sac investing the contents of the abdomen, always ready enough to take on inflammation. But the books contain many strange histories of such anomalous facts. Cheston records a case in which, without jaundice, the gall-bladder was found, after death, to contain two quarts of bile. Van Swieten tells us of a lad of 12 years in whom the same cavity contained eight pounds of bile. Cline relates an instance in which a tumor, pointing externally-the gall-bladder doubtless-was opened and discharged twenty ounces of" bilious matter." This patient did not die until seven days afterwards.

6. We meet occasionally with an obscure variety of jaundice of sudden and abrupt invasion. The symptoms of this class of cases are precisely similar to those recorded under the last head; pain at the pit of the stomach, sometimes also in the right hypochondrium and at the top of the right shoulder; nausea and vomiting, flatulent distension; tenderness on pressure over the belly; meteorism, obstinate costiveness or teasing diarrhoea with unnatural stools, acrid, and inflaming the parts about the anus; great mental anxiety; the pulse not affected for some hours, but afterwards excited, frequent, and tense; the eye and whole surface assuming a deep yellow or orange hue. But we can detect no gall-stone. The predisposition to this form of icterus. consists, doubtless, in some obscure hepatic derangement which the minutest examination, after death, has failed to point out. The excit ing causes are generally such as disturb the digestive function; a meal of improper food, or the undue use of acids; violent agitation from any passion, more especially grief and anxiety; exposure to cold, moisture, and sudden changes.

The treatment applicable to the last two classes of cases is precisely the same. If the patient be of ordinary strength and vigor of constitution, venesection must precede every other remedy, and requires to be carried out with a freedom and boldness proportioned to the urgency of the symptoms. The patient should be kept in the erect posture, or near it, in order that a more prompt and complete relaxation of the whole system may be effected. The warm bath will aid very much in bringing on this condition. Opiates must be freely administered and repeated until the intensity of the pain is subdued. If the stomach will bear it, the tincture of opium should be preferred; solutions of the salts of morphine are less offensive, but sometimes the pill only will be retained. Full doses are required; I prescribe from two to four grains of the drug, or their equivalent, repeating every hour pro re nata. It is well to combine it with calomel also in efficient amount. Opiate enemata should also be exhibited without delay, and fomentations or warm mustard poultices applied over the whole abdomen, but especially to the pit of the stomach.

I should not now hesitate in any case of such intense suffering to resort to the inhalation of chloroform, and to bring the patient without delay under its most excellent anæsthetic effect. This may be managed in the usual manner; but I prefer, as apparently safer, the breathing into one nostril, the other being closed, from a wide-mouthed vial containing the fluid. In a few minutes the influence begins to be felt, and increasing steadily can be graduated by the patient himself, who

may stop the inspiration as soon as the pain is sufficiently relieved. A preference is given by some to ether as less to be dreaded, and by others to the combination of the two valuable agents. When we have thus obtained some respite, an active cathartic must be given. If the patient can retain castor-oil, it is to be preferred; if not, the neutral salts may be substituted, and the use of these in proper doses and at requisite intervals should be continued for a considerable period, in combination with some of the resinous purgatives-aloes or rhubarb. Mercurials do not seem to me to be of the special necessity or advantage so often contended for, until the case has been protracted into its chronic condition, and the sufferings of the patient, whether from mechanical or specific irritation, have at least, in a great measure, subsided. They are now of great utility; small doses of them may be persevered with until the production of a light ptyalism, the disappearance of the sallowness of the skin and eyes, and the return of appetite and alvine regularity, mark an established convalescence. In this stage we may also make trial of the nitro-muriatic bath, whose introducer, Dr. Scott, affirms that he "has often known it, when used in the midst of a severe paroxysm of spasm in the bile ducts, operate like a charm, giving almost immediate relief."

Some practitioners are in the habit of prescribing emetics in these attacks, with the hope of promoting the more rapid advance of the calculi through the duct into the duodenum. They select, for this purpose, the mildest and most relaxing articles, such as oil or ipecac., and administer them in such doses as to give rise to prolonged nausea and full, free vomiting. But the cases I have met with have all been attended with retching and vomiting, frequent and abundant enough to render any further efforts in that way unnecessary, if not injurious and improper. Nor do I place any confidence in the exhibition of the proposed solvents of biliary calculi-turpentine, ether, nitric acid, etc., though recommended by Durande and others. I do not understand how their agency can be applied, and, except ether, they are all irritating and unsuited.

