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NUNQUAM AlJUn NATUPA, AIJIID SAPllCNTIA DICIT. 
 
DISEASES 
 
 THE LIVER 
 
 GALL BLADDER, AND BILIARY SYSTEM 
 
 THEIR PATHOLOGY, DIAGNOSIS, AND SURGICAL 
 TREA TMENT 
 
 BY 
 
 H. J. WARING, M.S., B.Sc. Lond., F.R.C.S. 
 
 DEMONSTRATOR OF OPERATIVE SURGERY, AND SENIOR DEMONSTRATOR OF ANATOMY, 
 
 ST. Bartholomew's hospital ; senior assistant surgeon, metropolitan 
 
 hospital; surgeon to the BELGRAVE hospital for children, LONDON. 
 
 EDINBURGH AND LONDON 
 
 YOUNG J. PENTLAND. 
 1897 
 
EDINBURGH : PRINTED FOR YOUNG J. PENTLAND, II TEVIOT PLACE, AND 
 38 WEST SMITHFIELD, LONDON, E.G., BY MORRISON AND GIBB LIMITED. 
 
PREFACE. 
 
 The present volume is a revised version of the Jacksonian 
 Prize Essay of the Eoyal College of Surgeons of England for 
 the year 1894. The original Essay had two Appendices, one 
 containing the clinical records of a considerable number of 
 cases, and the other an account of some experimental investiga- 
 tions on the surgery of the liver and biliary system, which 
 I carried out in the laboratories of the Eoyal Colleges of 
 Physicians and Surgeons. In revising the Essay for publication, 
 the subject-matter of these Appendices has been incorporated 
 in the body of the work, and at the same time an account 
 of the pathology of the different affections dealt with has 
 been introduced. 
 
 For permission to publish the book I am indebted to the 
 Council of the Eoyal College of Surgeons, and to them I beg 
 to offer my thanks. 
 
 I am greatly indebted to the members of the staff of St. 
 Bartholomew's Hospital, who have allowed me to examine the 
 cases under their care and make use of their notes, and also 
 for affording me the opportunity of having a number of 
 drawings and photographs taken from the preparations in the 
 museum of the Hospital. 
 
 I would also beg to offer my thanks to the friends who 
 have assisted me in the preparation of the book, especially 
 Dr. Edkins, for the chapter on physiology; Mr. W. Netterville 
 
vi PREFACE. 
 
 Barron, for making a number of the illustrations ; and Messrs. 
 D'Arcy Power and J. S. Sloane, for reading the proof sheets. 
 I have also to thank Mr. J. S. Sloane for making the index. 
 
 A bibliography of the most important works and papers 
 which have been published on diseases of the liver and 
 biliary system, and which have been made use of in the 
 preparation of the present volume, is placed at the end of 
 the work. 
 
 Nearly all the references have been verified by myself as 
 the work has been passing through the press. 
 
 H. J. WAEING. 
 
 9 Upper Wimpole Street, 
 
 Cavendish Square, W., 
 
 Aijril 1897. 
 
CONTENTS. 
 
 CHAPTER I. 
 
 Liver — Surfaces — Ligaments — Fissures — Lobes — Blood Vessels — Lym- 
 phatics — Nerves — Biliary Apparatus — Hepatic Ducts — Gall Bladder — 
 Common Bile Duct — Hepato-Cystic Ducts — Topographical Anatomy — 
 Of Liver — Of Gall Bladder — Of Conmion Bile Duct — Development — 
 Histological Structure ....... 
 
 CHAPTER IL 
 
 THE FUNCTIONS OF THE LIVER. 
 
 Secretion of Bile — Composition of Bile — Origin of the Bile Acids — Origin of 
 the Bile Pigments — Nature of Jaundice — Modification of Bile in 
 Abnormal Conditions — Cholagogiies — Glycogenic Function of the Liver 
 — Formation of Urea by the Liver . . . . .29 
 
 CHAPTER in. 
 
 JAUNDICE. 
 
 Pathology — Causes — Symptoms — The Urine in Jaundice — The Fseces in 
 
 Jaundice — Xanthelasma ....... 38 
 
 CHAPTER IV. 
 
 THE DIAGNOSIS OF DISEASES OF THE LIVER AND BILIARY SYSTEM. 
 
 Previous History — Sex — Age — Climate — Subjective Symptoms — Objective 
 Symptoms — Inspection — Palpation — Percussion — Auscultation — Ex- 
 ploratory Puncture . . . . . . .51 
 
 CHAPTER V. 
 
 MALFORMATIONS. 
 
 Congenital Malformations of Liver— Complete Transposition of the whole 
 Viscus — Presence of Accessory Lobes — Absence of Left Lobe-— Deep 
 
viii CONTENTS. 
 
 PAGE 
 
 Fissures — Congenital Apertures in Diaphragm — Hepatomphalos. Ac- 
 quired Malformations of Liver. Congenital Malformations of the Biliary- 
 System — Absence of Gall Bladder and Cystic Duct — Obliteration, 
 Stenosis, Obstruction of the Common Duct — Congenital Obliteration of 
 the Common Hepatic Duct ...... 58 
 
 CHAPTER VI. 
 
 ABSCESS OF THE LIVER. 
 
 Etiology — Traumatism — Gall Stones — Parasites — Pysemic Abscesses — In 
 connection with Acute Specific Fevers — Tropical Abscess — The Micro- 
 organisms of Hej)atic Abscess — Pathological Anatomy of Hepatic 
 Abscess — Symptoms — Complications — Diagnosis— Treatment — Prog- 
 nosis ......... 
 
 70 
 
 CHAPTER VII. 
 
 TUBERCULAR ABSCESS OF THE LIVER. 
 
 Pathology — Symptoms — Diagnosis — Treatment — Prognosis . . . 108 
 
 CHAPTER VIII. 
 
