CHAPTER LII
.
THE LIVER.
CONGENITAL DISPLACEMENTS OF THE LIVER.
The congenital defects and displacements of the liver which interest the surgeon are few. More or less transposition, sometimes complete _situs transversus_, is encountered. The same is true of more or less _hernial protrusion into the chest_, through a defect in the diaphragm, or such displacement as may be permitted by some defect of the abdominal walls or other viscera. Hammond has recently shown that the _left lobe of the liver is sometimes congenitally enlarged_ to an extent sufficient to cause symptoms, a condition alluded to by very few writers. In this way the liver may cover the stomach and even extend over the spleen. Similarly the _right lobe_ may be affected, but giving a different train of symptoms. Under these conditions mistakes may arise. Thus the left lobe might be mistaken for a large spleen, from which, nevertheless, it should be separated and differentiated by its free movement during respiration. Hammond even reports one case of this kind where, instead of removing the elongated portion of the liver, it was held up against the abdominal wall by sutures. For a similar condition Langenbuch has successfully resected a portion of this viscus. What is said here pertains to a true congenital variety, and not to acquired displacements or enlargements. In Fig. 625 is represented the case of xiphopagous twins united by a band of liver tissue and operated (by division of the band) by Baudouin.
[Illustration: FIG. 625
Xiphopagous twins, separated by division of a band of common liver tissue. Case of M. Baudouin. (Pantaloni.)]
WANDERING OR FLOATING LIVER.
The relations between congenital laxity of the natural supports of the liver and certain morbid conditions, especially those produced by marked enlargement followed by great reduction in size, to the so-called wandering or floating liver are very indefinite. The term “wandering” implies a mobility far beyond the normal, with more or less yielding of ligaments, especially the suspensory, which permits undue displacement. We often fail to realize that the liver, which is the heaviest of the viscera, is nevertheless, in man, placed at their top, and hence that it has, in at least some respects, very meagre support. This is one of the disadvantages of the upright position, and it does not prevail in animals. In addition to this may be mentioned the peculiar enlargement of the right lobe, very rarely of the left, so often seen in connection with biliary obstruction, and often spoken of as _Riedel’s lobe_. Floating liver is more common in women than in men by four to one, and is often ascribable to the ill effects of tight lacing. Repeated pregnancies, with the consequent relaxed and pendulous abdominal walls which often follow them, also conduce to the condition by weakening, in fact almost removing, its lower supports.
=Symptoms.=--The symptoms produced are those of indigestion, dyspnea, perhaps with cyanosis, nausea, vomiting, and occasionally biliary obstruction and jaundice. In addition to these the patient will show the ordinary physical signs of a displaced or displaceable liver, noticeable in the upright or in the knee-elbow position.
=Treatment.=--The treatment of milder cases will consist of support from below by suitably adapted and well-fitting abdominal binders or supports. Serious cases may necessitate surgical relief. This consists of _hepatopexy_, _i. e._, fixation of the liver to some of its upper surroundings. The operation is performed through an incision such as that used for exposure of the gall-bladder. The lower surface of the diaphragm and the upper surface of the liver are scarified until they ooze perceptibly. The anterior edge of the liver is then fastened to the abdominal walls, as also the gall-bladder, if it can be utilized for the purpose. The patient is then placed in bed with as much compression of the abdomen below the liver as can be tolerated, in order that the scarified surfaces may be kept in contact until adhesions result.
INJURIES OF THE LIVER.
By its size and construction the liver is made peculiarly liable to certain injuries, while from others it is made more or less exempt by its protected situation, especially by the ribs, which nearly enclose it. From contusions it may undergo different degrees of laceration, sometimes even to the degree of fragmentation and pulpifaction. Again it is frequently involved in punctured wounds (stab, gunshot, etc.), which may be inflicted from any possible direction, perforation sometimes taking place from above and through the chest, and involving the tissues beneath.
General indications of injury to the liver will be furnished by its nature and location, the degree of collapse, and the consequent abdominal rigidity, with the common signs of internal or intra-abdominal hemorrhage. There is no doubt but that minor injuries of the liver are nearly always repaired, and that they occur much oftener than is generally appreciated; but a severe tear of the liver is a source of great danger because of hemorrhage. In general, of these injuries it may be said that any traumatism which produces profound or increasing symptoms should be regarded as indicating a careful exploration, done with every precaution at hand for carrying out any possible indication. What the liver may safely bear in the way of ligatures, sutures, and operative disturbance will be indicated later. Many fatal cases show a period of a few hours of temporary amelioration of symptoms which may have lulled to a sense of false security, and during which internal mischief is still increasing. Moreover, any blow sufficiently severe to rupture the liver may do other harm. In such instances, then, it becomes a simple question of whether there can still be sufficiently early intervention to save life. To what extent this intervention may be required in stab and gunshot wounds it is difficult to state. If hemorrhage and puncture of any hollow viscus can be excluded and if no other serious symptoms be present, it may be advisable to wait; otherwise the possible harm of a judicious early exploration is so small, while the prospective benefits are so great, that it is far the wiser course. Here, again, the general rule may be applied. _When in doubt operate._ Further details of operative procedures will be given below.
ABSCESS OF THE LIVER; HEPATIC ABSCESS.
While _abscess of the liver_ is, like all other abscesses, due to germ
## activity, it may yet definitely follow injury or be the result of a
primary disease, or an extension from some one of the adjacent tissues or organs; as from _above_ (empyema, pyopericardium, subdiaphragmatic, spinal), from _below_ (gall-bladder and ducts, pancreas, stomach), from the _portal circulation_ (superficial or ulcerating piles, typhoid and other intestinal ulcers, peculiar or tropical parasites like amebas), from the _appendix_, from the _general circulation_ (pyemic, metastatic), through the _lymphatics_ (mesenteric nodes), from the _intestinal tube_ (ordinary round-worms and various parasites), from _cancer_ breaking down, as well as from _degenerating gumma_ or granuloma and from _hydatid cyst_.
Hepatic abscess may be acute or chronic, small or large, solitary or multiple. The tendency is to enlarge and finally to kill. This they do usually by _rupture_, _e. g._, either into the pleural cavity or the lungs, after adhesions have been contracted, the pericardium, the mediastinum, the peritoneum, any part of the upper alimentary canal, or the biliary passages. Finally they may open externally and perhaps be followed by spontaneous recovery.
A certain convenience of description is afforded by dividing these cases into the so-called _solitary_ abscesses and the _multiple_ forms, the latter being more commonly associated with tropical diseases of the amebic type or with pyemic processes. In most _solitary_ cases the abscess is located in the right lobe, its extent varying within wide limits, especially when the subphrenic space has been involved. Its contents may be of almost any color and the pus is often thick and foul in odor. (See Subphrenic Abscess.)
=Symptoms.=--Symptoms of the solitary type may be at the onset acute, with or without history of previous sickness, the patient being suddenly seized with severe epigastric or hypochondriac pain, which is followed by prostration, with fever, chills, and sometimes cough. Characteristic rigidity and tenderness follow and the liver increases in size, the whole type of illness being one of acute abdominal infection. The slower forms appear to come on without early liver symptoms, patients complaining of cough and discomfort in the chest, with loss of flesh and appetite. Gradually the indications point to the hepatic region, while chills or intermittent fever occur, the liver gradually increasing in size and becoming tender. Again, in some cases, the trouble begins with irregular fever, patients running down rapidly, yet showing few local signs until the abscess invades the subphrenic region. In such instances examination of the chest gives negative evidence, save that there may be found elevation of the diaphragm due to accumulation below it. In nearly all instances there arise, sooner or later, severe chest pains, with enlargement of the liver, tenderness, and often indications of fluid in the right pleural cavity, which on aspiration may be found clear or purulent. Tenderness along the liver border will be most marked among characteristic features. Sometimes there is intercostal tenderness. Any indication of local peritonitis should be taken as evidence of approach of pus toward the surface. Jaundice is an occasional accompaniment. Previous malaria should be excluded if possible and a careful case history is a great help.
Diagnosis is usually to be made between hepatic and subphrenic abscess and between the single and multiple forms of the former. The possibility of empyema or of one or two subphrenic abscesses should be carefully determined. In fact, first of all, the surgeon has to determine whether the lesion is above or below the diaphragm. Some of the subphrenic abscesses contain gas, and, should indications of its presence be found below the level of dulness due to the presence of fluid, interpretation of the facts is easy. Localized edema of the chest wall, or of the region of the liver, is of importance when present. It is necessary, also, to exclude phlegmons of the abdominal wall. These are cases where it is justifiable to use an exploring needle repeatedly, if necessary, in order to determine the presence and location of pus. After anesthesia the needle may be used even more freely, its use being not only of assistance in diagnosis, but it appearing to be an agent of great value in the relief of pain. I have known painful affections of the liver to be much relieved by such exploration.
The accompaniment of dysentery of amebic type, and the discovery of amebas in the stools, would quite settle the question of the origin and nature of such abscess. Hydatids are of slow growth and are almost symptomless until they produce pressure disturbances or those due to the presence of pus. The fluid withdrawn from them is clear and may contain hooklets. Cancer eventually produces jaundice and the resulting enlargements are nodular, while the lower border is irregular, and the liver itself less tender and more movable, and there is usually more or less ascitic fluid present. Syphilitic gumma may cause enormous enlargement of the liver, with difficulty in diagnosis, especially in the absence of a significant history. Under vigorous mercurial treatment it will steadily improve; without it such gummatous tumors may suppurate. It will often be advisable, in case of doubt, to make this therapeutic test. Actinomycosis produces granulomas which tend to increase, infiltrate, produce adhesions, and gradually work toward the surface, as well as eventually to break down, the débris thus produced containing not only pus, but the peculiar calcareous particles characteristic of this disease.
