DISEASES OF THE LIVER. 



every case of icterus, while these severe nervous affections are very 

 rare. Leyden attempts to meet this objection by calling attention to 

 the fact that the severest symptoms are avoided by the continued 

 excretion of the bile-acids through the kidneys, which prevents their 

 excessive collection in the blood. The correctness of this explanation 

 appears to be supported by the fact that a remarkable fatigue is 

 scarcely ever absent, no matter how slight the jaundice, as well as the 

 fact that a diminution of the secretion of urine has been always con- 

 sidered as having a bad effect on the course of jaundice. On the 

 other hand, it is opposed by the fact that, hi hsematogenous icterus, in 

 which, as Ley den very particularly notices, no bile-acids can be discov- 

 ered in the urine, the same severe nervous difficulties are observed 

 even more frequently than in hepatogenous icterus. I do not consider 

 the question as settled. The proportionately frequent occurrence of 

 severe disturbances of innervation in cases where there is only a slight 

 amount of icterus, but a severe and extensive degeneration of the liver, 

 may be far more readily explained by the hypothesis of Frerichs, 

 already alluded to, than by the equally hypothetical poisoning by the 

 bile-acids. Moreover, the assertion, that the excessive collection of bile- 

 acids in the blood and in the tissues is avoided by their continued ex- 

 cretion through the kidneys, is opposed by the fact that the excessive 

 collection of the bile-pigment is not prevented by its continued and 

 plentiful excretion through those organs. If the affair were as simple 

 as Leyden suggests, the frequency of the occurrence of symptoms of 

 poisoning would still be in some proportion to the intensity of the 

 icterus, which is not the case, as is well known. 



In slight grades of biliary obstruction, physical examination does 

 not show any enlargement of the liver. In higher grades, on the 

 contrary, such as those due to complete closure of the ductus hepaticus 

 or choledochus, we may often recognize very decided enlargement of 

 the liver by palpation and percussion. Its surface appears smooth, 

 and as the consistence is increased the lower border is very distinct. 

 If the ductus choledochus be closed, we may generally feel the dis- 

 tended gall-bladder as well as the liver-tumor. If the liver-dulness 

 diminish without decrease of the icterus, it is a bad sign, for it indi- 

 cates consecutive atrophy of the liver. 



TREATMENT. We can only treat those cases of biliary obstruction 

 successfully where we are in a position to fulfil the causal indications 

 Hence we are powerless against the cases caused by most hepatic dis 

 eases, such as echinococcus, carcinoma, or cirrhosis, while we are some 

 times successful in treating those cases due to obstructions in the bile- 

 ducts. The remedies vaunted as specifics in icterus are such as have a 

 favorable effect on the diseases of the bile-ducts ; we shall speak of then: 