 ACTINOMYCOSIS OF THE LIVER. 
 
 Pathology — Symptoms — Diagnosis — Treatment — -Prognosis . . .112 
 
 CHAPTER IX. 
 
 SYPHILIS OF THE LIVER. 
 
 Secondary Affections. Tertiary Affections— Diffuse Syphilitic Hepatitis — 
 Localised Syphilitic Hepatitis — Symptoms — Diagnosis — Treatment — 
 Prognosis — Amyloid Disease of the Liver . . . .117 
 
 CHAPTER X. 
 
 HYDATID CYSTS OF THE LIVER. 
 
 Life-History of Tcenia echinococais — Structure of an Adult Hydatid Cyst 
 — Frequency — Situation — Symptoms— Rupture of a Cyst — Suppuration 
 — Spontaneous Cure — Entrance of Bile into a Cyst — Hiemorrhage from 
 the Sac— Composition of Fluid from a Cyst — Diagnosis — Differential 
 Diagnosis — Treatment — Prognosis ..... 126 
 
 CHAPTER XI. 
 
 MULTILOCULAR ECHINOCOCCUS OF THE LIVER. 
 
 Pathology — Geographical Distribution — Symptoms — Diagnosis — Treatment . 144 
 
CONTENTS. ix 
 
 CHAPTER XII. 
 
 CYSTS OF THE LIVER. 
 
 PACE 
 
 Simple or Serous Cysts — Multilociilar Cystic Disease of the Liver — Cystic 
 
 Adenoma of the Liver — Dermoid Cysts ..... 148 
 
 CHAPTER XIII. 
 
 MOVABLE LIVER. 
 
 Pathology — Symptoms — -Diagnosis — Treatment .... 156 
 
 CHAPTER XIV. 
 
 TRAUMATIC AFFECTIONS OF THE LIVER. 
 
 Ruptures — Symptoms — Gunshot Wounds — Lacerated Wounds — Symptoms 
 
 — Diagnosis — Treatment — Complications — Prognosis . . . 160 
 
 CHAPTER XV. 
 
 TUMOURS OF THE LIVEK. 
 
 Benign Tumours — Angioma — Fibroma — Adenoma. Malignant Tumours — 
 
 Sarcoma — Carcinoma — Symptoms — Diagnosis — Treatment — Prognosis . 182 
 
 CHAPTER XVI. 
 
 PENETRATING WOUNDS OF THE GALL BLADDER AND THE BILIARY DUCTS. 
 
 Vai'ieties — Symptoms — Diagnosis — Treatment — Prognosis . . . 196 
 
 CHAPTER XVII. 
 
 RUPTURE AND PERFORATION OF THE GALL BLADDER AND BILE DUCTS. 
 
 Rupture from Violence — Ulcerative Processes leading to Perforation — 
 Perforation from Malignant Disease — Rupture in connection with 
 Obstruction of Common Bile Duct ..... 201 
 
 CHAPTER XVIII. 
 
 CHOLELITHIASIS. 
 
 Mode of Formation and Pathology of Gall Stones — Obstruction to Flow of 
 Bile — Relation of Micro-Organisms to Cholelithiasis — ^Amount of Bile — 
 Acids in Bile — Effect of Foreign Bodies — Place of Formation of Gall 
 Stones — Structure of Calculi — Varieties of Gall Stones — Occurrence — 
 Predisposing Causes — Symptoms — Diagnosis — Complications and 
 Sequelae — Treatment^Prognosis . . . . . .210 
 
X ' CONTENTS. 
 
 CHAPTEE XIX. 
 
 NEOPLASMS OF THE GALL BLADDEE. 
 
 PAGE 
 
 Benign Growths — Fibroma — Papilloma— Cystic Swelling of the Mucous 
 Membrane. Malignant GroAvths — Carcinoma — Sarcoma — Pathology — 
 Symptoms — Diagnosis — Complications — Treatment — Prognosis . . 247 
 
 CHAPTER XX. 
 
 TUMOURS OF THE BILE DUCTS. 
 
 Non-Malignant Growths — Papilloma — Gumma. Malignant Growths — 
 Carcinoma — Seat of Occurrence — Sex — Symptoms — Diagnosis — Treat- 
 ment — Prognosis . . . . . ■ . . .261 
 
 CHAPTER XXI. 
 
 SUBPHRENIC OR SUBDIAPHRAGMATIC ABSCESS. 
 
 Etiology — Symptoms — Complications — Diagnosis — Treatment — Prognosis . 27B 
 
 CHAPTER XXII. 
 
 BILIARY FISTULiE. 
 
 External Fistulte — Pathology — Symptoms — Diagnosis — Treatment — 
 
 Prognosis. Internal Fistulfe — Pathology — Symptoms . . . 286 
 
 CHAPTER XXIII. 
 
 GALLSTONE ILEUS OR INTESTINAL OBSTRUCTION DUE TO GALL STONES. 
 
 Pathology — Symptoms — Diagnosis — Treatment — Prognosis . . . 295 
 
 CHAPTER XXIV. 
 
 OPERATIONS UPON THE LIVER. 
 
 Aspiration — Puncture — Hepatotomy — For Abscess — For Hydatid Cysts — 
 
 Hepatectomy — Hepatojiexy — Hepatostomy .... 306 
 
 CHAPTER XXV. 
 
 OPERATIONS UPON THE GALI, Br,ADDER. 
 
 Tapping — Aspiration — Sounding for Gall Stones — Cholecystotomy — Chole- 
 cystendysis — Cholecystectomy — Cholecystenterostomy — Cholecystolitho- 
 trii)sy ......... 325 
 
CONTENTS. XI 
 
 CHAPTER XXVI. 
 
 OPERATIONS UPON THE BILIARY DUCTS. 
 
