704 DISEASES OF THE LIVER. 



by calculi ; but the true ground of the obstruction is at first entirely 

 obscure. In one patient, where there was finally no doubt about the 

 diagnosis, at the first consultation, I was obliged to limit myself to 

 saying, " There is an obstruction of the excretory bile-ducts, from some 

 cause unknown to me." Early in the disease, on examining the abdo 

 men, we find the liver enlarged; but even this symptom does not 

 enable us to make a diagnosis until the enlargement has become very 

 marked, or the resistance of the liver has greatly increased, and while 

 its surface remains smooth. Where the fasces are discolored and the 

 icterus excessive, we are most apt to ascribe the enlargement of the 

 liver also to biliary obstruction. On the other hand, if, while there is 

 excessive and obstinate icterus, and complete discoloration of the faeces, 

 we find enlargement of the liver, but not of the gall-bladder, we should 

 suspect multilocular hydatids. Under such circumstances, the obstruc- 

 tion is, most probably, not in the ductus choledochus, but in the ductus 

 hepaticus, for when the former is obstructed, the gall-bladder also is 

 usually distended by the obstructed bile. Obstruction of the hepatic 

 duct is rare, but probably its most frequent cause is multilocular hy- 

 datids, and hence, when we think we have found it obstructed, we 

 should suspect this disease. The suspicion that there is a multilocular 

 hydatid cyst in the liver increases, and may become a certainty, if, be- 

 sides the above symptoms, the liver becomes uneven and nodular as 

 the disease progresses. From that time swelling of the liver, from 

 simple biliary obstruction, may be excluded ; the case can only belong 

 to one of the varieties of liver-disease where the form of the organ is 

 thus changed that is, it must be cirrhosis, syphilitic, or carcinomatous 

 disease, or hydatids. The rest of these diseases are hardly ever accom- 

 panied by complete discoloration of the faeces, and excessive and obsti- 

 nate biliary obstruction, in which the gall-bladder does not participate, 

 while these are very frequent accompaniments of multilocular hydatids. 

 Hence, if we find a hard nodular enlargement of the liver with those 

 symptoms, we are justified in diagnosing a multilocular hydatid. 



In many cases, in the course of the disease, there are ascites, enlarge- 

 ment of the spleen, gastric and intestinal haemorrhage, occasionally 

 also haemorrhage from other mucous membranes, and effusion of blood 

 into the cutaneous tissue. But none of these symptoms are pathogno- 

 monic of multilocular hydatid ; they result from the great biliary ob- 

 struction and reabsorption of bile, and, as we shall show in the next 

 chapter, occur just as often in other forms of obstinate obstruction and 

 reabsorption of bile. 



TREATMENT. Treatment can accomplish nothing in multiloculai 

 hydatids; occasionally the inefficiency of the remedies used for the 

 icterus strengthens the diagnosis. Of course, there is no way of n> 