=Treatment.=--Multiple foci in the liver scarcely admit of successful operative treatment and are nearly inevitably fatal. The solitary liver abscess, even though large, is, on the other hand, usually satisfactorily treated by the general method of free incision and drainage, although, in exceptional cases, aspiration alone has seemed to suffice. Any collection of pus, no matter what the internal condition, so long as it be not distinctly cancerous, which tends to present externally, no matter at what point, should be thus treated. Incision may be made over any protruding or edematous area where pus seems to be nearing the surface. With a considerable collection of this fluid in the right lobe, especially nearer its diaphragm-covered portion, it is usually safe to assume that the upper surface of the liver has become adherent to the diaphragmatic dome above it, and that there one may follow the costal border or may enter between the lowermost ribs, or may even resect one or more ribs if necessary, and drain posteriorly or by counteropening, as may be indicated. When approached from beneath, the lower surface of liver thus affected will usually be found more or less matted to the colon, omentum, or pyloric region, as the case may be, so that by carefully opening the abdominal cavity, and walling it off with gauze, pus may be evacuated from below and cavities satisfactorily drained. In this work it is of advantage to use an exploring needle, the operator guiding his further procedures largely by what it may reveal. Vessels which may be divided and spurt should be ligated or secured _en masse_, while oozing is overcome by gauze pressure. Drainage of a cavity already protected is simple; otherwise it may require a very careful combination of large fenestrated tube, if possible sewed in place, with the margins of the opening carefully puckered and secured around it and protected with gauze. Counteropening may be made, as well as drainage of any neighboring purulent focus.
[Illustration: FIG. 626
Abscess of liver, opened by transperitoneal hepatostomy. (Pantaloni.)]
HYDATIDS OF THE LIVER.
Echinococcus disease is almost a surgical curiosity in the central portions of the North American continent, whereas in some parts of the world it is extremely common. Thus while very rare in the United States, in Winnipeg it is an exceedingly common disease, being brought there by immigrants from a locality where it is still more prevalent, namely, Iceland, where it is said that nearly half the inhabitants die of some form of hydatid disease. In New Zealand, also, as elsewhere, this form of parasitic invasion is very common. With most American practitioners, however, it is so seldom seen that its mere possibility may be overlooked. In the liver it produces cystic disease whose symptoms are rarely significant until the cysts have attained considerable size and have begun to suppurate. That the liver is so frequently affected is easily understood, as the parasites make their first invasion along the duct from the intestinal tract. The history of these cases is always slow, as four years is a short time and twenty-five years not an exceedingly long one in which hydatid cysts run their course. Small cysts may even undergo spontaneous retrogression and calcify. These cysts when large may rupture, just as do hepatic abscesses, and in various directions. (See above.) Ordinarily it is only when suppuration occurs that the general health suffers, and not until that time are they, at least intentionally, seen by the surgeon.
Hydatid cyst of the liver appears as a tumor, evidently cystic or fluctuating, growing painlessly and attaining considerable size. It may usually be excluded from abscess, cancer, dilated gall-bladder, aneurysm, gumma, hydronephrosis, renal cysts, or tumors of unknown origin. A tumor peculiar to the liver will move with that organ. The aspirating needle will probably need to be used before diagnosis is complete, the fluid withdrawn being clear unless suppuration has begun.
=Treatment.=--Hydatid cysts require radical treatment. Aspiration does not remove the mother-cyst nor any of its semisolid contents. Even the injection of iodine and resort to electrolysis hitherto in vogue have been abandoned. Open incision, first, of the abdomen, and then, after careful protection of the abdominal cavity, of the cyst itself, with scrupulous attention to prevention of escape of its contents save externally, is the only radical and promising procedure. These precautions should be taken because of the possibility of implantation of some living fragment of the parent organism, or its offspring, elsewhere in the abdomen and the growth of the same in this new location. After free evacuation of such a cyst it should be explored and thoroughly cleaned out, after which its edges are to be affixed to those of the parietal peritoneum if practicable, a large tube inserted and suitably connected up for drainage, while the opening around it is closed with sutures or packed with gauze. This connection of an interior cavity with the exterior of the body is called _marsupialization_.
SYPHILIS OF THE LIVER.
The operating surgeon as such is only concerned with gummatous tumors, not with diffuse expressions of syphilis which produce interstitial hepatitis or cirrhosis. The latter are often met in cases of general syphilis, and yield to suitably directed treatment. Either the _diffuse_ or the _gummatous form_ may produce enormous enlargement of the liver, with suspicion at least of an abscess. In one case of this kind, known to the writer, the lower border of the liver extended below the crest of the ilium, and yet within a short time, under vigorous treatment, the liver resumed its normal size. Gummas have, then, an interest for the surgeon, as no other similar enlargement ever reduces its volume so speedily under any other circumstances. Moreover gummas may occasionally break down and produce abscesses requiring incision and drainage. If syphilis can be recognized as the etiological factor prognosis is satisfactory in nearly every instance.
## ACTINOMYCOSIS OF THE LIVER.
The specific fungi of this disease may be easily carried from the alimentary canal to the liver through the portal circulation, and its peculiar granulomas, appearing first here, may spread to the diaphragm, to the abdominal wall, or in any other direction. Unless aided by the presence of other distinctive lesions diagnosis is rarely made until the presence of a granulating tumor and its ulceration, with the escape of the distinctive calcareous particles, makes it recognizable to touch as well as to sight. This often might be secured by an exploratory operation, which circumstances might justify. (See chapter on Actinomycosis.)
TUMORS OF THE LIVER.
Benign tumors in the liver are rare. So-called _adenomas_ of somewhat indistinct type, and _fibromas_, have been described as occurring here. The former are of uncertain origin and probably do not deserve the name given here. Nevertheless they have a structure more or less simulating true gland tissue. Fibromas may spring from any of the fibrous structures. Other benign tumors occur here so rarely as to scarcely warrant mention. _Aneurysms_ and large _venous dilatations_ also occur occasionally in the liver. Any of these lesions may justify exploration, and those favorably situated may be enucleated or excised, with subsequent suture of the liver and drainage of any remaining cavity.
Of the _malignant_ tumors the _sarcomas_ and _endotheliomas_ may arise in almost any part of the organ. _Primary carcinomas_ have their origin only about the gall-bladder and its ducts, from whose epithelial lining they may spring; otherwise they are products of extension or metastasis. By far the larger proportion of cancers arise from the gall-bladder, within which they begin to grow, either as the expressions of irritation or of parasitism. The presence of _gallstones in the gall-bladder is now known to be an extremely common provocation of cancer_, and the relation obtaining between the two is certainly more than accidental or casual. (See Cancer of the Gall-bladder.)
That an associated and solitary cancerous growth of this kind may be successfully removed has been proved in my own experience, by the good health persisting at least six years after operation upon a woman from whom I removed a large cancerous gall-bladder containing two large calculi, and with it a considerable amount of the adjoining liver tissue. It is, therefore, possible to successfully remove some benign tumors, as well as occasionally a malignant one, from the liver when other conditions are favorable; but this should always be done before it be too late, as a comparison of cases will demonstrate. If the lymph nodes or any other viscus be involved in malignant disease, then it is too late. The tumor is to be attacked from its most accessible aspect. A pedunculated growth, like a distinct benign hypertrophy, may be tied off, sutures being also used if needed. The actual cautery furnishes the best means of division of liver tissue, while with a sessile growth elastic constriction may be of assistance. The principal danger in these operations is from hemorrhage. Methods of meeting it are discussed below, as well as other general procedures. A tumor stump may be fastened to the abdominal wound, or it is better treated by being packed around with gauze, the latter being allowed to remain for three or four days.[62]
[62] As a means of preventing the ligature cutting in liver sutures Gillette has suggested the use of a piece of rubber tube drawn over a No. 10 catheter and placed along the proposed line of sutures, which are passed around this, and through the abdominal wall, making exit between the ribs, after the manner of a staple.
Von Bruns, in 1870, was probably the first to resect liver tissue, after injury, with good results. Modern surgery has done much to improve the prognosis in these injuries and to show that it can be attacked much more freely than previously supposed. Within the past fifteen years Ponfick and many other experimenters have shown the regenerative capacity of the liver by removing as much as three-fourths of it. The fear of cholemia, due to escape of bile, has also passed, and it has been found that peritoneal complications do not result from its presence, for bile, unless actually mixed with pus, is not septic, although its antiseptic properties have been much overrated. Most of the expedients which have been suggested by various operators for controlling hemorrhage have been abandoned for the more simple methods of the tampon and the suture, although the actual cautery is still generally used for the operative attack. For suture catgut is preferable to silk. Even large wounds may be successfully fastened in this way. Arterial bleeding is easily distinguished from venous oozing. Spurting arteries may be ligated _en masse_, while continuous oozing usually subsides under pressure. In contusions of the liver, when it is not practicable to bring hepatic surfaces together, loops of catgut may be passed with a large needle through the liver structure in such a way as to bind its edges whenever they are bleeding. The sutures or loops may be drawn tightly to check hemorrhage before they cut through the liver structure. When the attempt is made to actually suture liver tissue it is necessary here as elsewhere to avoid dead spaces. If liver surfaces can be brought into actual contact they will heal kindly. In fact when there is access, and the emergency is not too pressing, the portion to be removed may be excised with ordinary knife or scissors, and this is better when suture methods are to be employed. There are times, however, when the Paquelin cautery knife will perhaps be preferable. It is a mistake in these cases to try to work through too small an incision. For wounds located posteriorly Lannelongue has suggested resection of the thoracic wall along the anterior portion of the eighth to the eleventh costal cartilages, since the pleura does not extend down to that level. He makes an incision parallel with the costal border, 2 Cm. above the same, beginning 3 Cm. from the border of the sternum, and terminating at the tenth costochondral junction. After retracting the muscles the costal cartilages are to be resected. If, now, the rib ends be firmly retracted and pressed apart a large portion of the convexity of the liver can be made accessible.
In order to make better access to the upper margin of the liver it may be well to adopt Marwedel’s suggestion of retracting the rib arches by a curved incision, parallel with the costal margin, with complete division of the rectus and the external oblique, which latter is to be separated from the internal and transverse. The cartilage of the seventh rib is divided at its sternal junction and the cartilages of the eighth and ninth are also exposed and divided by blunt dissection. After thus loosening the lower ribs the lower part of the chest wall can be retracted, and much better access made to the region below the diaphragm. When necessary the left side of the abdomen may be treated in the same manner.
From the liver we pass to the consideration of the surgical aspects of cholelithiasis and other affections of the biliary passages.
THE GALL-BLADDER.
