forms--namely, the inguinal and femoral--I propose here to introduce
the views enunciated by Russell, of Melbourne, which seem to me
to furnish the actual explanation for nearly all instances. This
explanation refers to the _congenital origin of the condition, even
though it do not appear until the middle years of life_. In the case of
inguinal hernia it refers also to the persistence of the canal of Nuck,
or of at least incomplete obliteration of the original vaginal process
or prolongation of the peritoneum, which comes down with the migrating
testicle and whose lower portion furnishes the cavity of the tunica
vaginalis. It is more rational to explain the occurrence of hernia in
connection with this preformed sac than by the view that there are so
many instances of congenital weakness of the abdominal wall. That such
weakness exists in many cases of hernia is undeniable, but this is to
be regarded as the effect rather than the actual condition. From this
last statement it follows also that there is great advantage in early
operation, and in complete removal of the sac, which when performed
early will not only cure the hernia but prevent the weakening of the
abdominal wall itself. It follows, further, that the use of a truss,
save possibly in the case of young infants, is an improper method of
treatment. In other words, upon it is based the crux of the whole
matter of successful treatment, _i. e._, operative removal of the sac.
It will be seen, then, that the cause of inguinal hernia is closely
related with the cause of so-called congenital hydrocele of the cord
(_q. v._), the latter condition being one of sacculation of the canal,
with accumulation of fluid; and it is interesting to recall that
such sacculations are occasionally found in the ordinary so-called
congenital hernias, when they are seen early, and before all anatomical
surroundings have been merged together. _The existence of a hernia
implies the presence of a sac, and a congenital defect furnishes this
latter, while the variations in the type of hernia are due mainly to
the variations in the sac itself_, i. e., _in its location_.
[Illustration: FIG. 597
Congenital hernia.]
[Illustration: FIG. 598
Infantile hernia.]
Russell has traced out the relations between the peritoneal pouches of
the lower abdomen and the principal bloodvessels, and has shown how the
former arrange themselves about the latter and are carried with them
as they develop, assuming in consequence the type either of inguinal
or femoral hernia, according as they are placed to the inner or outer
and lower side of the same. He has insisted, and I think properly, that
the variations observed in the clinical manifestations of a hernia are
mainly determined by the size and the position of the sac, and that
these depend upon its relations to the femoral and epigastric vessels,
the associated sac and vessel being subject to the same vicissitudes in
development. In this way the occurrence at one time of a _congenital_
and at another of a so-called _infantile_ type of inguinal hernia may
be easily explained, as well as the differences between the so-called
_funicular_ and the partial form, and also the occurrence of the
_retroperitoneal_ or _properitoneal_ forms, which, as variations are
rare, and as clinical manifestations perplexing, but which nevertheless
are easily explained when viewed in this light (Figs. 597 and 598).
[Illustration: FIG. 599
Adhesions in hernial sac. Scarpa. (Lejars.)]
Thus viewed, then, what are the _relations of traumatism to congenital
defects_? When thus explained they seem to be as follows: By no means
every individual who sustains an injury to the abdomen suffers from
hernia, but when the parts are already weakened or prepared by the
preëxistence of these congenital defects, then a small amount of
strain or injury may serve to open them up and to produce a condition
apparently due to accident which otherwise could not have occurred.
The more I have studied the entire question the more I have come to
the conclusion that hernias of the ordinary type, save in case of
extreme violence, would not occur were it not for such a congenital
prearrangement and tissue permission, as it were; so that we are
justified in assuming that inguinal and femoral like umbilical hernias
are really of congenital origin.
=The Signs of Hernia.=--The signs of hernia include the existence of a
_tumor_, usually at one of the common outlets, which may be variable
in size, and fixed, changeable, or otherwise, according to whether it
consist of intestine or omentum. To a hernial protrusion consisting
of intestine alone may still be given the old term _enterocele_. One
consisting of omentum is known as _epiplocele_. Hernial protrusions
may attain tremendous dimensions, especially those appearing at the
umbilicus, and some of these sacs contain perhaps the larger proportion
of the intestine or even of the entire abdominal contents. Scrotal
tumors, again, may attain large size, _e. g._, that of the individual’s
head or even much larger. According to the nature of the contents such
a tumor will be more or less resonant on percussion, and more or less
compressible as well as reducible. _Reducibility_--namely, the ability
to be returned to the abdominal cavity--is the most characteristic
feature of a hernia and one possessed by nearly every such tumor, at
least at its inception. It may, however, be lost.
Loss of reducibility, when occurring gradually, is replaced by what
is known as _incarceration_, _i. e._, more or less complete fixation,
at the same time without such pressure on bloodvessels as to produce
necrosis. Incarceration may be the result of reduction in caliber
of the hernial outlet, or of the formation of adhesions between the
walls of the sac and its contents, such adhesions being common alike
to omentum and large or small bowel. (See Fig. 599.) _Strangulation_
is an acute process which may terminate either a reducible or
an incarcerated hernia. It implies some sudden change, such as
overcrowding of the bowel within the sac, or some peculiar kinking, by
which intestinal caliber is shut off, as well as blood supply affected
because of pressure, by which the vitality of the gut and of the sac
is compromised or perhaps quickly lost. Strangulation, then, includes
at least the possibilities and usually the simultaneous occurrence of
acute obstruction of the bowel with more or less gangrene of the sac
itself, as well as of the compromised gut.