 PAGE 
 
 Choledocholithotomy, or Choledochotoniy — Choledochostomy — Choledocho- 
 enterostomy — Choledocholithotrity, or Choledocholithotripsy — Chole- 
 dochectomy • — Choledochotoniy (by a lumbar incision) — Internal 
 Choledochoduodenostomy — Cysticolithotoniy — Catheterism of the 
 Biliary Passages ........ 347 
 
 Bibliography ......... 355 
 
 General Index ........ 378 
 
 Index of Authors ........ 383 
 
LIST OF ILLUSTRATIONS. 
 
 FIG. PAGK 
 
 1. The Abdominal and Thoracic Viscera (Anterior View) ... 2 
 
 2. The Abdominal and Thoracic Viscera (Posterior View) ... 3 
 
 3. Anterior Aspect of the Liver ...... 4 
 
 4. Structures in the Portal Fissure of the Liver . . . .11 
 
 5. The Gall Bladder and Biliary Ducts . . . . . 17 
 
 6. Mesentery which occasionally fixes the Gall Bladder to the Transverse 
 
 Colon ......... 18 
 
 7. Mucous Membrane of the Gall Bladder . . . . .19 
 
 8. Diagrammatic Section through the Gastro-Hepatic Omentum . . 22 
 
 9. Diagrammatic Section of a Lobule of the Liver . . . .26 
 
 10. Congenital Obliteration of the Ductus Communis Choledochus . . 63 
 
 11. Pyemic Abscesses of the Liver, after Perforation of the Vermiform 
 
 Appendix ........ 76 
 
 12. Pylephlebitis . . . . . . . .77 
 
 13. A Large Single Abscess of the Liver . . . . .82 
 
 14. A Large Single Abscess of the Liver . . . . .83 
 
 15. Tubercular Abscess of the Liver ...... 109 
 
 16. Actinomycosis of the Liver . . . . . . 114 
 
 17. Congenital Syphilis of the Liver ...... 120 
 
 18. Hydatid Cyst impacted in the Ductus Communis Choledochus . . 131 
 
 19. Hydatid Cyst of the Liver ...... 133 
 
 20. Calcareous Degeneration of the "Wall of a Hydatid Cyst of the Liver . 134 
 
 21. Large Simple Cyst of the Liver . . . . . .148 
 
 22. Simple Cyst of the Liver . . . . . . .149 
 
 23. Multilocular Cystic Disease of the Liver . . . . . 152 
 23a. Method of inserting "Purse- String Suture " for a small Rupture of the 
 
 Liver . . . . . . . . .168 
 
 24. Sarcoma of the Liver (Primary) ...... 189 
 
 25. Sarcoma of the Liver (Secondary) ...... 190 
 
 26. Carcinoma of the Liver (Secondary) ..... 191 
 
 27. Punctured Wound of the Gall Bladder . . . . .197 
 
 28. Varieties of Gall Stones ....... 216 
 
 29. Carcinoma of the Gall Bladder (Cubical-Celled) due to presence of Gall 
 
 Stones ......... 221 
 
xiv LIST OF ILLUSTRATIONS. 
 
 FIG. PAGE 
 
 30. Calculus impacted in the Cystic Duct .... 
 
 31. Total Obliteration of Lumen of Gall Bladder by a Calculus 
 
 32. Encysted Calculus of Neck of Gall Bladder and Cystic Duct 
 
 33. Gall Bladder forming Contents of Sac of a Strangulated Femoral Hernia 
 2>\. Dilatation of Intrahepatic Bile Ducts 
 3.5. Carcinoma of the Gall Bladder (Papillomatous Variety) 
 
 36. Carcinoma of Gall Bladder (Localised) 
 
 37. Carcinoma of the Gall Bladder (Columnar-Celled) 
 
 38. Carcinoma of the Gall Bladder (Cubical-Celled) . 
 
 39. Carcinoma of the Gall Bladder (Walls of entire Viscus involved) . 
 
 40. Carcinoma of the Common Bile Duct .... 
 
 41. Carcinoma of Aperture of Common Bile Duct into Duodenum 
 
 42. Subdiaphragmatic Abscess of the Right Side, containing Pus 
 
 43. Subdiaphragmatic Abscess of the Left Side containing Pus and Gas 
 
 44. A Large Gall Stone which caused Intestinal Obstruction . 
 
 45. Resection of Liver (Introduction of Sutures) 
 
 46. Resection of Liver (Sutures Tied) ..... 
 
 47. Resection of Liver ....... 
 
 48. Resection of Liver ....... 
 
 49. Needle for Introduction of Sutures into Liver 
 
 50. Incision for Cholecystotomy ..... 
 
 51. Cholecystotomy Forceps (Tait's Pattern) .... 
 
 52. Cholecystotomy Forceps (Anderson's Pattern) 
 
 53. Cholecystotomy Scoop (Tait's Pattern) .... 
 
 54. Method of inserting " Purse-String Suture " in Cholecystenterostomy 
 
 55. Cholecystenterostomy (Male Half of " Button") . 
 
 56. Cholecystenterostomy (Female Half of " Button ") 
 
 57. Cholecystenterostomy (Fixation of Gall Bladder and Duodenum) 
 
 58. Incision for Exposure of Common Bile Duct 
 
 223 
 228 
 229 
 235 
 236 
 250 
 251 
 252 
 255 
 256 
 264 
 265 
 280 
 281 
 297 
 320 
 320 
 321 
 321 
 322 
 328 
 329 
 329 
 329 
 341 
 342 
 342 
 343 
 348 
 
DISEASES OF THE LIVER, GALL BLADDER 
 AND BILIARY SYSTEM. 
 
DISEASES OF THE LIVER. 
 
 CHAPTER I. 
 
 ANATOMY. 
 
