The treatment depends on the diagno sis. 1. If it Le doubtful, an explora tory inci-ion is indicated if the patient's general condition ‘V :I. If lignant ili-svti,e be positively diagnosed, opt ration con. IN it il eXCept 1011,, tiO bIll ill ill' good sa‘e when all the dis eased tissue tail be removed. 3. If gall stones or of the first live factors be diagno-ed. operation is decidedly advk. able if the patient he itt all able to hear it. The two great dangers are hamior rhage and shock—accidents such as are liable to follow any severe abdominal t raninat km. .1 study of the unsuccessful cases will no doubt reduce the mortality even lower than it already is; within the last year it has dropped in chole dochotomy from 14.5 to 7.4 per cent. The anti-operative treatment of ordi nary ca:‘es is in no way different from that given for a general laparotonty, but when a Inemorrhogic condition is ex pected calcium chloride is fed in heroic doses, a8 this has been found to aid ma terially in limiting capillary In-emor rhage by increasing the eoaffulability of the blood. _1. 11-. May-o Robson (Brit. „Nled. Jour., Jan. 1S, 1902).
II. Toxminic Jaundice (1Immatoge nous Jaundice ; Hmmo-hepatogenous Jaundice ; Jaundice of Polychromia ; Non-obstructive Jaundice).
In this form there is said to be no obstruction in the bile-passages. Such in most, if not all, cases is not correct, because, although the larger ducts are free, the bile-radicles within and around the hepatic lobules are obstructed to a greater or less extent by swelled epithe lium, pigment-granules, and crystals of leucin and tyrosin. The obstruction in these cases is shifted from the larger ducts to the biliary radicles, many of which escape, so that the obstruction is rarely complete. The cause acts on the liver-substance in general and must, therefore, be toxic and conveyed to it by the blood, either of the general or the portal circulation. The toxin acts on the blood, and in its excretion by the liver leads to the secretion of a viscid bile, to irritation of thc biliary radicles, and it may be to degenerative changes in the liver-cells.
There are cases of obstructive jaundice in which tbe occlusion occurs witbin the biliary lobules and is due to swelling of the epithelial cells. Tbe swelling and de generation of the hepatic cells are the re sult of the action of toxic substances introduced through the circulation. The treatment of this form of jaundice con sists in the regulation of the diet, the improvement of tbe circulation and the blood, and remedies addressed to the liver to stimulate more active secretion, but, first of all, to reduce the cellular swelling so as to free the terminal biliary capil laries. Porter (Amer. Med.-Surg. Bull.,
Dee. 1, '94).
Hunter makes three groups of this class of cases:— 1. Jaundice due to poisons, as toluy lendiamin, phosphorus, arseniuretted hydrogen, and snake-venom.
2. Jaundice occurring in various spe cific fevers, as yellow fever, malaria, pyernia, enteric fever, typhus, and scar latina.
3. Jaundice occurring in obscure in fective conditions, as in epidemic, infec tious, febrile, or malignant jaundice, icterus gravis, Weil's disease, and acute yellow atrophy of the liver.
In this class the jaundice is usually less intense than in obstructive jaundice. There is only a partial absorption of the bile-pigment by the lymphatics of the liver. Bile appears in the stools at some period of the history; it may be in excess, causing very dark frecal discharges. There is usually more constitutional dis turbance than in obstructive jaundice. In severe cases this is very pronounced— high fever, dry tongue, delirium, subsul tus, convulsions, luemorrhages from vari ous parts, black vomit, all indicating severe constitutional infection.
All cases usually' show (1) destructive changes in the blood; (2) alterations in the quantity and quality of the bile; (3) changes in the liver-cells and bile-ducts, varying in degree according to the irri tant power of the toxin.
The destructive changes in the blood are shown by the occurrence of liwmor rhages especially from the mucous sur faces, as of the nose and stomach. The black vomit of yellow fever furnishes a striking example of such hmmorrhages. The changes in the bile are characterized by its increased viscidity, great increase in its pigment, and lessening of the bile acids. The parenchymatous changes in the liver are evidence of the action of the toxins on the liver. Similar changes occur in the kidneys.
In many varieties the toxins that excite these changes are generated in the in testinal tract, as gastro-intestinal symp toms are usually prominent in the initial stage of the illness. In this way we may account for the absence of specific organ isms in the liver in acute yellow atrophy, for example.
The form of icterus gravis in which the bacillus coli is found is accompanied by lowering of the temperature, while the other forms of the same disease which are accompanied by fever are characterized by the presence in the liver and blood of pyogenic microbes. Undoubtedly, how ever, the micro-organisms play a rele in the production of the lesions and symp toms of ieterus gravis. Hanot (Le Bull. AIM., Feb. 21, 11lay 6, '94).