_Reducibility_ as an ordinary feature of hernia is one with which the
patient himself is quite familiar, most patients with reducible hernias
being able to effect reduction in the horizontal position, accompanied
by some manipulation or maneuver. When in such cases reduction cannot
be accomplished incarceration or perhaps strangulation has begun and
the case immediately assumes serious proportions. Reduction is usually
accompanied by a peculiar gurgle, as well as disappearance of the
tumor itself, while the opening through which it has disappeared can
usually be identified with the finger, by invagination of the scrotum,
or by pressure over the femoral region. Such a tumor usually reappears
when the patient stands, or particularly when he coughs or makes any
straining effort, and the occurrence and recurrence of these phenomena
clearly establish the diagnosis of hernia.
Irreducible or incarcerated hernias usually give some _impulse upon
the patient’s coughing_, as do the reducible forms, yet in some cases
they lead to more difficulty of diagnosis. Ordinarily in the male
the question is mainly as between inguinal (or scrotal) hernia and
_hydrocele_. In the latter there is a pear-shaped tumor whose apex
should be found below the level of the inguinal outlet; a tumor which
will fluctuate, whose shape does not change, which gives no impulse
when the patient coughs, which is not influenced by pressure, even with
the patient in the horizontal position. It is only in incarcerated or
in peculiar types of congenital hernias, or in those combined, as they
may be, with hydrocele, in which doubt should not be easily dissipated.
While incarceration predisposes to acute obstruction it is not always
followed by it, but may produce a more chronic type of constipation,
with tendency to fecal impaction, because of the mechanical impediment
to freedom of bowel motility. This condition is more frequently met in
the aged.
_Inflammation of the hernial sac_, as well as of its coverings, leads
to a condition described as _inflamed hernia_. It is essentially one of
circumscribed cellulitis. It may be due to the irritation of a badly
fitting truss or to other external causes. The inflammation may extend
so as to involve the sac wall itself, and thus produce adhesions and
later incarceration, or it may set up actual peritonitis, which may
extend to the general abdominal cavity and terminate fatally. The more
superficial and less acute forms are scarcely distinguishable from a
local erysipelas which may terminate by abscess. Such a condition might
be mistaken for one of suppurating bubo. Nevertheless the existence
of the hernia itself should guard one against this error and make him
extremely cautious in using the knife, even though it be necessary for
the evacuation of pus.
[Illustration: FIG. 600
Gangrenous strangulated hernia; artificial anus; prolapse of bowel
requiring intestinal resection; eventual recovery. (Preindlsberger.)]
_Strangulated hernia_ has already been considered as the most common
cause of _acute obstruction of the bowel_. Its possibility should
be excluded in every case of this serious condition. While such are
its general features, locally there is added to the general bowel
obstructive condition that of more or less local destruction, which may
vary from the presence of exudate, fluid or solid, with infiltration of
adjoining tissues, to the most prompt and disastrous consequences of
venous stasis, namely, extensive _gangrene_, which, involving first the
bowel itself or the omentum, will later spread to the sac wall and its
surroundings. In this instance around the loop or loops of gut involved
will be seen a tight constriction or sulcus, above which the bowel
will be more or less discolored and distended, while below it will
be completely necrotic and perhaps actually sloughing. Minor degrees
of strangulation may produce conditions which would lead up to this,
but have not yet actually reached the stage of gangrene. Around such
bowel will be found more or less fluid, the result of transudation,
which will be swarming with bacteria and often offensive. The sac wall
closely corresponds in appearance to that of the bowel, and everything
about the sac and its contents will be infected and contaminated with
bacteria, often of most virulent activity. The gangrene may involve an
area of exceedingly small size, or the entire contents of the hernial
sac. In the former instance the condition is comparatively simple as
compared with the latter, which may require resection of several feet
of necrotic bowel. The proper treatment of these conditions will be
more fully dealt with below (Fig. 600).
=Symptoms.=--The symptoms of strangulation are those of acute
obstruction, plus the local evidences of a hernia, usually with added
pain and tenderness, sometimes acute. These symptoms may come on as
the result of strain or accident or without any known cause. Their
intensity will depend in some measure upon the completeness of the
blood stasis and the rapidity of the consequent gangrenous process. The
latter may vary in degree. Thus the death of the compromised bowel may
be practically determined within a few hours or within two or three
days. The hernial tumor, within which strangulation has occurred,
becomes more tense and incompressible, and, at the same time, more
tender. Sometimes there is marked augmentation in volume; at other
times this changes but little. So soon as a loop of bowel has lost
its blood supply and become actually necrotic it will have also lost,
when exposed, all of its luster or “sheen,” and will appear not only
black and lusterless, but will be more or less offensive in odor, and
of extremely septic character. The surrounding fluid will be found
swarming with bacteria, and will seriously and perhaps fatally infect
anyone inoculated with it.
Concerning the color of the exposed bowel and its appearance, it is
a fairly safe rule to follow that gut which has not lost its luster,
even though darkly discolored, is still viable, and may with safety be
returned to the abdomen, which is probably the safest place for it;
but when its sheen is actually lost the case becomes one either for
resection or for artificial anus. It is possible that such a case may
be seen only after absolute necrosis and fecal escape have occurred.
When actual sloughing is thus met it is a question for resection or
some other expedient.
=Varieties of Hernia. Inguinal Hernia.=--The inguinal form of hernia
comprises nearly four-fifths of cases in males, a much smaller
proportion in females. The hernial protrusion is always through the
external abdominal ring, either by way of the inguinal canal, which it
enters through the internal ring, or directly through the abdominal
wall. The former is called _indirect_, the latter _direct_. Such
a hernia is considered _complete_ or _incomplete_ according as it
descends below the lower margin of the inguinal canal. An incomplete
and direct hernia is often referred to as _bubonocele_. (Fig. 601.)
