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.
Fig. 625
Xiphopagous twins, separated by division of a band of common liver tissue. Case of M. Baudouin. (Pantaloni.)
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.
—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.
—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.
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.
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 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.
—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.
Fig. 626
Abscess of liver, opened by transperitoneal hepatostomy. (Pantaloni.)
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.
—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.
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.
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.)
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 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.
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.
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.
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.
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.
—In the early stage of such a condition the treatment is medicinal, but when the condition has become chronic biliary drainage may be required.
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.
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.
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.
—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.
—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.
—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.
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 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.
—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.
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.