 The liver is the largest glandular organ in the human body, and 
 is situated in the abdominal cavity at its upper part, and chiefly 
 upon the right side. It occupies portions of the right and left 
 hypochondriac, the epigastric, and the right lumbar regions (Fig. 1). 
 
 Shape. — It somewhat resembles a right-angled pyramid 
 (Fig. 3) with some of the angles rounded off, which is placed 
 transversely across the upper portion of the abdomen, the base 
 being situated upon the right side, and the apex towards the left. 
 
 Size.— It measures about 1 to 1 2 in. in its longest diameter 
 — that is, from the base to the apex of the pyramid ; 6 to 7 in. 
 antero-posteriorly ; and about 3 to 4 in. from above downwards at 
 the base or right lateral surface. As regards its bulk, the liver 
 usually contains from 90 to 100 cubic inches of hepatic tissue. 
 
 Weight. — The weight varies within certain limits, but in the 
 majority of healthy adults it is somewhere between 50 and 
 60 oz. According to Eeid,^ who has weighed the livers of 
 82 adult males, in 43 cases it was between 48 and 58 oz. ; and 
 in the adult female, in 17 cases out of 36 examined, it weighed 
 between 40 and 50 oz. The average weight in the male was 
 found to be 52 oz. 124 drms., and in the female, 45 oz. 3| drms.; 
 and the difference in weight in the two sexes, 7 oz. 9 drms. 
 
 Colour. — The colour of the hepatic tissue is usually of a 
 dark reddish-brown tinge (under healthy conditions), but this 
 
 1 Reid, E., "Anatomical and Physiological Eesearches," 1848, p. 386. 
 
AJVATOJ/V. 
 
 varies according to the amount of blood in the tissues. Generally 
 the most dependent portion is almost purple. 
 
 Consistency. — The liver tissue feels solid when it is exam- 
 ined from the external surface, but when it is cut into, the 
 exposed surface is somewhat friable, and is easily lacerated with 
 the finger. By pressure it can be moulded into almost any 
 
 shape, this pliability being 
 frequently demonstrated, when 
 the livers of women who have 
 been accustomed to wear 
 tightly-laced corsets, are exa- 
 mined post-mortem. After 
 death the liver soon loses its 
 pyramidal shape, and if it is 
 removed from the body and 
 left exposed to the atmosphere 
 for a short time it quickly 
 becomes flattened, and the 
 various surfaces appear almost 
 indistinguishable from one 
 another. 
 
 Coverings. — The greater 
 part of the superficial surface 
 of the liver is covered with 
 a layer of the visceral peri- 
 toneum, one portion being 
 derived from the greater sac 
 and the remainder from the 
 lesser sac. Posteriorly, how- 
 ever, there is a small tri- 
 angular area, which is destitute 
 
 Fig. L— The ahdominal and thoracic viscera gf ^^^g covering. At variouS 
 as seen from in front. — From a Modelin the ■ , ,^ ■, ^ 
 
 Dissecting Room of St. Bartholomeiv's. PO"lts the peritoneal COVermg 
 
 is reflected from the external 
 surface of the liver, to become continuous with the parietal layer ; 
 and it is in this manner that the peritoneal ligaments which 
 help to hold the organ in its normal position within the abdomen 
 are formed. Underneath the peritoneal covering there is a thin 
 layer of dense fibrous tissue, which forms a complete investment 
 for the whole gland, and is called the capsule of Glisson. From 
 the deep surface of this layer, processes of fibrous tissue pass 
 
SURFACES. 
 
 inwards into the substance of the organ and divide it up into 
 lobes and lobules, the largest and most distinct process passing 
 in at the portal fissure around the vessels which enter there. 
 
 Surfaces. — ^As we have already seen, the liver has the shape 
 of a right-angled pyramid, which lies transversely across the 
 upper portion of the abdominal cavity, the base being upon 
 the right side and the apex 
 on the left. Hence the liver 
 has four surfaces, which corre- 
 spond to the sides of the 
 pyramid, a base or right 
 lateral surface, and an apex. 
 These surfaces are called («) 
 anterior, (b) superior, (c) pos- 
 terior, {cl) inferior, and (e) 
 right lateral or base. They 
 are separatedfrom one another 
 by borders, which are named 
 (a) antero-inferior, (h) antero- 
 superior, (c) postero-superior, 
 {d) postero-iuferior, and (c) the 
 borders of the base. Many 
 of these borders are rounded 
 off, but some, as for example 
 the antero-inferior, are quite 
 sharp and well-defined. The 
 hase or right lateral surface 
 is situated upon the right 
 aspect of the gland as it lies 
 in the upper portion of the 
 abdominal cavity, and is in 
 contact with the inferior sur- 
 face of the right half of the Fig. 2.—Theabclommal and thoracic viscera as 
 
 diaphragm, where this struc- 
 ture lies on the inner surface 
 of the lower ribs and costal cartilages. It is irregularly 
 quadrilateral in shape, and is limited by four borders which 
 separate it from the other surfaces. These borders are for 
 the most part rounded off, except the inferior one and 
 the lower part of the posterior, which are sharp and well- 
 defined. The anterior surface (Fig. 3) is triangular in shape, 
 
 seen from behind. — From a Model in the 
 Dissecting Room of St. Bartholomeiu's. 
 