Holding the views above enunciated, regarding the congenital origin
of practically every inguinal hernia, it is necessary to pay less
attention to the distinctions insisted upon by the earlier authors
concerning the congenital, the infantile, or the encysted forms of
hernia, which depend upon the extent and degree of closure of the
vaginal process or the canal of Nuck, which is carried down with the
testis during its migration from the lower margin of the Wolffian
body, and which is normally obliterated at birth. Nevertheless these
conditions, however explained, are actually met during life and are
represented by the diagrams seen in Figs. 602, 603 and 604.
[Illustration: FIG. 601
Indirect inguinal hernia (bubonocele.) (Richardson.)]
[Illustration: FIG. 602
Congenital inguinal hernia.]
[Illustration: FIG. 603
Infantile or encysted hernia.]
[Illustration: FIG. 604
Hernia of the funicular process.]
In the female the canal of Nuck is a matter of minor importance,
containing only the round ligament. Nevertheless along it may proceed
an indirect inguinal hernia corresponding to that in the male.
The so-called _acquired indirect hernia_, according to the above
views, _would not occur were it not for the opportunity--as it were,
the temptation--already afforded by some deviation of the peritoneal
arrangement in this locality_. In these cases, however, the sac
appears to be new and is pushed along the inguinal canal anteriorly
to its normal contents. This may be the result of violent strain, or
of one which is apparently disproportionately small, but frequently
repeated.
_Direct inguinal hernia_ is generally an occurrence of adult life,
takes place commonly as the result of accident, is a direct protrusion
through the abdominal wall at the triangular weak spot, whose outer
limit is the deep epigastric artery, with the obliterated hypogastric
artery to the inner side and Poupart’s ligament below, _i. e._, the
so-called triangle of Hesselbach. This hernia appears always at the
external ring, from which it may descend and become scrotal.
[Illustration: FIG. 605
Scrotal hernia. (Richardson.)]
With complete or scrotal hernia there is usually little difficulty of
diagnosis (Fig. 605). An incomplete hernia, protruding at the external
ring, covered with considerable fat, and perhaps shifted a little in
position, is sometimes hard to distinguish from a hernia through the
femoral opening. The inguinal form escapes above Poupart’s ligament,
the femoral always below it, and Poupart’s ligament is to be located
by a line drawn from the anterior superior spine to the spine of the
pubis. The inguinal forms are usually nearer the middle line. If the
epigastric artery can be identified, either before or during operation,
the character of the hernia will be promptly demonstrated by its
relations to the neck of the sac.
Hernial protrusions give a familiar _impulse on coughing_ unless the
incarceration of an epiplocele may mask this feature. By it they are
to be distinguished from hydrocele, varicocele, aneurysm, undescended
testicle, and the like.
[Illustration: FIG. 606
Hernia of liver through congenital opening in the umbilicus.
(Richardson.)]
=Femoral Hernia.=--Femoral hernia is much more common in women than in
men, and constitutes about one-tenth of all cases. This form is also
nearly always congenital in the above sense, and is particularly liable
to strangulation. It escapes through the femoral ring into the femoral
canal, to the inner side of the femoral vein, and then, passing forward
through the femoral opening, finds its direction of least resistance
upward. In consequence a loop of bowel thus escaping from the abdomen
may first pass downward, then forward, and then upward, which will
illustrate the futility of the ordinary methods of taxis in the effort
to reduce it by manipulation. These hernias are usually small, hence
their greater danger. These cases have especially to be differentiated
from psoas abscess, from inguinal lymphatic enlargements, and tumors.
If the sac be entirely filled with omentum diagnosis is often difficult.
=Umbilical Hernia.=--Umbilical hernia is primarily permitted by failure
in obliteration of the opening at the navel for the omphalomesenteric
duct and for the urachus. Originally small, it may yet assume enormous
dimensions. Though actually of congenital origin, as just stated, it
may not be discovered until the later years of life. It occurs much
more commonly in females than males, and usually in connection with a
large deposit of fat in the abdomen, by which its existence, or, at
least, its limits and dimensions are masked. Through the umbilical
opening, which in the majority of cases is small, may escape other of
the abdominal viscera, as is shown in Fig. 606, illustrating hernia of
the liver. Fig. 607 illustrates the pendulous form which many of these
cases assume.
[Illustration: FIG. 607
Umbilical hernia of pendulous form. (Park.)]
An _infantile form_ (umbilical) is known, in which the actual
protrusion does not occur until the infant is several months old, and
which appears to be due to frequent strain, on a weak or incompletely
closed fenestrum, by coughing, crying, efforts to expel urine through a
strictured prepuce, and the like. These tumors at first are small and
always intestinal. It is often possible to so adjust a small pad over
these openings as to secure subsequent closure by natural processes.
On the other hand, the forms which come on in later life, acquired
during pregnancy, ascites, or in connection with excessive obesity,
assume sometimes relatively enormous size. Here the hernial contents
may be solely omental, but are usually at least partially intestinal.
Strangulation occurs in a large proportion of these instances and
incarceration is nearly always observed. Naturally, in consequence,
the patient complains of gastric disturbances, as well as of chronic
constipation, with frequent colicky attacks.[61]
[61] A rare form of hernia into the umbilical cord has been described
by Moran. It has been known as _hernia funiculi umbilicalis_, and has
been held to be due to abnormal persistence of the vitelline duct,
which holds the loop of intestine to which it was attached inside the
abdominal wall, the intestine continuing to grow, the umbilical ring
remaining open and the hernia thus enlarging. Occurring in this way
it happens about the tenth week of fetal life. Such a hernia has no
covering except the peritoneum and the amnion--_i. e._, is without
muscle or skin covering. It would be probably first noted when the
cord is about to be tied, when at its loop, as a translucent tumor,
varying in size from that of a small cherry to a lemon, the cord
being distended and assuming its own natural size only after it has
left the hernial tumor. The bloodvessels will run on one side of the
amniotic sac. Such sacs rupture easily, perhaps during crying efforts
or even during parturition. The condition is serious, and when
present no traction should be made on the cord. If easily reduced by
taxis an antiseptic compress should be fastened over the opening.
