saliva, semen, and milk, undergo similar changes. But the bitter taste of the milk observed by some, and the refusal of the breast by the infant, show that it must have sustained some qualitative change.

The characteristic pain of the liver, which sets in at the commencement of the disease, and accompanies it throughout, is of a nervous character, and is generally referred to a circumscribed spot over the left lobe. In slight cases it amounts only to a feeling of tension and oppression, with occasional fugitive stitches; aggravated by pressure so as to compel the patient to make a forced respiration. In bad cases it becomes very severe. It goes hand in hand with the loss of function and decrease in size of the

organ.

The increase in volume of the spleen, which keeps pace with the atrophy of the liver, is evidenced by feelings of tenderness and oppression in the left hypochondrium, which sometimes increase to severe pain obstructing respiration.

There is also a remarkable pain in the eighth or ninth dorsal vertebra; as well as pains in the limbs and joints of a rheumatic character, which alternate with a feeling of stiffness, and a consciousness of stupor, or total loss of sensation in the parts. As these painful affections are witnessed in cases where there has been violent vomiting; Dr. Horaczek thinks they may be attributed to the mechanical agitation of the body. Embarrassed respiration and constriction of the chest, which are increased at night, or on making any sudden movement, and sometimes induce fits of palpitation, he attributes to the diseased condition of the blood. Disease of the heart or lungs inducing similar symptoms may be detected by percussion and auscultation. The advanced stages and severer forms of the disease are marked by cephalic and nervous symptoms, which set in sometimes quite suddenly and unexpectedly. To restlessness, sleeplessness, high delirium, repeated vomiting, and tonic or clonic spasms, succeed apathy, diminished sensibility to external impressions, low muttering delirium, with rapid, feeble, unequal pulse, gradually increasing, and at length profound coma, paralytic affections, total unconsciousness, involuntary evacuations, cold viscid sweats, and death. This modification of the disease has been named nervous jaundice, or cephalocholosis. Sometimes the disease runs on to regular typhus, or it ends in dysentery, or the powers sink under coffee-ground vomiting and purging, indicative of passive hyperemia, and softening of the mucous lining of the intestinal canal.

Of combinations and complications, besides those just noticed the most serious is that with inflammation of the abdominal veins, which the author thinks may be attributed to the rapid shrinking of the liver inducing retarded circulation and partial coagulation of the blood. The coagulum so formed undergoes a purulent decomposition, and induces inflammation of the inclosing vessels, attended by the usual symptoms. One very important remark, especially in a practical point of view, is, that genuine healthy inflammation is incompatible with cholosis; though inflammatory congestion with softening of the mucous and serous membranes, and passive inflammations of the lungs and other parenchymatous organs are frequent enough.

All these processes are, however, slow and irregular, without any tendency to a critical termination, and partake of the nature of mere conges

tion and infarction, with a disposition towards decomposition rather than to proper inflammatory plastic processes. Whilst alluding to certain periods of life as predisposing causes of cholosis, he takes occasion to notice icterus infantum, respecting which he seems to doubt what may be its true relation to biliary disease in general. He thinks it probable that many cases belong to primary cholosis, both from the symptoms during life and appearances detected after death. Some may be referred to secondary

varieties of the disease, but there are not a few whose true circumstances and position remain to be determined by numerous and accurate observations. With respect to progress and duration, he defines the disease to be ("atypische") one sui generis, irregular in progress, undetermined as to limits, and of uncertain duration, which develops itself gradually or suddenly.

In some cases the symptoms disappear suddenly before they have become more than precursory, or they are so mild as scarcely to claim medical interference, or interrupt the patient's usual avocations.

The average duration of the disease is from four to six weeks. When prolonged beyond eight or ten weeks it passes into the secondary forms. It may, however, destroy life in eight or ten days. It is not the subject of proper critical efforts, for although a certain degree of alleviation sometimes follows deposits in the urine, general perspiration, discharges of blood, eruptions on the skin, and the restoration of suppressed secretions or excretions, yet Dr. H. does not consider them properly critical, because they do not appear at any regular period, are only accidental, and the disease often terminates favorably without them. Bilious stools frequently bring about a very decided improvement, but they have not always such a desirable result, nor is the time of their appearance determined; and, therefore, even they cannot be strictly called critical. The prognosis is generally favorable. Bilious dyscrasy sometimes, though not often, ends in other diseases; generally in bilious cachexia, with a disposition towards the reappearance of the original malady, or towards the development of its secondary forms. In such cases we have digestive derangement, chronic vomiting, irregular action or torpor of the liver, disposition towards the formation of gall-stones, shrinking and hardening of the liver, &c. It may also end in putrid fever; and if the brain has been much engaged, it may leave behind epilepsy, maniacal affections, or paralysis of the extremities.