4 AA^ATOMV. 
 
 and is limited below by the sharp antero-inferior border, to 
 the right by the rounded anterior border of the base, and 
 above by the antero-superior border which separates it 
 somewhat indistinctly from the superior surface ; the apex 
 of the surface lies towards the left in the left hypochon- 
 driac region. This surface is convex from below upwards, 
 especially at its upper limit, and is covered completely with 
 peritoneum. Opposite the middle line of the body the peri- 
 toneum is reflected over the remains of the umbilical vein or 
 the ligamentum teres, so as to form a double fold of serous 
 membrane, which is falciform in shape, and serves to fix the 
 
 Fig. 3. — Diagram of the anterior aspect of the liver, a, right lobe ; b, left lobe ; 
 c, inferior vena cava ; d, sus23ensory ligament ; e, fundus of gall bladder. 
 
 gland to the deep aspect of the anterior abdominal wall. This 
 fold is called the falciform or suspensory ligament. Its line 
 of attachment to the anterior and superior surfaces of the liver 
 divides the gland into two main lobes, that portion which lies 
 on the right side being the large right lobe, and that on the left 
 the smaller left lobe. The antero-inferior border is notched in 
 two places — first, opposite the middle line of the body, at the 
 anterior portion of the attachment of the falciform ligament ; 
 and, secondly, at a point in the right lobe opposite the ninth 
 and tenth costal cartilages. The first notch is deep and narrow, 
 and is caused Ijy the ligamentum teres as it passes to the trans- 
 
SURFACES. 5 
 
 verse fissure ; the second is much wider, and is quite shallow, 
 being caused by the gall bladder (Fig. 3). The superior surface 
 is also triangular in shape, and is limited in front by the antero- 
 superior border, behind by the postero-superior border, and to 
 the right by the superior border of the base, the apex lying 
 towards the left. This surface is covered for the most part by 
 peritoneum, derived from the visceral layer of the greater sac, 
 and is divided into two parts by the attachment of the falciform 
 ligament. The two layers of this ligament separate from one 
 another a short distance in front of the postero-superior border, 
 and become continuous with the peritoneum which, upon each 
 side, leaves the superior surface of the liver to be reflected 
 upon the inferior surface of the diaphragm, so as to form the 
 anterior layer of the coronary ligament. This layer is con- 
 tinuous with the peritoneum which forms the anterior portion of 
 the right and left lateral ligaments. A small area on the pos- 
 terior part of the superior surface is uncovered by peritoneum. 
 The antero-superior border and the superior border of the base 
 are rounded off, and on this account the superior surface passes 
 gradually into the anterior surface below and the base on the 
 right. The postero-superior border is much sharper and better 
 defined, and separates this surface from the posterior. It is 
 notched in three places— first, by the oesophagus, which forms 
 a wide and somewhat shallow groove, where it lies in contact 
 with the left lobe ; secondly, by the vena cava inferior, which 
 forms a deep and wide groove immediately to the right of the 
 middle line ; and, thirdly, by the fibrous cord which is the 
 remains of the ductus venosus, and forms a narrow notch just 
 to the left of the one formed by the inferior vena cava. The 
 posterior surface is triangular or somewhat rhomboidal in shape, 
 and is bounded on the right by the posterior border of the base, 
 which is rounded off at the upper part, but below is sharper in 
 outline ; above, by the postero-superior border ; and, below, by 
 the postero-inferior border, which is in reality divided into two 
 portions by the projection downwards of the lobulus Spigelii. 
 This projection, when well marked, causes the posterior surface 
 to have a rhomboidal appearance. The surface is divided into 
 two parts by the fissure for the ductus venosus or the posterior 
 half of the great longitudinal fissure. That part which lies to 
 the left of the fissure is triangular in shape, smooth, and covered 
 with peritoneum, convex on the left and grooved on the right 
 
6 ANATOAIY. 
 
 margin by the oesophagus, and it forms the posterior surface of 
 the left lobe. The surface which lies to the right of the fissure 
 is the posterior surface of the right lobe, and is subdivided into 
 two portions by a large fissure which lodges the vena cava in- 
 ferior. That part which lies to the left of the fissure is called 
 the lobulus Spigelii ; it is covered by peritoneum of the lesser 
 sac, is quadrilateral in shape, and at its inferior extremity it is 
 continuous with the inferior surface of the right lobe by a pro- 
 cess of liver tissue which is named the lobulus caudatus. The 
 part which lies on the right side of the vena cava inferior is for 
 the most part convex, except as regards the lower and left ex- 
 tremity, where there is an impression for the right suprarenal 
 capsule. This surface is rough and uncovered with peritoneum, 
 and lies in close contact with the inferior aspect of the diaphragm. 
 In some livers there is a bridge of hepatic tissue arching over 
 the inferior vena cava so as to unite the lobulus Spigelii with 
 the posterior surface of the right lobe. This, when present, is 
 called the ponticulus hepatis. When viewed from behind, the 
 posterior surface presents a large concavity, which is caused by 
 the projection forwards of the anterior portion of the vertebral 
 column and the pillars of the diaphragm. The inferior surface 
 is extensive, and bounded in front by the thin sharp antero- 
 inferior border, behind by the irregular postero-inferior border, 
 and towards the right by the well-defined inferior border of the 
 base. This surface is generally concave, and is divided into two 
 parts by that portion of the great longitudinal fissure which 
 lodges the ligamentum teres. That portion which lies to the 
 left of the longitudinal fissure is somewhat concave, smooth, and 
 covered with peritoneum, and presents a large impression where 
 it lies in contact with the stomach, and a slight convexity im- 
 mediately to the left of the longitudinal fissure which is called 
 the tuber omentale. This eminence lies in contact with the 
 anterior aspect of the gastro-hepatic omentum. The portion 
 which is situated on the right side of the longitudinal fissure 
 is subdivided into two parts by a large groove or fossa which 
 runs in an antero-inferior direction, and lodges the gall bladder. 
 This fissure is more than one inch wide in front, but as it nears 
 the postero-inferior border it becomes much narrower. Connect- 
 ing the posterior extremities of the fissure for the ligamentum 
 teres and tlie fissure for the gall bladder, there is a deep fissure 
 which is situated along the postero-inferior border, and called 
 
LIGAMENTS. 7 
 
 the transverse or portal fissure. It is here, that the blood vessels 
 and nerves enter the liver, and the lymphatic vessels and hepatic 
 ducts have their exit. The portion of the inferior surface which 
 lies between the umbilical fissure and the fissure for the gall 
 bladder is called the quadrate lobe, on account of its shape. The 
 remaining and largest portion of the inferior surface, which lies 
 to the right of the gall bladder, is smooth and covered with peri- 
 toneum derived from the visceral layer of the greater sac, and 
 has in front an impression for the hepatic flexure of the colon ; 
 behind this a large impression, which is caused by the upper por- 
 tion of the right kidney ; and at the left margin, just to the right 
 of the gall bladder, a third impression, caused by its close relation 
 with the duodenum, which lies in contact with it at this point. 
 