The gall-bladder is a convenient but more or less superfluous receptacle or reservoir for bile, whose normal capacity is from 50 to 60 Cc., but which, when distended, may, by virtue of its elasticity, contain at least 200 Cc. of fluid. Its normal position is beneath the ninth costal cartilage, at a point where it crosses the outer edge of the rectus. Only its lower surface is covered by peritoneum, in average cases, but when it is distended or hangs well down in the abdomen the peritoneum may enclose the larger amount of the sac. Its neck is bent into an S-shape, and contains two folds of mucous membrane, which serve as valves. When this neck is mechanically obstructed the sac itself may be distended with glairy, bile-stained mucus, amounting even to 500 Cc., but in patients who have had repeated attacks of gallstone colic and have suffered for a long period of time, the gall-bladder is usually contracted, shrivelled, and sometimes almost obliterated. Under these conditions there is a strong resemblance between it and so-called appendicitis obliterans, and when so contracted and buried in adhesions it may not be easily found. In certain cases of cirrhosis of the liver the gall-bladder is carried up well beneath the ribs and then descends with whatever motion depresses the liver. On the other hand when distended it may hang down into the abdominal cavity as a pear-shaped mass, which may even cause doubt and uncertainty in diagnosis, for it may be then found in the cecal region or in the pelvis.
The common duct is from 6 to 8 Cm. long. Its size is about that of a No. 15 French sound. It is both extensile and distensible, and may be dilated even to the size of the small intestine. About one-third of it is in intimate relation with the pancreas, whether wrapped within its head or lying in a groove upon it. This is of surgical import, for in enlargement of the pancreas the duct may be first pushed away and then obstructed; this explains why biliary drainage is indicated in so many pancreatic cases. The part which passes obliquely through the duodenum is expanded into a reservoir beneath the mucosa, into which opens also the pancreatic duct, the latter lying lower and being separated by a fold of mucous membrane. This dilatation, the ampulla of Vater, is 6 or 7 Mm. long, and is surrounded by an unstriped muscle fiber--a miniature sphincter. Its opening constitutes the narrowest portion of the entire biliary canal. Seen from within it forms a little caruncle or papilla, distant 8 Cm. from the pylorus. The duct of Santorini opens normally about 2 Cm. above this papilla, and is patent in about one-half of these cases, while in about 80 per cent. of cases it communicates with the duct of Wirsung. Many variations from the normal, as above epitomized, occur--especially in and about the ampulla. They are both congenital and acquired. Thus an _hour-glass gall-bladder_ is occasionally seen, or one so divided by a partition that one part may contain mucus and the other calculi. It is worth remembering in this connection that along the free border of the lesser omentum there are three or four lymph nodes which, when enlarged, may be easily mistaken for calculi. The gall-bladder lies in a peritoneal pouch, having the colon below it, the spine and the pancreas to its inner and posterior aspects, the liver above and the abdominal wall on its outer side. When this pouch is seriously affected it may be drained not only from in front but often to great advantage from behind, _i. e._, by posterior drainage. This pouch may hold a pint before it overflows into the pelvis, or through the foramen of Winslow into the greater peritoneal cavity. The right lobe of the liver is sometimes enlarged so as to form a tongue-shaped projection which may extend some distance below the costal margin. This is frequently called _Riedel’s lobe_. (See Plate LV.)
The gall-bladder is essentially a biliary reservoir, convenient but not essential, storing bile between meals and expelling it during digestion. It is absent in the horse and in many animals, and individuals from whom it has been removed seem to suffer thereby no inconvenience. Consequently there need be no hesitation in removing it when necessary. Bouchard claims that bile is nine times more toxic than urine, and that the liver of man may produce sufficient in eight hours to kill him if it cannot escape. _Consequently biliary obstruction may become a very serious matter._ Besides containing bile the gall-bladder has numerous minute glands of its own, which secrete the ropy mucus with which it is so often found distended. A mixture of bile and pancreatic juice seems ideal for perfect emulsification and digestion of fat. Hence the disadvantage of anything which interferes with the escape of bile into the duodenum. Bile possesses by itself slight antiseptic properties, _yet when uncontaminated is not septic_. It may be regarded as mainly excrementitious, and its function as an intestinal stimulant has been much overrated. The average quantity secreted in twenty-four hours is about thirty ounces. Its excretion is constantly going on, but is more abundant by day, is not much influenced by diet, nor nearly so much by the so-called cholagogues as has been generally supposed. All these points have a practical interest for the surgeon who has to do with the consequences of biliary obstruction, or who has to watch its progress for lack of a biliary fistula.
[Illustration: PLATE LV
Surgical Anatomy of the Gall-bladder and of the Omental Foramen and Cavity. (Sobotta.)
The probe enters the omental (epiploic) foramen. By retraction and removal of its anterior covering the cavity of the lesser omentum (omental bursa) is exposed, revealing especially the pancreas in situ.]
BILIARY FISTULAS.
These may be due to accidental injury during operation or to disease processes. They may be direct or indirect, and internal or external. An example of direct, external traumatic fistula is afforded by a cholecystostomy or a cholangiostomy; of indirect internal when the gall-bladder has burst into an abscess and this into a hollow viscus. A fistula might arise from a local abscess outside the biliary passages, later communicating in both directions, or it may be connected with the thoracic organs, with evacuation into the bronchi or esophagus, and cases are on record where gallstones have been passed from the mouth. The external or cutaneous fistulas tend in most instances to spontaneous healing, but the time required is often long. They may discharge thin, biliary mucus or true bile.
Mucous fistulas result from cholecystostomy where the obstruction in the cystic duct has not been overcome, as when it is the seat of stricture or extrinsic pressure. They cause but little inconvenience. Nevertheless if allowed to close the mucus accumulates and pain results from distention. In these cases either a small tube or drain should be worn, or a cholecystenterostomy may be made. Sometimes after the discharge of some foreign body, such as a silk ligature or small stone, such a fistula will close of itself, or it may be possible to frequently cauterize its interior with a bead of nitrate of silver melted upon the end of a probe, or perhaps by using a long curette to so destroy its mucus lining as to do away with the condition and its consequent discharge. Ordinarily cholecystostomy will not be followed by permanent or even long-continued fistula if the common duct have been thoroughly cleared, and if the gall-bladder be fastened to the aponeurosis and not to the skin. _Postoperative biliary fistulas_, with discharge of large amounts of bile (one to two pints per day) and their consequent inconvenience, will ordinarily not be long tolerated by the patient, who will insist on some further procedure for relief. If possible, in every such case, the real cause of the difficulty should be removed. If the ducts be cleared and stimulation with caustic be not sufficient, then the abdomen should be opened, the gall-bladder detached, and its fistulous opening freshened and sutured. If the patency of the common duct can be established this will be sufficient. Otherwise, after closing the gall-bladder, it should be anastomosed with the small intestine as near the duodenum as possible.
_Spontaneous or pathological fistulas_ often open at the umbilicus, the disease process having followed the track of the umbilical vein up to that point. Here, too, calculi are thus spontaneously extruded, one case on record including the discharge in this way of a stone three inches in diameter. In any such case as this the fistula cannot be expected to close until the calculi are all extruded. In the treatment of any such lesion the margin of the wound and the entire track of the fistula should be carefully curetted and disinfected, as at least a part of the procedure.
_Biliary intestinal fistulas_, due to escape of calculi into adherent intestine, are also occasionally seen. These often form without marked disturbance until perhaps at the last, when there may be destructive symptoms, both biliary and intestinal, symptoms which will suddenly subside when perforation or passage of a calculus occurs. After their occurrence patients may enjoy some relief for a considerable time, or until the contraction of the fistula may necessitate a subsequent operation. At other times their formation by ulceration is often accompanied by severe pain and fever, and possibly even by hemorrhage. Impaction of a gallstone in the intra-intestinal portion of the common duct is perhaps the most frequent cause of this kind of trouble. Fistulas into the colon are less common than into the small intestine. Such fistulas should never be intentionally made if it be possible to utilize any part of the small intestine. Although the pylorus and the gall-bladder often become firmly united to each other gastric biliary fistulas are rare. If, however, there be vomiting of gallstones, such a sign would make it quite certain. Mayo Robson has reported one such case where he separated adhesions, pared the stomach opening, closed it with sutures, and utilized the opening in the gall-bladder for the removal of calculi and subsequent drainage, the patient recovering.
INJURIES TO THE BILIARY PASSAGES.
These are less common than injuries to the liver proper. They may be caused by penetration or by severe blows and concussion. In those already suffering from local disease accidents are more likely to be followed by rupture. Injuries have also been attributed to traction and later adhesions. The fundus of the gall-bladder is the most exposed portion; therefore, that part is most often injured; while neighboring organs may suffer simultaneously--for example, the liver, stomach, and colon.
Injury will either produce such damage as to lead to acute local peritonitis, with extensive exudation for protective purposes, and with all the possibilities of subsequent infection, or there will be actual rupture, with extravasation of bile, and perhaps of blood, and the development of well-marked local as well as general symptoms. Fluid thus escaping will first fill the abdominal pouch, already described above, where it will then be confined by the mesentery until it begins to overflow. A small opening may be sealed by lymph, and a small collection of fluid may even be encapsulated, so that it may be subsequently opened and drained. The symptoms of such injury will include shock, pain, fever, fulness in the right side and hypochondrium, abdominal rigidity and the development in certain cases, after a few days, of jaundice, indicating absorption of bile. Should this bile have been aseptic, no great harm may ensue, but if infected a general and probably fatal peritonitis will result.
In any case where the condition may be recognized or where it is strongly suspected, abdominal section should be promptly made. According to the conditions thus disclosed the opening may be sutured, if possible or the gall-bladder or other cavity containing bile may be drained. It has been possible in some such cases to successfully suture a tear or wound in the duct, while in a few cases the duct has been doubly ligated and the bile flow been turned into the intestine by an anastomosis.
ACUTE CATARRH OF THE BILIARY PASSAGES.
The formation of bile takes place under low pressure and therefore is easily hindered by slight back pressure. In this way jaundice may be easily produced with no greater degree of chemosis of the duodenal mucosa than that produced by a relatively small amount of activity in the duodenum. Inasmuch as the common duct traverses the intestinal wall obliquely its small outlet would be the first to suffer. In minor catarrhal duodenitis it is of small surgical importance, but when the condition becomes chronic the obstruction then becomes a matter to be dealt with by the surgeon. Such conditions may occur in connection with typhoid fever, pneumonia, influenza, ptomain poisoning, and other diseases, and are often accompanied by vomiting and diarrhea, with referred tenderness and possibly enlargement, while even the spleen is sometimes enlarged.
=Treatment.=--In the early stage of such a condition the treatment is medicinal, but when the condition has become chronic biliary drainage may be required.
CHRONIC CHOLANGITIS.