When death does take place, Dr. Horaczek views it as the result of poisoning and paralysis of the cerebral nervous system, evidenced by the cephalic symptoms before enumerated, which follow the derangement or disturbance of the mutual relations between the nervous and vascular systems, and the subsequent softening of the organs chiefly implicated. Chemical analysis of the blood, and of the various secretions and excretions, is the most suitable, and, with the improvement of chemistry, will be the most certain method of diagnosticating cholosis.

We may thus determine whether cholosis, anemia, cachexia following the abuse of spirituous liquors, that which attends cancer, pyæmia, or purulence of the blood, phlebitis, &c., all of which are accompanied by more or less yellow discoloration of the surface, are also complicated with cholosis or not.

It is often difficult to distinguish primary cholosis from some of its secondary forms, dependent on disease of the liver, pancreas, pylorus, duodenum, pleura, &c., or on obstruction of the biliary ducts, feculent accumulations in the colon, or pregnancy. Disease of the hepatic parenchyma, attended with increase of volume, may, however, be detected by manual examination. There is, besides, in such cases emaciation, with longcontinued dyspepsia and dropsical appearances; the yellowness, moreover, is earthy, the skin is dry, harsh, and faded, and the symptoms indicating the narcotising effects of the accumulated biliary constituents on the nervous system are not well pronounced.

It is difficult to diagnosticate jaundice from gall-stones, from primary cholosis, especially if it attack young persons under the influence of mental emotions, and with acute symptoms, such as vomiting, pain in the liver, &c. Gall-stones are, however, generally a disease of persons advanced in life; the pain they cause is colicky, attended by a sensation of burning heat, sometimes remitting, or coming on at intervals like the pains of labour, and it often ceases suddenly, or is relieved by remedial agents. There are also cramps of the abdominal muscles, and of the whole body; the skin is covered with cold sweat, the pulse is contracted, the head is not engaged, and inflammation of the liver or neighbouring parts often succeeds.

Polycholia cannot readily be confounded with primary cholosis, as it is attended by increased size and increased functional activity of the liver, together with an overflow of bile into the intestinal canal; as well as by an increased formation of biliary matter in the blood, and jaundice, consequent on its insufficient separation through the liver. To polycholia belong bilious fevers, and bilious pneumonia and pleurisy.

It remains to notice some of the chief therapeutical indications according to our author, as well as the means by which he proposes to work them out.

The causes of the disease, if still in activity, must if possible be removed, or their operation be neutralized.

The restoration of the disturbed relations between the functions of the vascular and nervous systems he lays down as another indication. In reference to which he remarks truly enough, that as the precise nature of this disturbance, not less than of the normal relations of these functions to each other, is and ever will be a mystery, we can only resort to such rational or well-devised empirical measures, as tend to restrain their activity when in excess, and to excite it when unduly depressed.

We are as yet acquainted with no agents calculated to neutralize the injurious effects of the biliary elements on the blood, except those found to be useful in other cachectic and dissolved conditions of that fluid; of which the best are the mineral and vegetable acids, and preparations containing chlorine. The most important indication is to eliminate the biliary admixture from the blood, by exciting the activity of the liver; for this purpose purgatives must be used, of which he prefers rhubarb and aloes in full doses. Calomel must not be given except in occasional and purgative doses, lest the plasticity of the blood be still further reduced; and for the same reason the author objects to saline aperients, which merely in

crease the intestinal secretions, except in those cases where it is desirable to make the intestinal canal the seat of a vicarious discharge of the biliary elements, in consequence of a total and persistent suspension of the functions of the liver.

If we are unable to restore the functional activity of the liver, the best substitute for it will be excitement of the kidneys by means of diuretics.

If symptoms of biliary oppression of the brain display themselves, the restoration of the hepatic functions must be attempted by strong emetics, drastic purgatives, dry cupping, stimulating applications to the abdomen, and stimulating enemata.

