash should be applied for about an hour or two every night. It may be employed, also, with advantage by keeping cloths wet with the solution over the hypochondria and abdomen, and placing over them warm poultices; both the moistened cloths and the poultices being renewed from time to time." 628.

Mr. A. assures us, and we believe him, that he has seen the most decided advantages result from this remedy in chronic hepatitis, "and, indeed, in all functional disorders of the liver.' In the more chronic forms of disease of the liver, he observes, particularly where the structure is enlarged, and the biliary and intestinal secretions vitiated, "I consider it one of the most valuable remedies we possess." It should be continued two, three, or four weeks, unless it fulfils the intention before that time. It would almost appear, that this remedy has been rejected by English practitioners in consequence of that devouring rage for POLYPHARMACY, which is at once the bane and disgrace of British medicine! When the day arrives (and arrive it must) that will award the remuneration for skill and attendance instead of drugs, then will the external remedies be more employed-and the nitro

1

muriatic solution again come into favour. Mr. A. cautions us against the employment of mercurials during the use of the solution--but recommends purgatives to carry off diseased secretions.

"We have frequently observed, after it has been employed for a few days, that the patient has complained much of heaviness or drowsiness. When this is the case, active purgation should be instituted, in addition to the use of the solution, which will soon bring away morbid and offensive stools, and remove this symptom of disorder." 629.

Change of air, or a sea voyage, will often materially assist the salutary operation of the acid bath.

III. Nitrous Acid. This medicine has been a good deal employed internally, as an alterative, in hepatic diseases. As much as six drachms of the diluted nitric acid, in a large quantity of barley or rice water, may be taken in 24 hours. In the course of a few days it induces a slight salivation; but its beneficial effects are often observed from smaller doses, and without the salivary excitation. This medicine requires a longer administration than mercury, in order to insure its full operation. There is no incompatibility in the use of this medicine with mercury. Indeed, it is the opinion of Sir James M'Grigor, as well as of our author, that the conjoined administration of both, is superior to that of either singly.

To attempt to impregnate the system with mercury, in the active forms of hepatitis or in many cases of the chronic form, before the inflammatory action is, to a certain extent, subdued, leads, Mr. A. thinks, to want of success-nay, to positive injury. These objections do not apply to the nitrous acid, or to the nitro-muriatic bath; for, although these last are more serviceable after antiphlogistic measures have beeen employed, their premature use is not attended with any detriment.

IV. Blisters, Setons, &c. Blisters, of course, are not to be employed in the more acute forms till after depletion, on the same principle as in pneumonia, or any other internal inflammation. Afterwards they are salutary. In the more chronic and protracted cases, the drain of a seton or issue is more effectual. After a discharge has been established, Mr. A. recommends poultices to the part. We are a little surprised that Mr. A. does not mention the counter-irritation and purulent discharge produced by tartrite of antimony —an application extremely beneficial-and capable of being repeated from time to time without the constant inconvenience and pain of a seton. Tartar-emetic plaster is much superior to the ointment.

V. Tepid and Vapour Baths. These are serviceable in the course of the disease, whether in the active or chronic forms. In the latter, they should be followed by frictions, either with a coarse towel or flesh-brush, over the region of the liver, and, indeed, over the abdomen generally. The sulphur and chlorine baths are still more serviceable.

VI. Eccoprotics. "In the more chronic cases of hepatic disease, in addition to the external means already recommended, and particularly after local depletions have been resorted to whenever pain or uneasiness in the region of the liver manifested itself, a gentle aperient pill should be taken at bed-time, and saline laxatives through the day. The best pill which we can recommend for this purpose is that composed of the aloes and myrrh pill and blue pill, or the following:-R. Hydr. submur. Dj.; extract. colocynth. comp. Dij.; antim. tartar. gr. j.; pulv. ipecac. gr. jv.; sapon. Castil. gr. x; ol. car. q. s. M. ft. pilul. xviij. Two of these will generally be found to operate sufficiently, and may be taken

every night at bed-time, or every other night. In the majority of cases, however, one of them will prove sufficient, particularly when it is intended to continue the use of them for a considerable time, and when saline or other laxatives are also required through the day. Where the chronic disease of the liver is attended with enlargement, it will generally be found requisite to prescribe the above pills every night, the nitro-muriatic wash being employed externally night and morning; and a weak solution of the sulphates of soda, magnesia, and potash, either singly or combined, may be given in the morning, and, if necessary, again at mid-day, in order to keep up a gentle action in the large secreting viscera and bowels. If, however, a weak solution of these salts should occasion frequent and watery motions, with tenesmus, they may be changed for the solution of cream of tartar in tamarind water, or for the solution of the soda tartarizata, or the tartras potassæ. On many occasions, the factitious Cheltenham or Harrowgate salts may be given with advantage; and the Seidlitz powders may also be taken occasionally. Much benefit will generally accrue from changing, after a few days, the saline substances prescribed, particularly if the exhibition of the eccoprotic pill at bed-time, and the salts through the day, produce any degree of tenesmus. The cream of tartar solution, may, however, be given and continued for a longer time, without any risk of inducing this effect. If tenesmus occur, an emollient enema will always afford relief, and the medicines may be intermitted for a day

or two." 635.

From considerable experience in this class of, complaints, we would suggest a modification of the above eccoprotic pill, which we have found to be an improvement. We would substitute the pilula hydrargyri for the calomel, and we would double the quantity of the tartrite of antimony. As there is often much irritation prevailing in the bowels, and in the system generally, three grains or four of extract of hyosciamus at bed-time, will be found a very useful adjuvant.

VII. Bitters, Tonics, &c. The continual operation of deobstruents-the defective nutrition-the impaired digestion-the irritative fever which more or less obtains-all these tend to produce great languor, debility, and irritability, in the hepatic invalid. On these accounts, it is very generally necessary to combine bitters or even tonics with the alterative or deobstruent remedies, in order to support the strength and improve the digestive and assimilative processes. The infusions of calumba, gentian, chamomile, with some tincture of the same, and soda, are the usual forms of bitter medicines-to which is to be added the taraxacum. We are very much surprised that this remedy does not enter into the catalogue which Mr. Annesley has laid before his readers. As his experience has been almost entirely confined to India, where the taraxacum is little used, Mr. A. probably is practically unacquainted with its effects. But the more it is employed, the more certain proofs will it afford of its utility. The aperient and diuretic qualities of this root are unquestionable. The following will be found a very convenient, and not an unpleasant formula.

R. Decocti taraxaci.

Carb. soda

Extr. taraxac.

Tinct. gent. c.

3ij.

Misce fiat mistura, capiat coch. ij. vel. iij. mag. bis die.

Although tonics are precarious medicines, and can rarely be given while any inflammatory action is going on in any of the chylopoietic organs, yet a period sooner or later arrives when they become necessary, and are then