Should anything like strangulation occur operation is imperative and
should be done immediately.
=Ventral Hernia.=--Ventral hernia is of two types--the _spontaneous_,
usually _epigastric_, which is an omental escape in the middle line
above the umbilicus, occurring most often in fat women, in whom it
is likely to be mistaken for a hernia of ordinary umbilical type. By
fixation of its contained intestine and omentum there is more or less
dragging upon the upper abdominal viscera, with consequent disturbance
of function.
=Postoperative Hernia.=--Postoperative hernia often also spoken
of as ventral, occurs through the cicatrix of the wound which has
permitted it, whether this be in the middle line or elsewhere. It is an
unfortunately frequent sequel of laparotomy wounds which have required
drainage, but occasionally occurs in perfectly clean wounds which have
closed satisfactorily in the first place, but which have subsequently
parted because of unsatisfactory methods of bringing together their
deeper portions. (See p. 778.) Consequently it should be sufficient
here to remind the reader that the more accurate the method of
approximating the margins, layer by layer, and effecting a complete and
perfect union between them individually the less the tendency to this
unpleasant sequel.
Postoperative hernia may be so small as to be kept under subjection
with some form of abdominal support, or it may call for operations for
radical cure, as do other cases. They are subject to the same dangers
of strangulation of their contents.
=Diaphragmatic Hernia.=--Diaphragmatic hernia may be _congenital_, as
when occurring through a defect in this partition, or _acquired_, as
when under stress or strain some of the abdominal contents are forced
into the thorax, either through natural openings or through a rent
or tear. Such escape may include but a small portion of bowel; in
congenital cases one-half the abdominal contents have been found within
the thorax. The left side seems more often involved than the right.
Serious wounds of the diaphragm may be followed by this condition.
Under these circumstances the thoracic viscera are more or less
displaced, and the heart may be pushed considerably out of place. In
cases with a history of violent accident the surgeon may more readily
suspect and recognize the condition than in congenital cases, where
anatomical relations have long been disturbed, but apparently more or
less adjusted or compensated.
=Pelvic Hernia.=--In the lower part of the pelvis, under rare
circumstances, hernial protrusions occur either through the
sacrosciatic foramina, in which case they are known as _gluteal_ or
_ischiatic_ (Fig. 608), or through the obturator foramen, when they
are known as _obturator_ hernias, the latter occurring more often in
stout women. Unless these constitute some form of recognizable tumor,
or produce acute obstruction by strangulation, they will pass quite
unrecognized. A _perineal_ form of hernia is also known, which occurs
in Douglas’ cul-de-sac, behind the bladder or uterus, the levator ani
muscle being more or less disturbed, and the protrusion occurring
somewhere between the labium and the anus. In such hernial sacs the
ovary has been found, as well as intestinal loops, and the so-called
_ovarian_ hernia includes some anatomical anomaly of this kind.
[Illustration: FIG. 608
Ischiatic hernia. (Richardson.)]
[Illustration: FIG. 609
Hernia into foramen of Winslow.]
=Lumbar Hernia.=--In so-called lumbar hernia, which is very rare, the
hernia escapes along the outer border of the quadratus lumborum muscle
into the triangle of Petit. Such a tumor, usually small, may be easily
mistaken for lipoma or for cold abscesses.
Other anomalous types of hernia may occur in connection with congenital
defects of the bones or the less dense structures of the pelvis proper.
=Retroperitoneal and Properitoneal Hernia.=--Retroperitoneal and
properitoneal hernia are types which seem to corroborate the views
already enunciated concerning the essentially congenital origin of
the ordinary forms. The former implies a protrusion into an internal
peritoneal pouch, and is usually found in the upper abdominal cavity
in the duodenojejunal fossa, although it may also occur lower down on
either side. It will not be recognized save by its effects, which will
usually be those of acute intestinal obstruction, and even then will
only be diagnosticated after the operation which the condition will
necessitate. Hernia through the foramen of Winslow has already been
mentioned in the chapter on the Small Intestines. (See Fig. 609.)
_Properitoneal hernia_ implies usually the existence of a double sac,
with a common opening, its inner portion lying between the peritoneum
and the abdominal musculature, while its outer portion takes the
usual position of the hernial sac, either the inguinal, the femoral,
or the umbilical form. It may be suspected when reduction which has
been apparently successful has later evidently failed. It occurs most
often in the inguinal region, where it is usually referred to as
_inguinoproperitoneal_ hernia, and where it was first recognized by
Parise, and later fully described by Krönlein. It may be with equal
propriety called _interstitial hernia_, and is often associated with
imperfect descent of the testicle, which perhaps has served to deflect
the descending hernia in an unusual direction. The properitoneal sac
is most often found between the internal ring and the anterior spine,
although it may be directed downward and inward toward the bladder,
or backward toward the iliac fossa. In size it is usually small as
compared with the external portions. Its existence may be suspected
when a patient with a hernia previously easily reducible suddenly
develops strangulation, which is apparently relieved by taxis, only to
recur a little later. So far as its radical treatment is concerned all
that is necessary is the extirpation of the extra sac, with perhaps
separate treatment of its neck, when dealing with the greater and more
completely filled pouch in front (Fig. 610).
[Illustration: FIG. 610
Properitoneal hernia. This illustrates also incomplete reduction of
hernia. (Richardson.)]