This is frequently a sequel to the above acute condition, and generally accompanies jaundice, no matter how produced. It is a frequent concomitant of cancer and often the actual cause of its accompanying jaundice. It has been known to lead up to suppurative lymphangitis, the lymph nodes along the border of the lesser omentum, already described, being nearly always involved and occasionally suppurating. _Pylephlebitis_ may also have this origin. Gallstones nearly always provoke a certain degree of cholangitis and cause the formation of thick, ropy mucus which causes pain when passing, this pain being often mistaken for that produced by calculi. Riedel believes that two-fifths of the cases of jaundice occurring in connection with gallstone disease are really produced by accumulations of mucus and thickening of the mucosa, rather than by the stones themselves. Moreover, there is a form of membranous catarrh, both of the ducts and gall-bladder, where actual casts are shed, this condition corresponding to fibrinous bronchitis or enteritis. Thudichum believes that these casts often form nuclei for gallstones. The condition has been spoken of as _desquamating angiocholitis_, and casts of the duct or even of the gall-bladder have been found in the stools.
The surgical interest attaching to these conditions lies in the fact that the symptoms produced are often identical with those caused by gallstones, and the desired relief is to be sought in the same way--_i. e._, by operation. The operator should not feel chagrined if on opening the abdomen he finds the gall-bladder containing such material rather than calculi.
CHRONIC CATARRHAL CHOLECYSTITIS.
This is often mistaken for cholelithiasis, although when the gall-bladder is opened only thick, ropy mucus will be found. This, as just remarked, may give rise to very painful spasm. The trouble when present is usually connected with similar trouble in the ducts. Moreover, around such a gall-bladder numerous adhesions are formed which give rise to much pain, tenderness, and local distress. Under these conditions the gall-bladder is enlarged and thickened.
Here, too, the curative treatment is essentially surgical, although pain may sometimes be temporarily relieved by aspirin in doses of from 0.5 to 1 Gm.
_Cholecystitis obliterans_ corresponds closely to appendicitis obliterans, and is a condition characterized by a reduction in the size of the gall-bladder or its almost complete obliteration. In order to account for this it is seldom necessary to assume a congenital defect. The morbid process which produces it begins early, perhaps even during fetal life. The bile ducts are extremely small at birth and further stenosis is easily produced. The accompanying enlargement of the spleen will illustrate the toxicity of the condition which led up to it, and which may have occurred in infancy or early childhood. In a small proportion of cases early constriction of the ducts produced by local peritonitis and infection along the track of the umbilical vessels may account for the condition.
ACUTE CHOLECYSTITIS AND CHOLANGITIS SUPPURATIVA.
A suppurative condition within the gall-bladder is necessarily an expression of an infection, in nearly all instances proceeding from the intestine. The colon bacilli and those of typhoid are the organisms usually at fault. As has already been shown in the earlier part of this work they are facultative pyogenic organisms. Mixed infection with the ordinary pus-producing germs may also occur here. Such infections may spread through the walls of the gall-bladder and cause at least local and sometimes fatal general peritonitis. The condition is an especially frequent complication of typhoid fever, occurring sometimes relatively early, at other times after apparent recovery from the disease. In most of these instances it is supposed that the bacteria reach the gall-bladder by migration along the ducts, although direct penetration or infection through the blood is not to be denied. Impacted gallstones especially predispose to such infections. The result of all such cases is the formation and retention of pus--_i. e._, _empyema of the gall-bladder_--save in those rapid virulent or fulminating infections when it quickly becomes gangrenous, as does the appendix when similarly infected.
=Symptoms.=--In acute infections of the bile passages patients suffer severe pain, made worse by movement, with general malaise, rapid loss of appetite and flesh, extreme tenderness over the gall-bladder and often around it, because of the accompanying local peritonitis. It is frequently possible to make out enlargement of the gall-bladder, which will move with the liver during respiration--this at least until it has become fixed by local inflammation--after which the patient will have thoracic rather than abdominal respiration. As such a case progresses local indications of disease will be added, with finally visible tumefaction and redness of the overlying skin. Jaundice is an uncertain feature, depending on the patulency of the common duct.
_Pus when formed may escape and burrow in various directions_; thus it may follow the suspensory ligament of the liver and appear at the umbilicus, or it may pass along other reflections of the peritoneum and appear about the cecum or above the pubes, or it may pass into the liver and appear as an hepatic abscess, or around it and thus give rise to a perihepatic or subphrenic abscess. It may even perforate the diaphragm and produce such collections of pus or such phenomena as have been described in the previous chapter, including empyema, pericarditis, abscess of the lung, etc. Again it may burst into the hollow viscera, stomach or intestines, or into the general peritoneal cavity, where it will cause speedily fatal peritonitis. Pulmonary abscess, with discharge of pus and bile, has been cured by Mayo Robson by removing a stone from the common duct. Gallstones have also been found in the pleural cavity and have even been passed by the mouth. Finally pus collecting in the right abdominal pouch may also be mistaken for perirenal abscess.
_Acute phlegmonous cholecystitis, with gangrene_, corresponds to the fulminating form of gangrenous appendicitis, and only received its first description in 1890 by Courvoisier. This is not common, but when met with becomes a disastrous lesion. It is essentially a still more virulent expression of infection and consequent necrosis than the condition described above. It may be so rapid as to destroy the gall-bladder before it has had time to fill with pus. It may occur with or without a history of previous trouble, in the absence of which a diagnosis will be made more perplexing. As the condition declares itself and progresses there will usually form about its site a protective barrier of lymph and omentum, which may prove, when present, the salvation of the patient, especially if the surgeon who makes the operation, _and this should be early_, recognizes the value of these protections and does not break them down. The condition occurs in connection with gallstone disease, but may follow typhoid fever, cholera, puerperal fever, or other intense infection.
_Symptoms_ of gangrenous cholecystitis are essentially those of the less severe types of infection, only more pronounced. They include severe pain of sudden onset, rapidly growing worse, spreading over a larger area, extreme tenderness and muscle spasm, rapid thoracic respiration, quick pulse, intense depression and collapse, vomiting, rapidly increasing tympanites, anxious facies, with every expression of intense sapremia. Jaundice is an inconstant symptom, while fever is usually present, but is of little importance. The disease may be so rapid as to quickly kill. At all events local destruction occurs early, either with abscess or gangrene, or both.
=Diagnosis.=--The diagnosis consists virtually in a recognition of the cause of the intense local peritonitis, after which a history of previous disease, if obtainable, may help. The condition is to be differentiated especially from perforated ulcer of the stomach or duodenum, from acute pancreatitis, and from acute mesenteric embolism or thrombus with gangrene of the intestine. It is also occasionally to be distinguished from an acute appendicitis, and this may be difficult, since the appendix is sometimes found high up and the pain widely referred or not accurately localized. In acute cholecystitis the pain is more likely to be subcostal, and the tenderness and muscle spasm are more marked in the upper part of the abdomen, to which the various local expressions of the disease are referred rather than to the lower. In any or all of these troubles symptoms of acute peritonitis are likely to be present and paralytic ileus or bowel obstruction may complicate the case.
Ransohoff has called attention to a hitherto unnoted sign of gangrene of the gall-bladder--namely, a localized _jaundice about the umbilicus_, apparently brought about by staining of the fat beneath the peritoneum, and noted after incision, if not previously. He considers it the result of imbibition, and that it appears at the navel first because here the abdominal wall is thinnest, it being also possible because of the anatomical relations of the round ligament of the liver to the transverse fissure, where there may be a retrograde flow of bile through the lymphatics and toward the navel.
_Fortunately all of these acute conditions as between which doubt may arise are to be dealt with in only one way--namely, by prompt operative intervention_--and minute diagnosis is of less importance than ability to appreciate necessity for immediate operation as it may arise.
_Gangrene_ is the extreme degree of disaster in these cases, and its occurrence may be marked by sudden cessation of the pain, a most important symptom, which may be deceptive to the uninitiated. Gangrene may be due to thrombosis of the vessels of the gall-bladder, to bacterial invasion, to extreme tension because of obstruction of the duct, or to all three.
_Acute cholangitis_ was first described by Charcot, who called it intermittent hepatic fever. It is usually due to the presence of one or more gallstones in the common duct, but any obstruction of the hepatic or common ducts may favor infection of retained bile and involvement of the duct. Thus it has followed chronic pancreatitis, cancer, hydatid disease, pancreatic calculus, typhoid fever, and the presence of the parasites. Mertens has collected forty-eight cases in which _ascarides_ have been found in the bile-duct, their entrance having probably been facilitated by the previous escape of gallstones and enlargement of the duct end. Round or lumbricoid _worms_ have also been found in the duct, as they are occasionally met with in the duodenum, and I once saw a long one in the appendix. Cancer in this neighborhood is also a not infrequent exciting cause in producing acute cholangitis.
_Symptoms._--There is usually a history of spasmodic pain covering a considerable period, and then of such an attack followed by chill and fever, with more or less jaundice, which may persist for some time. Such attacks as these become more severe and more frequent; the gall-bladder enlarges if it contain no stone, or contracts if calculi be present. This association was especially noted by Courvoisier, who formulated a statement to this effect, often absurdly known as his “law.” Later the entire liver or its right lobe may enlarge, while patients complain of tenderness over the gall-bladder, as well as of loss of appetite and flesh, and those vague symptoms included in the term “dyspepsia.”
Such a condition may possibly subside in time, but is more likely to be followed by acute trouble of one of the types already described. In the matter of diagnosis it may be distinguished from malaria, especially in districts where malaria prevails by absence of relief from quinine, and the results of a carefully completed examination, combined with the fact that in the former it is usually the gall-bladder which is enlarged, and in the latter the spleen. When the condition has proceeded to its suppurative form the occurrence of still more significant symptoms and signs should lead to prompt operation.
=Treatment.=--In the acute infections and affections, both of the gall-bladder and of the duct, _operative intervention_ is imperative. The more acute the case the more urgent the indication. _Free evacuation and drainage are the indications to be met, and as early and completely as possible._ These cases call for cholecystostomy, often for choledochotomy, with drainage of both gall-bladder and duct, and perhaps of the peritoneal cavity, while possibly even posterior drainage may be indicated. So true is this that the back should be as carefully prepared for operation as the abdomen, in order that no time be lost during the operation, should one decide on the wisdom of a posterior counteropening. Of course much will depend upon the patient’s condition at the moment and what it may appear he can endure. By free opening of the gall-bladder evacuation of its septic contents and removal of calculi are secured, if present, while the ducts are permitted to empty themselves and free flow outward of all septic material is invited and permitted, pressure is relieved, the tumor is disposed of, respiration allowed to become normal, and no small load removed from the kidneys; and the chronic pancreatitis which so often accompanies many of these cases is allowed to subside by virtue of the other relief thus afforded.