It is highly desirable to prevent the recurrence of these paroxysms, as they are attended not only with unspeakable suffering to the patient, but with urgent risk of enteritis, and must by repetition break down and destroy the firmest constitution. I know no means which promise more benefit than those already advised, as tending to promote, hasten, and render permanent the lingering, irregular, and uncertain convalescence from chronic hepatitis: a change of climate, carefully avoiding the summer and autumn of hot malarial districts; annually repeated visits to the established watering-places, purgative and diuretic springs, such as Saratoga, the White Sulphur, etc.; great prudence in abstaining from all excesses, mental and physical; the observance of nice temperance in the pleasures of the table and the use of vinous and alcoholic drinks; the wary adaptation of the clothing to alternations of atmo spheric temperature and condition; the abandonment of all sedentary and indolent indulgences; and the establishment of resolute habits of energetic occupation and systematic exercise.

SPLENITIS.

In all warm climates, subject to the influence of malaria, enlargement and induration of the spleen are familiar phenomena. As the consequence of intermittent fever, it is, indeed, well known, wherever that disease prevails, whether in Lincolnshire, Walcheren, or South Carolina. The nature of this enlargement is not well understood. The organ is of the erectile structure, and is liable to sudden intumescence, as has been repeatedly observed during the chills of a tertian. Andral noticed remarkable changes of bulk in the spleen of a dog, during a painful experiment upon the animal. Ague cake is supposed, by some writers, to be a mere passive congestion or hypertrophy, and sometimes attains, from the repeated concussions of ague, an immense size. Lieutaud mentions a woman who had for seventeen years a spleen that weighed thirty-two pounds. Sauvages speaks of a scirrhous spleen weighing thirty-three pounds. The largest that I have ever seen weighed but ten pounds. Some of the most enormous in bulk do not, by any means, prove proportionally heavy.

I am satisfied that this ordinary condition of mere hypertrophy degenerates not unfrequently into a chronic inflammation. It maythough this must be very rare indeed-give rise to acute splenitis. Yet I am unwilling to allow even this, unless some incidental contin gency be added, some influential and energetic cause of novel character, brought into play. Among all the numerous cases of enlarged spleen that I have had occasion to see, but a single one has terminated in this way. A little girl, æt. five years, who had suffered much from fever in our low country, and had labored under a chronic inflammation of the spleen, with great enlargement, giving rise to much suffering and inconvenience, was seized, while on a visit here in May, 1838, with scarlatina. She passed through the disease, which treated her severely enough, but when convalescent, complained anew and loudly of her side, which was very much distended and painful when pressed upon. After some weeks' illness, she died, vomiting pus in large quantities and of very offensive odor. I was not permitted to examine the body, but was fully satisfied that the matter flowed from a splenic abscess, which, by adhesion, had connected itself with the stomach, and burst into its cavity. In a very large majority of cases, the swollen and indurated viscus remains little changed throughout life, giving annoyance by its weight and bulk, and inducing anasarcous swelling of the lower extremities, and perhaps even ascites, by its mechanical pressure upon the abdominal vessels.

I have had under my care two well-marked instances of chronic splenitis, neither of which had any connection with previous fever. Their cause was obscure; in one, the termination was fatal-the other, after suffering many months, has perfectly recovered her health.

The symptoms are not likely, I think, to be in any degree equivocal. The locality of the pain complained of, the bulk of the tumefied viscus, and the absence of the specific tokens of the disorder of other organs,

leave little or no room for error, and these remarks apply as well to the acute as to the chronic variety of splenitis.

The changes which the spleen undergoes from the action of disease are various; suppuration, hemorrhage, tuberculation, hypertrophy, with induration on the one hand, and softening on the other, and a peculiar alteration or dissolution of its substance. This latter is described by Heberden and Abercrombie, and is affirmed to have been the usual consequence of fatal attacks of the celebrated Walcheren fever. The term scirrhus is often employed when speaking of indurated spleen, but Baillie denies its propriety.