=Littre’s or Richter’s Hernia.=--These terms have reference to
strangulation of intestine in which, nevertheless, the entire lumen
of the bowel is not completely involved, rather only a small area,
which soon becomes sacculated, or perhaps by a diverticulum becoming
involved in the occlusive and later gangrenous process. These forms
are most frequently seen in women and at the femoral ring. They are
peculiarly dangerous in that they produce symptoms which do not include
those of total and acute bowel obstruction, and hence are often allowed
to go unoperated until gangrene has already occurred. These forms,
then, will produce signs and symptoms of partial strangulation, with
incarceration, followed after hours or perhaps days by those of local
cellulitis, with perhaps necrosis; conditions which when opened may
expose gangrenous bowel and promptly become fecal fistulas.
=Treatment of Hernia.=--Hernia is treated for three different purposes:
for the _relief of strangulation_, _i. e._, as an emergency, for
_palliation_, or for _radical cure_, according to the nature of the
case and the wishes of the patient.
_The relief of strangulated hernia_ becomes a measure of instant
importance so soon as the condition is recognized, mortality being due
to delay, practically every case being curable could it be recognized
and operated promptly. The symptoms of strangulation, as repeatedly
indicated, are those of acute obstruction of the bowel, including
fecal vomiting with meteorism, and the local indications which may be
trifling, as in very small hernial protrusions, or unmistakable, as in
large hernial masses. The indication in every instance is to restore
the occluded bowel to the abdominal cavity. Occasionally this may be
effected by the method of _manipulation_ or by _taxis_, which should
never be thought of save at the very outset, and which may be aided by
the local use of cold, or especially by the Trendelenburg position,
which may be exaggerated. Under these circumstances, as Richardson has
said, minutes are precious and delay adds materially to the danger, so
that usually all non-operative methods are to be condemned.
[Illustration: PLATE LIV
Strangulated Right Inguinal Hernia. (Richardson.)
The sac has been opened and its edges are drawn apart by means of
forceps. The inguinal canal and spermatic cord have been dissected.]
=Taxis.=--The principal danger in connection with taxis is that of
doing harm to the occluded bowel by rough manipulation. The method
includes a coaxing pressure in the proper direction, with more or less
compression of the external mass, the effort being to gently persuade
it back into the abdominal cavity. In this effort the temptation,
especially among the inexperienced, is to use too much force, by which
extravasation is produced, exudate increased, and the local condition
in every way made worse. That which is possible during the first hour
after strangulation has occurred may be impossible a little later, when
edema and exudate have distorted the parts or cemented them together.
The effort should not be prolonged, but rather very brief, and if after
a very few moments no gain be made it should be discontinued.
_Reduction “en bloc”_ is an unusual but ever-present danger. It implies
forcing back the peritoneal sac as well as its contained intestine
unreduced, so that while the external tumor is dissipated the actual
condition of strangulation is not influenced. Its effect would be in
no way to diminish the danger of the condition, but rather to more
seriously menace the patient, under the supposition that reduction had
been accomplished satisfactorily.
Two or three axioms in the treatment of strangulated hernia are
imperative:
_Very little time, if any, should be wasted in manipulation or taxis._
_Taxis failing or there remaining any suspicion of reduction en bloc,
open operation is imperative._
_The time to operate is just after the diagnosis has been made and
the condition recognized. Every hour of delay increases danger of
obstruction and of gangrene._
_Operations for strangulated hernia_ should thus always be done early
and before much exudate or local disturbance has occurred, as when thus
performed they may be combined with measures for radical cure, which
are hardly to be thought of when infection has occurred. (See Plate
LIV.)
Strangulated hernia, then, being always a dire emergency, is in
nearly every instance best treated by _herniotomy_, whose principles
are the same, no matter whether applied to inguinal, femoral, or
umbilical hernia. By a suitably planned incision the sac is exposed.
In the inguinal region this follows the general direction of the
cord and inguinal canal. In the femoral region it is best to raise
a flap, while in umbilical hernia, although the first incision may
be in the middle line, it will usually be found necessary to make an
elliptical excision of the overlying skin, in order that both it and
the sac may be removed. Under conditions of long existent hernia, plus
strangulation, the original anatomical conditions are much altered,
and it is not necessary to waste time in the endeavor to recognize
the various coverings of the sac. One cuts directly down upon it
with such care that he may recognize it as he comes upon it, usually
by its color and by the sensation of proximity to its strangulated
contents. This is ordinarily not a difficult matter; all bleeding
vessels should be secured before the sac is finally opened. Final and
complete identification may be made by finding that the sac itself may
be pinched up between the fingers or forceps, while the underlying
contents slip away. Only when parts are bound together in exudate will
there be difficulty in this regard. The surgeon should still proceed
with caution, although the sac will usually contain sufficient fluid
of transudation to protect against injury to the enclosed bowel.
Nevertheless the greatest care should be observed not to wound the
intestine, which sometimes lies very closely under the skin, especially
in the middle line of an umbilical hernia, although there may be
masses of fat on either side of it. Sometimes the sac distended with
discolored fluid is itself mistaken for the bowel. Error can usually be
avoided by following it upward and identifying its continuity with the
surrounding tissues.
When opened its contained fluid may be found quite clear,
blood-stained, purulent, extremely offensive, or even fecal, according
to the relative age of the condition and the degree and results of
strangulation. Under all circumstances it is advisable to disinfect the
sac and its contents before endeavoring to release them. This may be
done with dilute peroxide of hydrogen or with any ordinary irrigating
fluid.