ULCERATIONS AND PERFORATIONS OF THE BILIARY PASSAGES.
These may occur anywhere along the biliary tract, and vary as between the superficial and the perforating, the former being sometimes multiple, the latter solitary. Of these lesions cholelithiasis is the most common cause, while typhoid and cancer should be ranked next. They are all of pathological import, because of their possible sequels, _i. e._, not merely perforations with fistulas, but possible strictures or hemorrhages, or peritonitis with sepsis. When ulceration is extensive a previous local difficulty may be supposed, with more or less adhesions, but as the trouble becomes more serious the local excitement will extend to the peritoneum, at least that of the area involved. In fact most cases of gallstone disease are accompanied by more or less peritonitis, and adhesions which are protective, although they may cause other troubles as well, such as dilatation of the stomach from displacement of the pylorus. Hemorrhage is not a frequent event, for thrombosis usually precedes erosion. Some degree of sapremia or septicemia will be present in nearly all cases.
_Stricture of the ducts_ is the most common result, especially of the cystic duct. If this occur and the mucous membrane be still active the gall-bladder will become distended with pus or mucus, or both. These are the cases which perhaps give the best results after ideal cholecystectomy.
Perforation is a constant possibility whose menace cannot be estimated, but which is always actual, the great danger depending on the virulence of the extruded material and the consequences of delay in operating. Although healthy bile is but slightly toxic, these cases do not furnish it, and one may always look for consequences of infection. Nevertheless if diagnosis be made sufficiently early to bring about immediate operation prognosis is good. Occasionally during such an operation there will be found a gallstone endeavoring to extrude itself, but not yet completely escaped. It might be, in rare instances, possible to utilize the opening which it has partially made for subsequent drainage purposes.
It is not advisable to permit patients with distended gall-bladders to go unoperated, even in the absence of serious symptoms, because the risk of operation is small and that of rupture is large.
_Acute intestinal obstruction due to gallstones_ will usually, but not invariably, involve the upper intestinal tract. It may be due to the actual occlusion of a large stone which has escaped from the gall-bladder or duct, or it may be caused by volvulus due to intense colic accompanying peristaltic effort, or it may depend upon adhesions after a local peritonitis due to previous disease of the gall-bladder or to stricture following ulceration; or again it may be purely paralytic, and in this way result from a local peritonitis. Impaction of a biliary concretion may happen at any point, but most often at the ileocecal valve, where the intestinal tube is narrowest. The size of the stone is not the only consideration. Obstruction depends perhaps as much upon spasm above and below as upon any local disturbance that its presence may have caused. Biliary concretions may enlarge as they pass downward, growing by accretion of calcareous and of fecal matter. The larger the calculus the more likely it is to obstruct the upper intestine. The majority of these calculi have escaped from the gall-bladder by a previous process of ulceration, and usually into the duodenum, rarely into the colon.
=Symptoms.=--Symptoms of this condition, thus produced, will obviously be those of acute obstruction from any cause, the most marked features being severe pain and early frequent vomiting. Bile may be raised in quantities because of the biliary fistula so near the stone, and from which it is supposed to have escaped. The higher the exciting cause the more violent the symptoms and the less the distention of the abdomen by gas. A significant history may help in assigning the cause for the evident obstruction.
=Treatment.=--Since more than half of these cases treated expectantly die without relief early operation is to be urged. It should always be preceded by lavage in order that the stomach may be thoroughly emptied. When a stone has been exposed within the intestine it is advisable to open the bowel a little below where it rests, so as to make the division at a point where the chances of repair are not compromised by previous excitement. In severe cases a temporary enterostomy may be made, but this should of necessity be high. The volvulus may be relieved by untwisting the kink or by an anastomosis. Obstruction due to adhesions will require separation of these adhesions, with perhaps an anastomosis.
CHOLELITHIASIS, GALLSTONE OR BILIARY COLIC, BILIARY CALCULI.
There is so much which may be said about the formation of gallstones and the troubles which they may produce that it is necessary here to epitomize as much as possible and to refer mainly to the surgical features of this condition. _Gallstones_ are of all _sizes_, from the most minute to that of a hen’s egg, are present in _numbers_ varying from a single calculus to thousands of calculi, are found commonly in the gall-bladder, in the cystic duct, or in the common duct, but occasionally are met with just escaping into the duodenum, through the duodenal ampulla, or in the smaller ducts of the liver or the main hepatic duct (Fig. 627). In at least 99 per cent. of cases they will be seen in one of the locations first mentioned.
[Illustration: FIG. 627
Gallstone presenting at the ampulla of Vater, _i. e._, endeavoring to escape into duodenum. (Pantaloni.)]
Pages might be devoted to a discussion of the reasons for their formation. That cholesterin, their principal component, should more readily deposit in such a way as to produce these calculi, and more often in some individuals than in others, is hard to explain, but may be held to be largely due to its formation in excess in certain individuals and to concentration of those fluids which hold it in solution. Increase of cholesterin seems to be connected with catarrh of the membrane which produces it, and thus stagnation of bile may predispose. That bacteria have much to do with biliary calculi is now conceded, and a history of typhoid is obtainable in many cases. It has been shown experimentally that aseptic foreign bodies introduced into the gall-bladder remain indefinitely without becoming covered with precipitate, while virulent organisms set up disturbance, and only the attenuated or moderately infectious organisms produce calculi, and usually then only when some trifling foreign body is introduced at the same time. It will thus be seen that a nidus may be afforded by a clump of epithelial cells or débris.
It is not at present so much a question of what organisms are at fault, although they are usually the colon and typhoid bacilli and the ordinary pyogenic organism. It has been shown, moreover, that in typhoid fever the gall-bladder is often invaded, and that the typhoid bacilli may live there indefinitely, and that they tend to clump or agglutinate themselves in a very suggestive way into trifling masses which may serve as minute foreign bodies. Thus each predisposing factor reacts upon the other, and by a vicious circle either an acute lesion may be established or calculi may be formed in varying numbers.
Gallstones have been found in the _newborn_, but are relatively infrequent below the age of twenty-five, and are most common in the later years of life. The condition is by four to one more frequent in women than in men. The only predisposing habit seems to be such lack of exercise as gives no expulsive movement to the gall-bladder by action of the abdominal muscles. They are more common in the gouty and in those predisposed to uric-acid diathesis, while abundance of nitrogen seems rather protective. Biliary calculi have never been found in the wild carnivora.
McArthur has formulated the following conclusions of interest in this connection:
1. Not all gallstones originate within the gall-bladder.
2. The origin of a cholesterin stone is probably the gall-bladder, with subsequent accretion, either in passing through, or in the duct, where it may have lodged.
3. Bilirubin calcium is the principal constituent of the smaller intrahepatic duct stones.
4. Calculi in immense numbers may exist for months in the ducts without producing serious symptoms.
5. Under these circumstances the surgeon need not reproach himself if there be recurrence of symptoms after common duct drainage.
_Biliary calculi are serious menaces_ to a patient’s welfare, not alone because of the obstructive symptoms which they may produce, but because of the acute or chronic conditions to which they indirectly give rise. These have been in some degree already mentioned. Thus cholecystitis and cholangitis of all degrees of severity, from the milder chronic forms to the phlegmonous and fulminating varieties, may be at least associated with the presence of such calculi and seem to be to a greater or less extent due to their presence. Around such foci of excitement there will always occur local peritonitis, which will result in adhesions, and the consequent tenderness with referred as well as local pains to which it necessarily gives origin. The viscera suffer not only in this direct way, but functional disturbances are produced, and are usually covered under those vague terms “dyspepsia” and “indigestion” with which patients crudely describe their discomforts, and under which physicians too often conceal their failure to appreciate the actual condition.
Furthermore there is always a possibility of cirrhosis resulting, because of distention of the hepatic ducts and backing up of the hepatic secretion. Thus the liver becomes larger and more dense, is colored green, its edges become more rounded, this occurring especially in the right lobe, or at least attracting more attention in that location because more easily recognized from without. Again the more acute inflammatory conditions sometimes cause paralytic ileus, or at least paralysis of the lower bowel, and thus lead to conditions almost identical with, and difficult to distinguish from acute intestinal obstruction.
Of equally great and growing importance is the fact that, according to Schroeder, some 14 per cent. of gallstone sufferers develop cancer, the presence of these irritating foreign bodies in the biliary passages having much the same relation to cancer of the liver as does the existence of previous ulcer to cancer of the stomach.
=Symptoms.=--There is scarcely any morbid condition which is at one time characterized by such significant symptoms and at another by none at all as cholelithiasis. In rehearsing the list of the ordinary symptoms produced by the conditions exceptions should be made, for no matter how complete the list something may be omitted which has been noted in some particular case.
Gallstones confined within the gall-bladder proper may produce few or no symptoms, this being particularly true so long as the ducts are free and there are no persistent consequences of previous acute trouble. A stone may grow in the gall-bladder to a large size and cause little or no distress until it begins to work its way by the ulcerative process. Doubtless small concretions pass with little or no disturbance, or only that which would be considered a “temporary dyspepsia.”
When, however, gallstones produce symptoms these usually include more or less paroxysmal pain, occurring unprovoked and at irregular intervals, referred not alone to the upper abdomen, but radiating to the rest of the trunk, as well as in the direction of the right shoulder-blade. (The shoulder pains of biliary and renal lesions are due to the connection of the pneumogastric nerves with the ordinary sensory nerves above, and below with the sympathetic ganglia.) Attacks of pain are usually followed by nausea and vomiting, and if extremely severe by more or less depression and collapse. At times there will be a sensation as of distention in the region of the gall-bladder. Tumor in this location may or may not be present, and _jaundice is an uncertain_ symptom, not occurring unless the ducts are occluded. The stomach so far sympathizes that digestion is at least temporarily disordered. In proportion as angiocholitis is produced by the passage of calculi we may meet with more or less septic features. The pain produced is uncertain in severity and duration, and is often relieved by the relaxation which may accompany or follow vomiting. After subsidence of severe pain there remains a dull ache for several days, lasting perhaps until another acute paroxysm. These pains are sometimes referred to the left side and over the stomach, in which cases it will usually be found that the gall-bladder is adherent to the stomach, while when the pain is felt in the right side of the thorax it is usually because there are numerous adhesions between the lower surface of the liver and the viscera below it. Such pain may even simulate angina pectoris or may involve the genitocrural distribution. In fact it may be referred to almost any part of the body.