If the cerebral oppression be caused by hyperemia, or an inflammatory state of the brain, which is sometimes, though rarely, the case, we may resort to local bloodletting, cold applications to the head, sinapisms to the feet, or stimulating pediluvia, repeated doses of tartar emetic in decoction of tamarinds, and cooling acid drinks.

If the cerebral affection be purely nervous, besides external stimulants and revulsives applied to the head itself, as well as other parts of the body, the author resorts to the internal use of stimulants and tonics, enumerating in addition to those generally used in these countries, phosphorus and the flowers of the arnica, which last he prefers to all others, on account of its specific effects on the brain.

Pain in the liver, which is almost always purely nervous, he treats with external emollients, derivatives, and sedatives.

He subjoins a tolerably extended list of popular and superstitious remedies, to which additions, equally whimsical and disgusting, might be made from sources nearer home.

The book concludes with a detailed narrative of upwards of 90 cases. More than one third of the number terminated fatally, and the morbid appearances which they presented on post-mortem examination are also given, so that we are furnished with copious illustrations by which to test the doctrines and precepts inculcated by the author.

We here conclude our account of Dr. Horaczek's work, from which we have extracted largely. Although the author's pathological views are not always very definite, and are sometimes very open to criticism, we still think the book is well worthy of a careful perusal, as it supplies an important addition to our knowledge of a very obscure class of diseases, which it presents under aspects chemical, pathological, and even semeiological, in some respects both new and important; and induces us to look with considerable interest for the fulfilment of Dr. Horaczek's intimated design, of giving a complete view of the subject, by the publication of his researches on the other forms of bilious dyscrasy.

ART. III.

Transactions of the Provincial Medical and Surgical Association. New Series. Vol. II.-London, 1846. 8vo, pp. 285.

THE Contents of the present volume are the following:-1, The Retrospective Address in Medicine, by Edward Charlton, M.D.; 2, The Retrospective Address in Surgery, by Thomas P. Teale, Esq.; 3, On Grinders' Asthma, by C. F. Favell, M.D.; 4, On the Inverted Displacement of the Urinary Bladder, by J. G. Crosse, Esq.; 5, Report of the Reading Dispensary for the years 1841-4, by Charles Cowan, M.D.; 6, A Statistical Report of the Surgical In-patients of the Royal Berkshire Hospital from 1839 to 1845, by George May, Esq.

I. Our readers have had so much from ourselves in the form of Reports of the progress of medical science in its different branches, that they will excuse us for not giving any account of the two excellent addresses with which the volume opens. We must also content ourselves with referring to the original report of the Berkshire Hospital and Dispensary, which do great credit to the industry and talents of their authors. It is surprising, when we consider the great number of hospitals scattered over all our counties, that so few of their brethren have emulated Dr. Cowan and Mr. May in enriching the pages of these Transactions with similar documents.

II. Mr. Crosse's paper gives the history of a case of rare occurrence, and is important, as exhibiting the value of a careful examination and consequent just diagnosis, and the dreadful risk attending a mistake in this particular. We extract the more material points of the narrative:

"In the year 1829, a highly respected colleague of mine, since deceased, received under his care a healthy-looking female child, aged between two and three years, on account of a tumour, about the size and shape of a walnut, projecting visibly at the external labia pudenda. It was of a florid red colour, and somewhat granulated upon its surface, so as to resemble a large strawberry; and the surgeon entertained a notion that it was a vascular tumour, which might be removed by ligature, on which account he requested me to inspect it.

"After a slight examination, I expressed my doubts as to its being a vascular tumour, and dissuaded him from the hasty application of a ligature. I could not, however, immediately explain its nature, having no conception how such a tumour could be formed by the displacement of parts only, without any superadded morbid growth. Towards the posterior part of the tumour, and on its sacral aspect, there was an aperture, which was conjectured to be the entrance into the displaced urethra. A very small female catheter easily entered this aperture, and passed along a channel a little to the left side of the median line: urine distilled in drops through the catheter, but there was not a gush, although the instrument had entered so far that we concluded it must have reached the cavity of the bladder. Besides what thus oozed through the catheter, slightly tinged with blood, there was an oozing of urine from another source, which was not explained until a second and more strict examination, instituted a few days afterwards, on my casually coming to the patient's bedside, just as the surgeon was prepared to apply a ligature round the neck of the tumour.