Within the sac, when thus identified and opened, may be imprisoned
omentum or bowel, or both, in any degree of preservation from that
which is almost normal, and with circulation but slightly disturbed,
to that which is absolutely gangrenous. Congested bowel will nearly
always be more or less discolored. So long as it is dusky or even
almost black, _but has not lost its luster_, it may probably be safely
returned to the abdominal cavity; but if green or if luster be gone,
or if the contained fluid be distinctly putrefactive, then serious
doubt as to its viability will arise. In case of actual perforation,
gangrene, or fecal abscess there will be no doubt as to the danger of
returning such bowel, and other measures should be adopted.
The _viability_ of the bowel having been determined and the sac
disinfected the location and degree of tightness of the constricting
ring should now be determined. In inguinal hernia the constriction may
occur either at the external or internal ring; in femoral hernia it
is usually at the femoral ring; in umbilical hernia, at some portion
of the umbilical opening; while in all three forms constriction may
occur within the sac itself and with little reference to the ordinary
hernial outlets; all of which needs to be clearly kept in mind. This
identification is usually done with the tip of the little finger,
gently insinuated and used as a probe. The operator who is sure of his
methods does not necessarily need to expose the constricting ring in
order to nick it or divide it, but he who is not as proficient should
extend and deepen his incision until the parts are clearly exposed, so
that he may be sure of not doing more harm than good.
Ordinarily it is necessary only to nick at one or two points the margin
of the ring, which will feel much like a wire loop, and then to use
the finger as a dilator, stretching and perhaps tearing, _i. e._,
making the knife do as little and the finger as much work as possible,
in order to so loosen up the constricted canal that by gentle taxis
or manipulation reduction can now be accomplished. The text-books on
anatomy give minute descriptions of the relations of these hernial
outlets to important bloodvessels, with which even the student should
be perfectly familiar. Nevertheless by following the subjoined rule,
and never departing from the principle thereby indicated, the operator
may safely proceed in practically every instance. _This is to cut in
the direction of the patient’s nose._ The knife used for this purpose
is ordinarily the _herniotome_, _i. e._, a blunt, slightly curved
bistoury, with but a small exposed cutting blade, whose dull point is
passed along the finger until the constriction is reached, and then, by
the sense of touch, beneath and beyond it, until the wire edge of the
ring rests upon the cutting part. The handle is then turned until this
edge points upward and is moved with a gentle sawing action always in
the above-specified direction, until the peculiar resistance is felt
to have yielded. It may then be turned a little and another nick be
similarly made. These nicks should not be more than one-quarter of an
inch deep, after which the knife is withdrawn and the finger now made
to dilate and tear. With these precautions there is very little danger
of dividing an anomalously placed vessel.
Dilatation of the ring being now sufficient it is well to pull the
hernial mass a little downward, in order that the condition of the
bowel at the point of constriction may be exactly noted. It should
therefore be gently coaxed into the wound, once more subjected to
inspection, and then to disinfection. The surgeon should now determine
what to do both with the bowel and the omentum. Omentum which is
covered with exudate or darkly discolored, or surrounded by offensive
material, should be first liberated, then ligated, above the original
point of constriction, and the undesirable part removed, the stump
being returned to the abdominal cavity. The bowel, if decided by above
indications to be viable, may then be gently coaxed back if handled
with care.
But gut which has perforated, or is so compromised as to be threatening
gangrene, should _not be returned_ into the abdominal cavity, but
treated by resection, or by fixation and the formation of an artificial
anus, decision depending both upon the condition of the patient and of
the bowel. Some of these cases are too nearly moribund when operated to
justify such procedures as resection, and are suffering too profoundly
from the consequences of obstruction to make it advisable to do more
than open the bowel for its immediate relief. Artificial anus is,
therefore, the inevitable necessity in some forms of strangulation.
When the bowel is gangrenous it is not necessary even to endeavor to
draw it farther down into the sac, but it may be simply opened _in
situ_.
_Intestinal resection and suture_ instituted under these circumstances
are essentially the same as those already described in the chapter on
the Small Intestines. With the formation of an artificial anus there
results the inevitable fecal fistula which will require subsequent
operation, probably secondary resection.
In non-septic and favorable cases, the reduction having been
accomplished, the operator then may proceed to extirpation of the sac
and the closure of the hernial outlet, _i. e._, operate for radical
cure, this being a modern extension and addition to the old operation
for relief.
If obstructive symptoms should persist after operation the possibility
of twisting of the intestine, or a possible reduction _en bloc_,
may be feared, which is not likely to occur if the open part of the
operating have been done thoroughly.
Clean cases of strangulation may be closed without drainage. In case of
doubt, however, it is advisable to provide at least a capillary drain,
while every case known to have been contaminated should be perfectly
drained.
[Illustration: FIG. 611
Bassini’s operation. Ligation of the sac by means of a purse-string
suture passed through the internal surface of its neck. The cord is
drawn to one side. The aponeurosis of the external oblique is drawn
apart with forceps. (Richardson.)]
[Illustration: FIG. 612
Bassini’s operation. Suture of the conjoined tendon to the internal
surface of Poupart’s ligament. Fortification of the posterior surface
of the canal. (Richardson.)]
=Radical Cure of Hernia.=--From the earliest times rude and crude
methods of endeavoring to effect a radical cure of hernia have been in
vogue. While sometimes effective they have always been dangerous and
always clumsy. Not until the antiseptic method was introduced could
they be regarded as in any way safe or reliable. With the introduction
of Listerism it became practicable to do this work, upon principles
simple in character and ordinarily easy of performance, which may be
summed up in the formula: _Isolation and obliteration of the hernial
sac, with permanent closure of the hernial outlet._ Easy as such
description may sound it has been found more or less difficult in
practice, and numerous methods, apparently both simple and ingenious,
have proved defective and have called for the most pronounced
modification. Considerable space could be devoted to operations for
radical cure, but the intent here shall be to simplify the subject
as well as the method, and consequently but two or three will be
described. Suffice it to say that while all are based on the same
principle they vary somewhat in detail, and that some of these details
have to be adapted to the special requirements of individual cases.