_Vomiting_ which is at first paroxysmal and colicky may become persistent, continuous, and even dangerous. It is essentially an expression of pneumogastric irritation. The vomited matter may contain bile or even, by retrostalsis, fecal matter. The depression which at first occurs may merge into complete collapse; it may even be fatal. It will necessarily be more marked when the paroxysms are more frequent.
A significant feature in nearly every case is _muscle rigidity_, especially of the upper abdominal muscles on the right side, but not necessarily confined to these. This muscle spasm is a symptom common to many serious conditions and is not of itself indicative. It simply _implies a serious condition within_. Tumor or enlargement in the region of the gall-bladder may be met with, but are by no means constant. These may become more pronounced with each attack, being reduced between times because of the escape of bile between paroxysms. It is a valuable symptom when noted, but no importance should be attached to its absence.
The presence of gallstones _in the stools_ is, of course, indicative, but most valuable time is often wasted when waiting for their discovery. Moreover, a number of hours, or even days, may elapse, the time depending on the activity of peristalsis, between the escape of calculi into the duodenum and their appearance in the stools. A convenient way to search for them is to let the stool be stirred with a 1 per cent. solution of formalin and then strained through a sieve which has about sixteen meshes to the inch. The question of the wisdom of operation can practically always be decided without reference to the appearance of calculi. In this way the surgeon may feel that his diagnosis is corroborated by it, but in no sense weakened without it.
_Jaundice_ is always a significant sign when present, but is absent in at least four-fifths of cases which nevertheless should be subjected to operation. Its occurrence is a matter of interest along with the previous history of the case. It is, however, of great value if it were noted in connection with the first pains or cramps. In chronic obstruction by stone in the common duct it is important to determine the _intensity_ of the jaundice, since this may indicate whether we deal with calculous disease or obstruction from tumor. In _chronic obstruction by stone_ the color changes are _less marked_, and often clear up entirely, while when produced by tumor they become gradually more intensified.
_Deep and persistent jaundice is suggestive of malignant disease._ The degree of cholemia rather predisposes these patients to hemorrhage or persistent oozing during operation. Jaundice gradually deepening with each attack of pain is also very suggestive. Such attacks, coming on with symptoms like those of malaria, chill, sweating, and pyrexia, are extremely suggestive and _always call for surgical intervention_, _i. e._, _drainage_. In brief it may be said that jaundice, with enlargement of the gall-bladder, is at least suggestive of cancer, while a history of gallstone colic, without much enlargement of the gall-bladder, is indicative of stone in the common duct. Although this statement is probably true for the majority of cases there are occasionally marked exceptions to it, as, for instance, when a gall-bladder is distended with hundreds or even thousands of small calculi, or to such an extent that it may form even a pear-shaped tumor hanging down within the abdomen.
In addition to these features thus rehearsed there might be made a long list of possible “extras,” by which the original condition is complicated and made to appear in unusual aspect or even life endangering. Such a list would include nearly every imaginable lesion of the upper abdomen. Suffice it to say that the liver, stomach, and the pancreas especially may suffer, while other viscera and the larger veins, with the surrounding tissue, may any or all of them become involved.
=Diagnosis.=--Diagnosis has to be made mainly from _non-calculous obstruction_; from the _acute gastric conditions_, ulcer, etc.; from _renal colic_; from the acute or subacute _pancreatic_ affections, _duodenal ulcers_, _renal lesions_, _localized peritonitis_ from some other cause; from _cancer_, _lead colic_, _angina pectoris_, _pneumonia_, _pleurisy_, and even _hysteria_. Not so rarely pneumonia and pleurisy begin with pains which are referred to the upper abdomen and are suggestive of gallstone disease, while they seriously perplex the medical attendant. Much stress is to be laid on the first location of the pain, especially if this be in the direction of the right shoulder, and upon concomitant vomiting and jaundice, if present, as well as on the location of the greatest tenderness and muscle rigidity. _Recurrence_ of more or less similar attacks is also suggestive. Diaphragmatic pleurisy may cause pain, referred especially along the esophagus, and intensified during the act of swallowing or vomiting. Affections of the _appendix and gall-bladder may co-exist_, as well as be easily mistaken one for the other. The former is so true that when operating for one condition it is always advisable to explore in regard to the other. When the appendix is placed high, especially behind the colon, confusion may confound. Biliary colic is usually free from the associated ordinary symptoms which are so often met with in renal colic, while in the latter the urine will contain no bile pigment and the pain will usually be referred to the external genitals. In lead colic the characteristic line upon the gums and the habitual constipation which always accompany it will be suggestive. When the stomach is at fault and the pylorus obstructed this viscus will usually be dilated, and the vomit is of a different character, while, at the same time, actual stomach movements may or may not be made visible. With gastric or duodenal ulcer pain it is more regular and associated with food taking after a definite interval, longer in the latter case.
_Chronic pancreatitis_ is so often associated with cholelithiasis that it is impossible to disassociate their symptoms, but the referred pain is rather midscapular or even on the left side. It will be particularly suggested by rapid loss of flesh. In acute pancreatitis the symptoms are usually more excessive, the distention earlier and greater. Cancer of these various organs does not commence with pain, but has a more gradual, distinctive downward course, with cachexia. These are some of the considerations which may aid in differential diagnosis.
The detection of bile pigment in the urine and blood will have corroborative value.[63]
[63] Hanel has shown that a small capillary tube filled with blood, sealed at both ends, may afford a convenient corroborative test. After standing for a few hours in a vertical position its separated serum can be examined against the light. Normal serum is colorless, while even a trace of bile pigment will give it a distinctive yellow tint.
Baudouin’s test for the urine will be the most satisfactory in the matter of precision and simplicity. If two or three drops of a ¹⁄₂ per cent. solution of fuchsin be dropped into urine containing bile it immediately develops a fine orange tint, in marked contrast with its own red. No other coloring matter in the urine gives this reaction; which is very delicate. (Mayo Robson.) Methyl blue and methyl violet each give a reddish tint; Loeffler’s blue solution gives a green tint which vanishes on heating, to reappear on cooling. There are numerous other tests, but these are the simplest and most satisfactory.
=Treatment.=--The general subject of cholelithiasis and its associated lesions constitutes an important topic in the so-called “border-land” between medicine and surgery, where views and advice regarding prognosis and treatment will depend on the experience and the training of the medical attendant. Surgeons now recognize, and physicians are being gradually converted to their view, that _gallstone disease is essentially a surgical disease_, _i. e._, one to be combated by surgical intervention. While it is not to be gainsaid that many patients live and die with gallstones who are never conscious of their presence, and while others who have had serious attacks live to die of some other disease, nevertheless the general statement may be boldly made and easily defended, that _when the disease is well marked and when patients suffer more or less constantly from it the only successful method of treatment is the surgical_, and that, in other words, operation offers the only prospect of permanent relief. Regarding its associated dangers it may be said that _danger comes from delay rather than from operation_, and that here, as with many other conditions, patients often wait too long, partly from lack of proper advice, partly from timidity, and that a septic and moribund patient, allowed to become so for lack of earlier application of the resources of surgery, is a reflection on the one who waits rather than on the surgeon, who, endeavoring to save, still unfortunately loses his patient.
This is not the place to discuss non-operative measures--_i. e._, medicinal and dietetic treatment--valuable as they may be in certain cases. Most of the drugs which are supposed to be effective in their power of solution of gallstones or of facilitating their escape are disappointing, and at best are vague and uncertain in their action. The hydrotherapeutic treatment, such as carried out, for instance, at Carlsbad, will do good in many cases, especially for those who have been indulgent in their appetites and careless in their habits. Cases of any description not too far advanced would be benefited by a careful regimen of this character, but that Carlsbad or any other waters will certainly cure cholelithiasis is now absolutely disproved. As a preparation for operation a sojourn at some such place may be advised; as a substitute for it, never. Large doses of glycerin (50 to 150 Cc.) often temporarily relieve the pain of biliary colic.
In general, then, it may be said that cases which give a history of recurring attacks of biliary colic, with or without recurrent jaundice, and with those varied concomitant symptoms which are usually grouped under the term “indigestion,” in which there is definite tenderness over the region of the gall-bladder, with or without muscle spasm, and with the other referred pains so often present in this condition, should be regarded as legitimately surgical, where operation is more than justifiable and usually decidedly advisable, even too often imperative. The same is true of those cases of distended gall-bladder with obstruction of the duct where perhaps no calculi are present, but where the patient suffers in much the same way as though they were present. _Biliary drainage is equally called for, and the presence or absence of calculi is but a minor feature_ upon which too much stress should not be laid nor too much disappointment expressed if they be not found.
Many cases of chronic cholelithiasis have become more or less toxemic, as well as cholemic. It is a well-recognized fact that cholemic patients are more likely to cause inconvenience to the surgeon from free hemorrhage or persistent oozing, because of the slowness with which coagulation of their blood takes place. When time is afforded for preparation it is of great value in these cases to administer calcium chloride, of which several doses may be given each day, in considerable water, the former varying in amount from 1 to 2 Gm. When time suffices, too, it is always of value to prepare these patients for the operation by measures already discussed, improving their elimination, reducing the degree of their toxemia, and fortifying their circulatory systems by well-known measures. The value of such preparation is perhaps more apparent in such instances than in most others. On the other hand, many cases calling for operation are almost as imperative as those of acute appendicitis, where every hour’s delay is to the disadvantage of the individual. The operations which are practised upon the biliary tract will all be discussed together in a section by themselves.
TUMORS OF THE GALL-BLADDER.