It is not well understood why this organ should suffer so much in fever. Andral has suggested that, in malarious cases, it is owing to changes wrought in the blood itself by the miasmatic poison. But it occurs in typhoid cases also, in forty-six dissections of which, by Louis, the spleen was found natural only in four. Rush, and some other physiologists, have imagined the function or use of this organ to be, to serve as a diverticulum in fevers universally, and the idea is, at least, plausible. The distensibility of its vessels is remarkable, and it is peculiarly liable to passive congestion. Its tissue seems unlike others both in elasticity and in tenacity. It is subject to rupture of vessels from many causes, and to laceration of its substance-an accident that frequently occurs from external violence.

The treatment of splenitis is unsettled, and by no means successful. In acute cases, depletion by the lancet, cups, leeches, and saline purgatives is indicated, and must be carried into effect promptly, and with as much energy as circumstances demand and admit of. If it assume the chronic form, our task is a very difficult one. The mercurial treatment, formerly so much relied on, has of late fallen into comparative disuse. A majority of modern physicians prefer to depend upon the continued exhibition of drastic cathartics, as the combination of aloes with rhubarb and colocynth, etc. Some, borrowing from the practice of the Hindoos, who give vinegar and steel, while they purge the patient actively, have added tonics to their purgatives, and prescribe both iron and bark, alternately with their cathartics.

For my own part, I cannot recommend any particular formula with great confidence, in this obstinate malady. I think I have found most benefit from the use of iodine combined with mercury, as in the deutiodide of mercury and potassium, while the patient's bowels were kept soluble by the employment of blue pill, with rhubarb, in such doses as were requisite, never pressing this matter very far. Cups or leeches over the tumor relieve pain. Fomentations applied to the side are also useful.

The diet of the patient should be light and nutritious. Tonics may be occasionally required, in which contingency I have been disposed to prefer iron, especially in the new preparation known as the tinct. ath. acet. ferri. If the pain be constant and annoying, I do not hesitate to resort to anodynes and sedatives. Many have recommended conium and hyoscyamus, but the preparations of opium, and the salts of morphine, are the only articles of this class that deserve the least reliance. Enlargements of the spleen, though far more commonly met with in

malarious regions, are not confined, it would seem, to these localities. Dr. Jackson lately exhibited to the Pathological Society of Boston a spleen which weighed several pounds, and was hard to the feel. The patient had never had intermittent fever, nor visited any district of country where such fever prevailed.

PAROTITIS MUMPS.

Among the affections of the collatitious viscera, we must not omit to notice this familiar form of disease, which derives some importance, indeed, from the very fact of its frequent occurrence. It is, as its name imports, an inflammation of one of the salivary glands, the parotid; arranged in Cullen's nosology as a species of Cynanche, C. parotidea, and entitled by Parr, Angina parotidea. From the difficulty of opening the mouth to speak, and the sullen expression of countenance produced by this enforced silence, and the attendant swelling, it has received the English appellation of mumps, by which it is universally recognized.

It consists in a painful swelling of the parotid, which renders all motion of the lower jaw difficult and uneasy; there are occasional paroxysms of severe suffering, intense aching, in which the ear of the swollen side is apt to partake; deglutition is very inconvenient. Both glands may be affected, but it is often confined to a single one. In the former case, the tumefaction usually becomes enormous, extending over the neck beneath the chin, down upon the breast, impeding respiration more or less, and up along the cheeks, and eyelids, and forehead, so as very much to disfigure the countenance. It is attended meanwhile by symptomatic fever, with the usual phenomena-hot dry skin, hard frequent pulse, thirst, furred tongue, gastric uneasiness, sometimes running on to retching and vomiting, general distress, restlessness, and dejection of spirits. It is specifically contagious, and attacks but once.

A singular and interesting point in its history is the marked tendency which it exhibits to a so-called metastasis-translation of the morbid affection from one gland to another, from the part first assailed to other and remote organs. In males the testis, and in females the mamma are liable to this secondary inflammation, which occurs only at, or after, the age of puberty. A similar metastasis, or transfer of morbid action, or obscure sympathetic extension of inflammatory excitement, is sometimes determined to the brain, producing phrenitis. Of this, which is denied by some writers, I have myself known three very serious and perfectly well marked instances. The duration of parotitis, when it runs its ordinary course in a single gland and subsides without metastasis, is not generally more than four days, and the patient, especially if a child, may complain very little, except when eating, or after talking freely. If it extend to both sides successively, a day or two will be added to the indisposition. If the metastasis occur, which, as I have said, is very apt to take place in the adult, the protraction of the case is irregular and indefinite, depending somewhat