With increase in experience has come enlarged confidence in the
operation, and it is now regarded as justifiable in nearly every
instance among individuals otherwise in good condition. It has a double
purpose--namely, the avoidance of the danger of sudden strangulation
and the riddance of necessity for wearing trusses, or suffering the
discomforts of hernia without any mechanical control. Some modern
methods include the utilization of some portion or all of the sac,
while in others it is entirely cut away. Consequently some operators
have endeavored to utilize such portion of the sac as could be made
available for either purpose, either as plug or suture material.
The _method of Bassini_ for relief of inguinal hernia, more or less
modified to meet individual demands, seems to have become of late years
the most popular and widely adopted. The incision is made over the most
prominent part of the tumor, extending as far downward upon the scrotum
as necessary, and upward to near the anterior superior spine. Through
it the external ring, with its pillars, is exposed, and then the sac,
by a dissection long and sufficiently wide to fully reveal it. The
exposure is made more complete by dissection of the aponeurosis of the
external oblique from the level of the external ring upward and outward
for an inch or so above the external ring. By seizing the edges of
the aponeurosis on each side with forceps and retracting there is now
afforded an excellent view of the hernia proper. (See Fig. 611.)
[Illustration: FIG. 613
Park’s method of utilization of sac, showing its isolation and one way
of employment in making the suture further represented in Fig. 614.]
By careful dissection the sac and cord are identified and isolated,
while the sac is opened and its edges held apart by forceps, after
which it is carefully separated from the other structures of the cord.
After thus isolating the sac, and with the least possible disturbance
of the cord and of the testicle, it is ligated as high as the internal
ring, or, if possible, higher yet. This leaves the cord uninjured; its
size should next be reduced by cutting away all superfluous tissue.
Some operators remove all the veins, but this seems unpromising and
dangerous.
[Illustration: FIG. 614
Park’s operation. Continuous suture made with a long thin sac.]
By all this dissection and reduction the inguinal canal has been
temporarily, cleared, and the sac having been elevated, ligated, and
cut away it becomes now a question of what to do with the cord. The
lower surfaces of the external oblique and of Poupart’s ligament are
next freed, the edge of the internal oblique, of the transversalis with
its fascia, the outer border of the rectus and the conjoined tendon
being all exposed to view by whatever dissection may be required, all
fat and areolar tissue being removed. The cord is finally disposed
of by holding it out of the way, usually by a loop of gauze, while
the deep layer of the external oblique and the external portion of
Poupart’s ligament are sewed to the muscle edges of the internal
oblique and transversalis, as appears in Fig. 612, by a line of sutures
which include the conjoined tendon, at the lower angle of the wound,
which should be affixed to the outer border of the rectus. In the
deeper portion of every such wound there is danger of injury to the
external iliac vessels as well as to the epigastric. For the escape of
the cord, and to avoid its undue constriction, an opening should be
left for it, _i. e._, a new _internal_ ring, adapted for the purpose
and not too small. This is made by not suturing the upper part of the
wound. The cord being afforded this exit is now dropped, and the edges
of the external oblique are brought together over it, the sutures
extending well downward, but being omitted at the lower portion, where
a new _external_ ring is thus left, only not of its original size, but
sufficiently large to accommodate the cord.
Such are the essentials of the Bassini method, which has been modified
by Halsted in such a way that the cord, reduced as much as possible,
usually by removal of most of its veins, is now not left within the
inguinal canal, but transplanted entirely outside of the external
oblique, escaping at the upper part of the incision and requiring no
further accommodation in its course toward the testicle. In children,
or even in adults with very small veins, he does not so reduce the
cord. After isolation, opening and transfixion of the upper end of the
sac, and its secure ligation, he drops the stump back into the abdomen.
The muscular and tendinous layers of the ring and abdomen are united
also, by layers, with quilted sutures.
[Illustration: FIG. 615
Park’s method. Shoelace suture made with a sac split into two strips.]
In these as in many other methods, much, practically everything,
depends upon the certainty and durability of the sutures used for
disposal of the inguinal canal. For some years surgeons used silver
wire, which has now been abandoned. The choice now seems to depend on
_silk_, thoroughly and freshly boiled, or _animal sutures_, such as
kangaroo or reindeer tendon. McArthur suggested to dissect off a strip
from the margin of the opening in the external oblique, or from the
aponeurosis, and to use this strip of the patient’s own tissue for
suture material. I have modified this method, as will be described
later. Kocher devised a method of isolation of the sac, without such
complete emptying of the inguinal canal, the sac being drawn up through
the canal, then through the internal ring, and finally through an
opening in the external oblique, over the internal ring, where it was
twisted and fastened, after which the external portion was removed.
My own preference in operations for radical cure has been, until
recently, an exposure similar to that of Bassini’s, with complete
isolation of the sac, which is separated up to the level of the
internal ring or even higher. At this point it is drawn out through an
incision made in the external aponeurosis, twisted and fastened. The
inguinal canal is then closed, its deeper layers by a shoelace suture
of tendon, threaded into two stout curved needles, by which the deeper
margins of the canal are brought accurately together. Sometimes I have
transplanted the cord and again have dropped it back, the layer of
shoelace sutures closing the external aponeurosis over it. It has not
seemed to me to make any difference which method was adopted, and I
have practically never seen any atrophy or permanent disturbance of the
testicle.
More recently it has occurred to me to utilize the sac itself for
suture material, and this is the method which I now adopt in those
cases that permit of it.