This expression refers rather to actual neoplasms of the gall-bladder itself than to distention of the sac by which an intra-abdominal tumor may be formed. The latter subject may be dismissed with the mere statement that the gall-bladder may become distended with bile, with mucus, with pus, with concretions, or with the products of such disease as echinococcus, actinomycosis, etc. In this way it may be so much enlarged as to be easily felt through the abdominal walls or to be even mistaken for other conditions. In the latter case it may have to be differentiated between such a condition and a movable right kidney, a tumor of the kidney itself or of its capsule, as well as from tumors of the stomach, especially the pylorus, of the liver, or of the intestine and from the enlargement of the right lobe which often accompanies cholelithiasis, or from fecal impaction. It would be best to abstain from the use of the aspirating needle in these cases, as more harm might be done by the escape into the abdomen of deleterious fluid than would be atoned for by the information which the procedure would afford. Even when the abdomen is open the gall-bladder should rarely be punctured in this manner, unless one is prepared at the same time to open it and drain. In other words, there is less risk about a small exploratory incision than in puncture.
Nearly all varieties of _malignant_ and many of _benign_ tumors have been reported as occurring in this location. It will be sufficient in this place, however, to say that _cancer_ of the gall-bladder, which, of course, may extend in various directions, is by no means an uncommon affection, and is _usually a complication of gallstones_. In fact, it may be doubted whether primary cancer of the gall-bladder ever occurs in the absence of such a source of irritation. These cancers vary in type between the round-cell and the squamous, most of them, however, being of the former character. Although Musser has put the percentage at 65 and Zenker as high as 85 of instances where gallstones are found within cancerous gall-bladders, it does not follow that the above statement may not be true regarding their almost universal association and causal relation, for any gall-bladder found empty at a given time may at some other time have contained a calculus. This frequent association is justly among the valid arguments which surgeons may now use in making a plea for earlier operation, and for making it a more standard procedure.
_Cancer_ may be suspected in cases of progressive and unintermittent jaundice, especially when there can be felt in the region of the gall-bladder a distinct tumor or an enlargement of the liver. Pain is a frequent but by no means a constant or reliable symptom. As the disease spreads the adjoining textures will become matted together, and a low grade of local peritonitis may still further cement them into a mass which will occupy a considerable portion of the upper part of the abdomen.
But few cancers of the gall-bladder which are so apparent as to be recognized without exploration can be considered as still amenable to surgery, which for them can hold out but little prospect save perhaps a temporary relief by biliary drainage. It is the cases in their earlier stages, when the condition is made out by exploration, and by it alone, which still afford prospects of more or less permanent relief. The very impossibility of detecting the condition in these earlier stages without exploration affords one of the strongest arguments for such a procedure in every vague case of the kind. That cases of this character are not necessarily hopeless is instanced by an experience of my own, where on opening the abdomen of a large and fleshy woman I found a distinctly cancerous gall-bladder containing two large calculi, and removed the entire mass, with a considerable portion of the surrounding hepatic tissue, the removal being effected with the actual cautery. At present date of writing, nearly six years after the operation, the patient is apparently perfectly well and doing her own housework.
OPERATIONS UPON THE GALL-BLADDER AND BILIARY PASSAGES.
The small area included under the above title has been made the field for a variety of operations, dignified with formidable names, the entire list of which might be made quite long. In order to simplify their arrangement and illustrate their purposes they may be referred to as (1) operations upon the _gall-bladder proper_; (2) those _upon the ducts_; and (3) the more complicated operations upon one or both of these in connection with some other part of the intestinal tract; or, to catalogue them somewhat definitely, the operations upon the gall-bladder include _cholecystotomy_, _cholecystostomy_, and _cholecystectomy_, according as the surgeon opens the gall-bladder and closes it, makes a more or less permanent opening, or completely removes it. Again, upon the _ducts_ he may make _cholangiotomy_ or _cholangiostomy_, or, using their practically equivalent synonyms, _choledochotomy_ or _choledochostomy_, these terms referring to operations upon the cystic and the common ducts; while when similar procedures are applied to the hepatic duct they have been spoken of as _hepaticotomy_ and _hepaticostomy_. _Cholecystenterostomy_ refers to an anastomosis between the gall-bladder and the upper bowel, while when this is effected between the common duct and the bowel it is referred to as _choledochenterostomy_. When a stone lies partly in the common duct and partly within the wall of the duodenum, and it becomes necessary to incise the latter, it may be spoken of as _duodenotomy_. The operation of merely crushing biliary calculi, hoping that the fragments will be passed on with the flow of bile, and spoken of as _cholelithotrity_, is now almost abandoned, and the term has historical rather than present value.
To even attempt to epitomize directions for these various operations into space available here would be impossible, for large volumes have been devoted to this subject alone. The main thing for the student and the junior practitioner is to appreciate the indications for their performance, at which he should certainly have assisted before attempting to perform them himself. General directions, however, may be given as follows, the usual preparations having been made both of the patient and the environment: A woman who has borne children and who has, in consequence, relaxed abdominal walls, makes a more favorable subject for operation than a muscular man whose abdominal muscles cannot be relaxed until a profound degree of anesthesia has been obtained. In many instances exposure is made better by placing a sandbag behind the region of the liver, especially on the side to be operated, by which the costal angle is more outlined and the parts pushed forward.
A preliminary incision should be made of, say, three inches in length, and is best placed a little to the inner side of the outer border of the rectus, whose fibers are separated and its tendinous intersection divided. This incision may be extended upward and curved toward the middle line, as recommended by Bevan, or downward, as the exigencies of the case may require. The beginner especially should provide himself with sufficient space for manipulation. The posterior sheath of the rectus and the peritoneum are best divided together. Sufficient opening being thus made, a finger may be inserted for the purpose of exploration. In the presence of adhesions, and especially in acute cases in which pus is likely to be present, this should be done with great caution. When no adhesions are present gauze pads may be inserted and so disposed as to permit exposure to view of the lower surfaces of the liver. The operator should be prepared for any and all conditions--one of dense adhesions or their complete absence, as well as for cobweb-like adhesions which surround foci of infected exudate or of pus. The more reason he may have for suspecting the presence of pus the more carefully should the region be walled off with protective gauze. Adhesions are most likely to form between the omentum and the colon, in front and below, and with the stomach, duodenum, and colon below and behind. Those who have had experience with abdominal operations will appreciate whether these adhesions are recent and likely to cover purulent foci, or old, and will proceed accordingly. Occasionally tissues will be so matted that even an experienced operator will scarcely be able to differentiate them.
The endeavor should be, if possible, to expose the gall-bladder itself, both to touch and sight, in order that after orientation concerning its actual condition its duct may be followed into the common duct, and this into the intestine. This is sometimes an exceedingly easy matter, and again impossible. The presence or absence of pus will of itself indicate what should be done. When, for instance, the gall-bladder is found black or partly gangrenous the surgeon will content himself with doing the least possible amount of separating, endeavoring rather to provide the widest outlet for drainage. It might be better to make simply a small opening and permit the escape of fetid débris, and to postpone until a later day further attempt to remove the calculus, which presumably has produced the difficulty. Local indications, then, should be considered along with the general condition of the patient.
The lower surface of the liver will afford the guide to the location of the gall-bladder, and when the latter is nearly obliterated its discovery sometimes taxes the resources of the surgeon. When not contracted it is usually easily exposed, and so far freed that it may be even drawn up into the wound. After having thus isolated and perhaps secured it, it must be decided by further exploration how it shall be treated. It is of great importance to liberate the ducts from surrounding adhesions.
=Cholecystotomy.=--Cholecystotomy, sometimes fallaciously spoken of as ideal, consists in simply opening the gall-bladder, emptying it of calculi or other contents through a small incision, and closing this by sutures. The operation is ideal in but one way, but conditions which permit it rarely justify it, for any gall-bladder so diseased as to call for operation needs either removal or drainage.
=Cholecystostomy.=--Cholecystostomy includes provision for drainage over a considerable length of time. A distended gall-bladder which permits of easy manipulation and isolation may be sufficiently long and large to justify uniting its surface to the peritoneum and deep margins of the wound, in such a way as to permit discharge of its contents through the latter. The old method was to unite it to the skin. This should never be done, as fistulas thus resulting are more likely to be permanent. If the gall-bladder be thus affixed to the parietal peritoneum the better way is to insert a drain, its arrangement being left somewhat to the choice of the operator. For my own part I prefer a rubber tube, not too flexible, inserted two or three inches into the gall-bladder, through a small opening closed around it, with invaginated edges, by a purse-string suture of chromic gut, by which it is intended to prevent leakage into the abdominal cavity. By another suture of common gut the tube may be so fixed as to avoid danger of being lost in either direction. If the gall-bladder be sufficiently long to permit additional fixation to the depths of the abdominal wound the operation is made still more ideal; but in the case of a short and contracted cavity the tube may be left to follow it into the abdominal recesses. Within forty-eight hours the exudate which has been thrown out around it will have become sufficiently organized and well ordered to form a canal in which the tube shall rest, and which shall serve later as a conduit to conduct bile to the surface after removal of the tube itself. Into such a tube, after the application of the dressings, may be conducted another more flexible tube, whose upper end shall connect with a receptacle of some kind, which may later be a bottle held within the dressing, to receive the discharge, and thus avoid soiling.
This operation has been done occasionally in two sittings, the gall-bladder being brought into the upper part of the wound and fastened to the peritoneum by sutures, which should not perforate its walls, as that leakage would occur which the method is intended to avoid. After waiting a day or two for adhesions to form the cavity is then opened with a knife or scissors and drainage thus accomplished. This method has been practically abandoned, for the reason that it permits no digital exploration by combined manipulation.