 Ligaments. — The liver is held in position in the abdominal 
 cavity and fixed to the surrounding structures by means of 
 ligaments, and also by its close connection with the inferior 
 vena cava. These ligaments are reflections or folds of the 
 peritoneum, with the exception of the ligamentum teres, which 
 is the remains of the foetal umbilical vein. The peritoneal 
 ligaments are {a) falciform, (b) coronary, (c) lateral (right and 
 left), and {d) gastro-hepatic, or the lesser omentum. The 
 falciform ligament is a double fold of peritoneum, derived from 
 the greater sac, which surrounds the remains of the umbilical 
 vein ; it is triangular in shape, its base being free and extending 
 from immediately above the umbilicus to the notch which forms 
 the anterior extremity of the great longitudinal fissure ; whilst of 
 the two sides, the upper is fixed to the deep surface of the 
 anterior abdominal wall and the inferior surface of the 
 diaphragm, along a line which is represented upon the 
 surface of the body by the upper portion of the linea alba ; 
 the lower is attached to the anterior and superior surfaces of the 
 liver, along a line which extends from the notch for the liga- 
 mentum teres in front, almost to the upper extremity of the 
 fissure for the ductus venosus behind. This ligament consists of 
 two layers of serous membrane, between which lie the remains 
 of the umbilical vein, together with some small blood vessels 
 and lymphatics. Along the line where the ligament is in 
 contact with the liver, the two layers separate and become 
 continuous with the peritoneum which covers the surface of the 
 right and left lobes, and posteriorly it leaves the surface of the 
 gland to form the anterior layer of the coronary ligament. The 
 
8 ANATOMY. 
 
 coronary ligament consists of two layers of peritoneum, which 
 are not in apposition, but are separated from one another by 
 those portions of the posterior and superior surfaces which are 
 directly fixed to the inferior aspect of the diaphragm, and devoid 
 of a peritoneal covering. The anterior layer of this ligament is 
 formed by the reflection of the peritoneum, at the upper border 
 of the bare area, from the liver to the lower surface of the 
 diaphragm ; and the posterior or inferior layer is formed in a like 
 manner by the reflection of the peritoneum from the inferior 
 margin of the bare area to the inferior vena cava and the upper 
 part of the right kidney. The right lateral ligament is a small 
 fold of peritoneum which fixes the posterior portion of the right 
 lateral surface to the inferior surface of the diaphragm, and it 
 results from the juxtaposition of the two layers of the coronary 
 ligament at the right extremity of the bare area. The left 
 lateral ligament is larger than the right, and is somewhat 
 triangular in shape, its base beiug directed towards the left, and 
 having a concave free border. It consists of two layers of 
 peritoneum, which are the lateral continuations of the left half 
 of the coronary ligament, and it attaches the liver to the 
 inferior surface of the diaphragm immediately in front of the 
 oesophageal aperture. The gastro-hepatic, or lesser omentum, is 
 a double fold of peritoneum which passes from the transverse 
 fissure of the liver to the lesser curvature of the stomach. The 
 anterior layer is derived from the greater sac, and is continuous 
 above with the peritoneum upon the inferior surface of the 
 liver, whilst below it passes into the layer of peritoneum which 
 covers the anterior surface of the stomach. The posterior layer 
 is part of the anterior wall of the lesser sac, and is continuous 
 above with the inferior portion of the coronary ligament, and 
 below with the layer whicli clothes the posterior aspect of the 
 stomach. On the right it presents a free, somewhat thickened 
 border, which extends from the right extremity of the portal 
 fissure to the upper border of the first part of the duodenum, 
 and it forms the anterior boundary of the foramen of Winslow, 
 whilst upon the left the two layers become continuous with the 
 serous coats of the stomach. This ligament is thickest on the 
 right, where it has between its two layers the hepatic artery and 
 the bile duct, together with the portal vein and the lymphatic 
 vessels and nerves. Towards the left it is much tliinner, and has 
 small holes in it which give it a fenestrated appearance (Fig. 8). 
 