Figs. 613 to 616 show the method of thus utilizing the sac. A long thin
sac may be twisted into a cord and used as an over-and-over suture, by
which the margins of the canal are brought together. If found thick
and unwieldy it may be trimmed down into a single suture, or it may be
_split_, with more or less trimming, into two portions, by which the
canal is then braided together or closed with a shoelace suture, the
ends being tied or fastened at the lower portion. Fig. 616 shows how a
short sac not otherwise available can be lengthened and made sufficient
for the purpose.
[Illustration: FIG. 616
Park’s method. A short sac is so divided as to be elongated
sufficiently for use as a suture.]
This again is utilization of the patient’s own tissue, he himself
furnishing his own animal ligature, which, being fresh and sterile, may
be regarded as reliable. The method, furthermore, has this advantage,
that there is reason to believe that tissue so utilized becomes
organized, in time, and that the union becomes more reliable rather
than otherwise. At all events in a considerable number of cases it
has yielded satisfactory results, and in no case has it caused any
disappointment.
[Illustration: FIG. 617
Radical cure of femoral hernia. Dissection of the saphenous opening.
The sac of the hernia has been tied. (Richardson.)]
[Illustration: FIG. 618
Radical cure of femoral hernia, showing method of application of
purse-string ligature to close saphenous opening. (Richardson.)]
[Illustration: FIG. 619
Radical cure of femoral hernia. Sutures applied to pectineal fascia,
fascia lata, and Poupart’s ligament. (Richardson.)]
[Illustration: FIG. 620
Obliteration of the femoral opening by purse-string suture. (Coley.)]
_Recurrence_ after these operations occurs less and less frequently
as operators gain in experience and technique is improved. At all
events the procedure has now become standard and disappointments are
relatively rare. It is useless to quote statistics of individuals, for
they necessarily differ. In general, however, it is probable that from
90 to 96 per cent. of cases properly operated suffer no recurrence.
_In the female_ inguinal hernia is treated in practically the same way,
conditions being simplified by the absence of necessity for making any
provision for the blood supply of the testicle or cord. The canal and
rings may, therefore, in the female be absolutely closed.
_Femoral hernia_ is radically treated on the same general principles,
but with greater difficulty, as anatomical conditions are less
favorable. A flap is raised below Poupart’s ligament, with its centre
over the tumor, and the sac exposed and completely dissected, then
opened, as in inguinal hernia. Its contents being reduced obliteration
of the sac and its utilization, if possible, are in order. It is rarely
difficult to separate it from its surroundings well up in the femoral
canal. It may be twisted and its neck ligated, or it may be possible
in some cases to either infold or reduce a sufficient portion of it
to thus form a plug, which, being pushed upward, serves as a means
of closing the femoral opening from above. Whatever use may be made
of it it should be obliterated as a pouch, and its descent prevented
by closure of the canal around it. This is difficult because of the
proximity of the femoral vein and the somewhat unyielding character of
the falciform and crural fasciæ. By some form of purse-string suture,
or by a little dissection and sliding of aponeurotic flaps, it is
usually possible to bring the surrounding structures snugly together.
Even here I have been able to apply my principle enunciated above,
and, by cutting away a strip of the sac, utilize it for the purpose of
closing the femoral canal; but it is not often that a femoral pouch
will be sufficiently large to afford tissues for this purpose. Figs.
617, 618, 619 and 620 will save the necessity for further description.
[Illustration: FIG. 621
FIG. 622
Graser’s method of dealing with umbilical hernia.]
In many inguinal and umbilical and in a few femoral hernias the
operator will be hampered by _adhesions_ between the omentum or between
the bowel and the sac wall. These may be infrequent and slight or
extensive and dense. They are relatively unimportant so long as they
involve only the omentum, which may at any time be cut away, the stump
being dropped back into the abdomen, after being suitably secured; but
when bowel, especially large intestine, is thus adherent, great care
should be exercised, avoiding all possibility of shutting off the blood
supply while securing every divided vessel.
Particularly is this true in treatment of umbilical hernias, either
radical or under conditions of strangulation. In stout individuals,
usually women, umbilical sacs sometimes contain several feet of bowel,
and adhesions may be met at many points, difficulties arising not only
in their separation, but in the final disposition and accommodation
of all this bowel within the abdominal cavity, from which it has been
so long absent. Radical cure will in these cases leave intra-abdominal
viscera in a rather overcrowded condition.
The essential details of _radical treatment of umbilical hernia_ are
the same, modified by the extent of sac which has to be removed,
and by the wisdom in many instances of a large elliptical excision
of the overlying skin and removal of much superfluous tissue. After
freeing the contents and reducing them, the sac wall being completely
separated, there is the choice of two or three methods of closing
the umbilical opening, either by overlapping of flaps, which may be
cut from the thickest portion of the sac, which will be close to the
outlet, or by dissecting them from the aponeurosis, as suggested by
Mayo, and turning the upper down over the lower, or by any other
expedient which individual peculiarities may suggest (Figs. 621 to
624). I have been able to employ, to apparent advantage, my method
of securing suture material for this deep closure from the sac wall
itself, this not preventing the employment of any other method or
improvement.
[Illustration: FIG. 623
FIG. 624
Method by transverse closure of both deep and external incisions.]
_Ventral and postoperative hernias_ are operated on in essentially
the same manner as the forms above described. Adhesions may be found
in these cases, and plastic methods should be devised for bringing
together irregularly shaped openings and holding them in the firmest
possible manner. In any extensive abdominal hernia, umbilical or
ventral, it is advisable to use buried sutures, closing the abdominal
walls, layer by layer, and finally to insert at some distance a
sufficient number of through-and-through retention sutures, guarded by
plates or small rolls of gauze, these taking off tension from the wound
and affording protection against any special strain, such as vomiting.
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.