=Cholecystectomy.=--Cholecystectomy includes the removal of the whole or the greater part of the gall-bladder. It has already been stated that this is a _reservoir_, convenient and advantageous, but not needed in a way, and not essential to life. It figures as a superfluous organ, then, similar to the appendix, and there is no reason why, when diseased and troublesome, it should not be _extirpated_. Its removal will sometimes be a matter of choice, and at other times a necessity. The former is the case when the surrounding conditions lend themselves to its dissection from the lower surface of the liver without too much violence to other tissues; the latter when it is involved in malignant processes or when its interior is seriously infected. An incomplete method of treating the gall-bladder under the latter circumstances might include the _scraping or removal of its thickened mucosa_, without removing the entire thickness of its structure. In this case, however, drainage would be required. That the gall-bladder may be completely separated and thus isolated, with comfort and speed, requires that its wall be sufficiently strong to stand the ordinary manipulation. This may not be true of the perfectly normal gall-bladder, but in such case no one would think of removing it, whereas the cyst, which is diseased sufficiently to justify removal, will usually permit of the necessary manipulation. Even if somewhat torn in the process the procedure may be effected without much added difficulty. This procedure consists essentially in separation of the overlying peritoneum and enucleation of the gall-bladder from its bed or the depression in the liver in which it lies, which, as already indicated, may be narrow or wide and deep. Actual separation from liver tissue will be followed by oozing and at least two or three vessels in the surrounding structures and at the neck of the gall-bladder will require to be secured. Removal should not be attempted in cases which do not permit of it, but may be practised in those cases not too infected, when after emptying the sac (full of calculi, for instance) it can still be established with the probe that the common duct is patulous. These are ideal cases for such complete work. The gall-bladder having thus been isolated down to its cystic termination, the surgeon proceeds much as though it were the appendix, by firmly ligating the duct with chromic gut, guarding against escape of contents while it is divided on the distal side of the ligature thus applied. The stump of the duct is then cauterized with pure carbolic, after which oozing is checked by tamponing for a few moments. It then is often possible to bring together the peritoneum beneath the torn liver surface and almost completely cover it anew. The liver tissue will bear a ligature or suture not too tightly drawn. If the case have been one otherwise surgically clean, and the operation properly conducted, the abdominal wound may be closed without drainage. If, however, doubt be felt a small cigarette or a tubular drain may be placed, to be left not more than thirty-six hours. Every infected gall-bladder, if not removed, should be thoroughly cleansed, its interior being mopped with gauze, preferably with the addition of hydrogen dioxide. An important step, next to attention to the gall-bladder proper, is to demonstrate the patency of the ducts. This is done by gently passing a probe, which should be bent to suit the case, along the duct and into the intestine. This, of course, cannot be done if calculi are discovered by manipulation, neither can it always be done when calculi are not present. Gallstones in the duct can usually be distinguished by the fingers with which the exploration is made, and failure to thus pass a probe may be brought about by stricture rather than by calculous obstruction. The importance of this determination will be seen in removing the gall-bladder, as to remove it in an obstructed case is to leave no outlet for bile except into the abdominal cavity, whereas to fail to drain such a case is to plainly neglect to meet the indication.
[Illustration: FIG. 628
General scheme of cholecystectomy; detachment of gall-bladder and duct from their investments; ligation of cystic duct and arteries. (After Kehr.)]
=Cholecystendysis.=--The term cholecystendysis, now almost obsolete, implies practically a cholecystotomy with drainage, the gall-bladder having been opened for the purpose of removal of one stone or more and then united to the abdominal wound.
Of the _operations upon the ducts_ there is something to be said in addition to the directions already given. Inasmuch as they lie more deeply they are more difficult of access, and variously shaped retractors, with walling off the cavity with gauze, are more often required, while in proportion as deep adhesions have enwrapped the structures they are made more difficult of exposure. At present surgeons have less hesitation in leaving duct incisions unclosed than was formerly felt. It was formerly held that every incision into a duct should be closed with sutures. It has been later found that satisfactory results ensue when the end of the drainage tube is left resting, or even fastened, within the duct opening, the operation being thus made shorter and simpler and the difficulties of deep suture thus obviated. As elsewhere noted the common duct may become enormously _dilated_, and may be almost mistaken for the small intestine. The passage-way between this duct and the gall-bladder may be so obstructed that double drainage will be of advantage, or this may be a case where
## partial removal of the gall-bladder may be effected, with drainage
of the common duct. Such cases should be judged upon their merits. The more infectious the existing condition the more is free drainage demanded. When a stone is impacted in the ampulla of Vater there should be no hesitation in dividing the walls of the duodenum in order to extract it. In such a case the duodenum is sutured, but the duct or the gall-bladder must be drained (Fig. 629).
These deep operations require free incision, several inches in length, and it will astonish the beginner to see how the liver may be delivered from the abdominal cavity through such an opening. Much assistance will here be gained by a large pillow or sandbag placed beneath the back. Bleeding vessels need to be secured, at least temporarily, with forceps, and usually with sutures or ligatures _en masse_. The exposed or torn surfaces of the liver will ooze freely at first, but bleeding usually ceases with the pressure of a gauze tampon. From the uninflamed gall-bladder the peritoneum is usually easily separated, with but trifling hemorrhage. For deep work traction on the middle portion of the duodenum makes more prominent the junction of this part of the bowel with the gastrohepatic omentum, at which point the peritoneum may be incised and separated along the free border of the duodenum until this portion is free from external peritoneal covering. There will be exposed here the second portion of the common duct where it lies upon the pancreas, it being more or less embedded in the latter further along. When it is necessary to cut away more tissue it is better to sacrifice a portion of pancreas rather than of duodenum itself. Blunt dissection alone should be made here. When it is necessary to cut it will be better to use the thermocautery.
[Illustration: FIG. 629
Removal of gallstone entangled at the papilla. Kocher’s method of displacing the duodenum: _a_, incision in the paraduodenal peritoneum; _b_, pancreas; _c_, location of the stone; _d_, duodenum; _e_, sutures used either for retracting or closing opening in the common duct; _f_, retroduodenal venous plexus. (Kehr.)]
These various cutting operations have superseded the previous methods of endeavoring to crush stones within the duct and force the fragments along by pressure. The Mayos have recommended the use of two fine parallel sutures, introduced longitudinally into the duct, between which the incision should be made, and which may be used as tractors, or subsequently for purposes of closure.
Practically every gall-duct case should be drained with a tube extending down to the deepest portion of the site of the operation. This may be done with what has been called a “dressed tube,” made by surrounding an ordinary rubber drain with a few layers of gauze and covering this with oiled silk. The lower end of the tube is then bevelled or trimmed in fish-tail fashion. This may be passed into the depths, or it may be used for gall-bladder drainage as well.
Of the _anastomotic operations_ there is less heard now than a few years ago. There are now considered to be but a few conditions which are not better dealt with by biliary drainage as made above than by any other method. Occasionally, as, for instance, when the common duct is strictured or involved in pancreatitis or cancerous deposit, and bile is backing up into the gall-bladder, it may be of great advantage to effect an anastomosis between the latter and the bowel. At one time the colon was used for the purpose, but this prevented the utilization of the bile in the upper bowel, where it is most needed. Consequently it should always be made into the upper portion of the bowel, the duodenum, or one of the upper loops of the jejunum. For this purpose a small Murphy button is probably still the speediest and best expedient. This is true also when it seems necessary to drain the common duct into the bowel, since the field of operation in most cases lies too deeply to permit of accurate and satisfactory suturing. A further and more difficult as well as later application of this principle has been suggested for certain cases of permanent obstruction of the common and main hepatic ducts. Under these circumstances the operation last mentioned would be useless and a cholangiostomy would be objectionable, as it would constitute a permanent fistula. As practised by Kehr and others this _hepato-cholango-enterostomy_ is performed by removing from the lower surface of the liver a strip of its tissue about 7 Cm. long and 2.5 Cm. wide. The hemorrhage is checked with the thermocautery, and with it an opening is made into the liver, of such a depth that several of the bile ducts are thus divided and opened. The uppermost loop of bowel which then can be utilized without tension is opened and sutured to the margins of liver wound. The method is still on trial, and yet in at least one successful case it was shown that the liver tissue tolerated this unavoidable contact with the contents of the upper abdomen (Fig. 630).
[Illustration: FIG. 630
Demonstrating the technique of anastomosis between the gall-bladder and the jejunum. (Cordier.)]
=After-management.=--What to do with these cases of biliary drainage after it has been effected is sometimes a serious problem. No hard-and-fast rules can be laid down regarding the length of time during which drainage should be maintained. In instances where the gall-bladder has been removed the drain should be taken out within thirty-six hours, but in those cases where a tube has been fastened into the gall-bladder for so-called permanent drainage the term “permanent” may be regarded as elastic, and covering a period of from ten days to perhaps ten weeks. In the majority of instances three weeks or so of such drainage suffice to meet the original indication. In cases, however, of chronic pancreatitis a long period of easy outflow will be demanded, while in rare cases of cancer drainage once thus made cannot be abandoned.
When the gall-bladder has not been fastened nor allowed to adhere to the skin, but only to the peritoneum, the fistulas thus made will usually close and rarely need stimulation. Should, however, the granulation process by which closure is effected be too sluggish it may be stimulated by the application of nitrate of silver, either in solution upon a swab, or in solid form, as when melted into a bead upon the end of a suitable probe. Firm pressure will also assist in final closure.
It is not reasonable to expect that after so much intervention, within the rudely triangular potential cavity occupied by the gall-bladder and the ducts, adhesions will not form as a part of the reparative process. In fact it may rather be expected that as it becomes obliterated adhesion must necessarily follow. In consequence there may result an agglutination around the gall tract, and into a common mass, of the liver, the colon, and the pyloric end of the stomach. In spite of these adhesions bad symptoms rarely ensue, and when discomfort persists it is usually in those cases in which no stone was found or those in which stones have been overlooked. Andrews regards such postoperative adhesions as unavoidable and even desirable, and, having no faith in any measures to prevent their formation, differs from Morris in regard to the technique of their subsequent removal. It appearing from observation and experience that the stomach is the organ which suffers most by extensive adhesion to the liver, he has proposed to substitute the colon for the stomach in this necessary union of surfaces, and would even practise it in old cases after separation of old adhesions.
The operation suggested by Andrews, and which he calls _cholehepatopexy_, or _colon substitution_, is made with an incision through the middle line of the right rectus, avoiding any old scar, long enough to afford plenty of room. The stomach is then carefully separated from the liver, tearing liver tissue rather than that of the former, if something must be torn, and checking bleeding by hot sponges. The pylorus having been exposed the stomach is invaginated into it in order to demonstrate its patency. The freshly separated viscera will now fall again into immediate contact unless the transverse colon be pulled up and held in place between the liver and the pylorus, this not being so much of a displacement as would appear, as the bowel is not rotated and does not cross over the stomach. The colon is held in its new relation by attaching its omentum to the gastrohepatic ligament, to the liver surface, or to remnants of old adhesions in the angle between the pylorus and the liver. The looser the omentum and the more easily it can be interposed in this way the better. Andrews’ conclusions are that gall-tract adhesions are unavoidable, both in disease and after operation, that they are harmless except in a very few cases, and often beneficial, and that in the few cases where they do harm this comes from malposition rather than from adhesions _per se_. He even believes that certain vague gastric adhesions which might have been benefited by this operation have been previously treated by gastro-enterostomy.
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