FISSURES — LOBES. 9 
 
 Fissures. — The following fissures are met with upon the 
 various surfaces of the liver, namely, (a) the longitudinal 
 fissure, {h) the transverse fissure, (c) the fissure for the gall 
 bladder, (c/) the fissure for the inferior vena cava. The longi- 
 tudinal fissure is a deep groove, which commences at the antero- 
 inferior border and extends directly backwards to the left 
 extremity of the transverse fissure, beyond which it is continued 
 vertically upwards across the posterior surface as far as the 
 postero-superior border, dividing the inferior and superior 
 surfaces into right and left portions. It is the boundary 
 between the right and left lobes upon these surfaces. Its 
 direction corresponds exactly with the line of attachment of the 
 falciform ligament upon the anterior and superior surfaces. 
 The portion of the fissure on the inferior surface is called the 
 umbilical fissure, and in it lies the remains of the umbilical vein, 
 which is now called the ligamentum teres. In some livers this 
 fissure is partially converted into a tube or canal by a process 
 of liver tissue bridging it over, which, when present, is called the 
 pons hepatis. That portion of the fissure which is situated on 
 the posterior surface is called the fissure for the ductus venosus, 
 since it contains a fibrous cord which is the morphological 
 remains of this structure. The transverse fissure is a somewhat 
 deep sulcus situated along the postero-inferior border, and com- 
 mencing at the longitudinal fissure, whence it extends to the 
 right for about two inches. At this fissure the ducts and 
 lymphatics of the gland have their exit, and the portal vein, 
 hepatic artery, and nerves, their entrance. The fissure for the 
 gall bladder is a broad groove, somewhat wider in front than 
 behind, which runs across the inferior surface, and extends 
 from the right extremity of the transverse fissure to the 
 antero-inferior border, almost parallel with the anterior 
 portion of the longitudinal fissure. In it lie the gall bladder 
 and the cystic duct. The fissure for the inferior vena cava is a 
 deep groove upon the posterior surface, to the right of the pos- 
 terior portion of the longitudinal fissure, which runs obliquely 
 from below and on the right, uiwxtrds to the left. The inferior 
 vena cava lies in it, and it is occasionally converted into a canal 
 by a process of liver tissue, which passes superficial to the vein. 
 This process, when present, is called the ponticulus hepatis. 
 
 Lobes. — The liver is primarily divided into a large right 
 and a small left lobe by the longitudinal fissure on the inferior 
 
lo ANATOMY. 
 
 and posterior surfaces, and the attachment of the falciform liga- 
 ment on the superior and anterior surfaces. The posterior and 
 anterior surfaces are further subdivided. Upon the inferior 
 surface that portion of the liver wliich is situated between the 
 umbilical fissure and the fissure for the gall bladder, is, from its 
 quadrilateral shape, named the quadrate lobe ; and, as we have 
 already seen, the bridge over the umbilical fissure, when it 
 exists, is called the pons hepatis. On the posterior surface that 
 portion of the gland which lies between the fissure for the 
 ductus venosus and the fissure for the inferior vena cava is 
 known as the lobulus Spigelii, and the occasional process over 
 the fissure for the vena cava is called the ponticulus hepatis. 
 The part of the liver which connects the inferior surface of the 
 right lobe and the lobulus Spigelii is called the lobulus caudatus. 
 Blood vessels. — The hepatic artery is a large vessel, measur- 
 ing more than one quarter of an inch in diameter, which 
 conveys nearly the whole of the arterial blood going to the liver 
 (Fig. 4). It is one of the terminal branches of the coeliac axis, 
 and is given off from this vessel at the upper border of the head 
 of the pancreas. From its origin it first passes forwards in an 
 antero-posterior direction, bending slightly to the right over the 
 upper border of the pancreas and below the lower margin of the 
 foramen of Winslow, in order to reach the upper part of the 
 pyloric end of the stomach, where it gives off its first branch, 
 the arteria gastro-duodenalis ; next, it curves slightly backwards 
 and gives off a pyloric branch to the lesser curvature of the 
 stomach, and then ascends between the two layers of the gastro- 
 hepatic omentum, where it is surrounded by some connective 
 tissue, which separates it from the common bile duct on the 
 right and the portal vein behind. The artery, as it ascends, lies 
 in front of the lesser sac of the peritoneum, immediately to the 
 left of the foramen of Winslow, and after a course of 
 about li or 2 in. it reaches the neighbourhood of the trans- 
 verse fissure, a short distance from which it divides into its 
 two terminal branches, the right and left hepatic arteries. The 
 right hepatic artery passes obliquely to the right, and crosses 
 generally behind the hepatic and cystic ducts, but occasionally 
 in front of the hepatic duct, and gives off the cystic artery to 
 the gall bladder. After a short course it reaches the right 
 extremity of the transverse fissure of the liver, where it divides 
 into several branches, usually two to four, which immediately 
 
BLOOD VESSELS. 
 
 II 
 
 pass into the substance of the liver. The cystic artery passes 
 between the cystic and hepatic ducts in its course to the neck of 
 the gall bladder, where it divides into two branches, the superior 
 
 Fig. 4. — Diagrammatic view of the structures in the portal tissure of the liver and 
 on its inferior surface, together with the adjacent viscera. (After Testut.) 
 
 Inferior aspect of liver. 13. 
 
 Eight kidney. 14. 
 
 Right suprarenal capsule. 15. 
 
 Left kidney. 16. 
 
 Pancreas. 17. 
 
 Cardiac portion of stomach. 18. 
 
 Spleen. 19. 
 
 Duodenum. 20. 
 
 ,, 1st part. 21. 
 
 2nd „ 22. 
 
 3rd „ 23. 
 
 4th „ 24. 
 
 Junction of duodenum and jejunum. 25. 
 
 Jejunum. 26. 
 
 Cardiac orifice of stomach. 27. 
 
 Pylorus. 28. 
 
 Cceliac axis. 
 
 Arteria gastro-duodenalis. 
 
 Hepatic artery. 
 
 Splenic artery. 
 
 Superior mesenteric artery. 
 
 Superior mesenteric vein. 
 
 Gall bladder. 
 
 Cystic duct. 
 
 Common hepatic duct. 
 
 Common bile duct. 
 
 Cystic artery. 
 
 Portal vein. 
 
 Aorta. 
 
 Inferior vena cava. 
 
 Inferior mesenteric artery. 
 
 Spermatic artery. 
 
 and inferior cystic arteries. The superior ramifies in the coats 
 of the gall bladder, supplying that portion of the viscus which 
 lies in direct relation with the inferior surface of the liver, whilst 
 the inferior supplies the peritoneum-covered surface of the gall 
 
12 ANATOMY. 
 
 bladder in a similar manner. The left hepatic artery is con- 
 siderably smaller than the right, is given off from the main 
 trunk at an acute angle, and passes obliquely to the left, 
 towards the left extremity of the transverse fissure. In its 
 course it gives off one or two small branches to the lobulus 
 Spigelii, and then terminates by dividing into two or three 
 branches, which pass directly into the liver at the left extremity 
 of the transverse fissure. The branches of the hepatic artery 
 accompany the branches of the portal vein and bile ducts in the 
 substance of the liver. The minute distribution of the terminal 
 branches will be given with the histology of the gland. 
 
 Abnormalities of the Iwpatic artery. — The hepatic artery 
 presents several varieties as regards its origin. It may arise 
 directly from the abdominal aorta, or as a branch from the 
 superior mesenteric or splenic arteries. The cystic artery may 
 also come from the superior mesenteric vessel. Small accessory 
 hepatic arteries have been described as taking origin from the 
 coronary, superior mesenteric, inferior mesenteric, the abdominal 
 aorta, or the right renal.^ 
 
 Portal vein. — The portal vein is a wide and somewhat thiu- 
 walled vessel, which commences in front of the body of the first 
 lumbar vertebra, and is formed by the union of the superior 
 mesenteric and splenic veins. At its commencement it lies a 
 short distance to the left of the inferior vena cava, and has the 
 head of the pancreas in front ; in its course upwards it inclines 
 slightly to the right, and passes behind the head of the pancreas 
 and the first portion of the duodenum, and then it enters the 
 gastro-hepatic omentum, between the two layers of which it runs 
 to the transverse fissure of the liver. As the vein lies in the 
 gastro-hepatic omentum it has the common bile duct and the 
 hepatic artery in front, the former being on the right and the 
 latter on the left ; it is also surrounded by a considerable amount 
 of fibrous connective tissue, which is continuous with Glisson's 
 capsule ; and in this tissue lie the efferent lymphatic vessels of 
 the liver and numerous filaments of the hepatic plexus of nerves. 
 When the portal vein reaches the right extremity of the trans- 
 verse fissure, tlie lumen of the vessel becomes dilated so as to 
 form a localised enlargement, called the sinus of the portal vein, 
 immediately beyond which it divides into two branches, a large 
 and sliort right and a smaller and longer left. The ri";ht branch 
 
 ^ Quaiii's "Anatomy/* 10th eilition, vol, ii. pt. i. p. 460. 
 
PORTAL VEIN. 13 
 
 enters the substance of the liver at the right extremity of the 
 transverse fissure, and divides into a number of branches, each of 
 which is accompanied by a branch of the hepatic artery and one 
 of the small bile ducts. The left branch courses across to the 
 left extremity of the transverse fissure, where it enters the liver 
 and divides and ramifies in a similar manner to the right. As 
 the left branch of the portal vein crosses the longitudinal fissure, 
 it is connected in front with the ligamentum teres by a fibrous 
 cord, which is a part of the remains of the foetal umbilical vein, 
 and behind with the inferior vena cava by a similar cord, which 
 is the remains of the ductus venosus. As the portal vein passes 
 through the gastro-hepatic omentum it receives the pyloric and 
 coronary veins, and the right division the cystic vein from 
 the gall bladder. The portal vein measures about 3 in. in 
 length. In the adult the portal vein and its larger tributaries 
 contain no valves, but, in the child, valves are said to be present 
 in the veins of the stomach and intestine, which soon disappear 
 (Hochstetter and Bryant quoted by Quain).^ Accessory portal 
 veins have been described by Baumgarten - and Sappey.^ These 
 are small veins which return the blood from the peritoneal liga- 
 ments of the liver, and enter the liver substance either directly 
 or by joining the branches of the portal vein. 
 
 Communications l)etween the idortal vein and the general 
 venous system. — These are important because they are liable 
 to become enlarged in certain hepatic affections and give rise to 
 definite symptoms. They are the following, namely, [ci) a 
 small vein, which is the remains of the umbilical vein ; it 
 commences in the region of the umbilicus, where it communi- 
 cates with the epigastric veins and the small veins of the 
 anterior abdominal wall, and then runs in the ligamentum 
 teres to join the left division of the portal vein ; (&) occasional 
 parumbilical veins, which lie in the superficial part of the 
 ligamentum teres, and communicate externally with veins in 
 the region of the umbilicus, and internally with the portal 
 vein or the unobliterated remains of the umbilical vein ; (c) 
 small anastomoses between the veins of the pancreas and the 
 veins of the adjacent portion of the posterior abdominal wall ; 
 {cl) small veins of the second and third portions of the 
 
 1 Quain's "Anatomy," lOtli edition, vol. ii. pt. i. p. 543. 
 
 - Baumgarten, Centralbl. f. d. vied. Wissensch., Berlin, Bd. xv. s. 721. 
 
 3 Sappey, Mem. Acad, de med., Paris, tome xxiii. p. 269. 
 
14 ANATOMY. 
 
 duodenum, which have communication with the veins of the 
 posterior abdominal wall ; (c) the veins of the ascending and 
 descending colon with the veins of the posterior abdominal wall ; 
 (/) veins in the walls of the second and third portions of the 
 rectum, which are connected with the tributaries of the internal 
 iliac vein ; (g) veins of the lower part of the rectum which com- 
 municate with the inferior hsemorrhoidal vems ; {h) the communi- 
 cations between the tributaries of the coronary vein and the 
 oesophageal veins. 
 
 Hepatic veins. — The blood which has been conveyed to the 
 liver by the hepatic artery and the portal vein is collected by the 
 radicles of the hepatic veins, which commence within the sub- 
 stance of the liver, and then unite to form the larger hepatic 
 veins. The hepatic veins are usually two or three in number, 
 occasionally more, and have the form of large, short, wide vessels, 
 which open into that portion of the inferior vena cava which lies 
 in the groove upon the posterior surface of the liver. In their 
 course through the liver the hepatic veins run obliquely upwards. 
 At the point of entrance into the inferior vena cava a semilunar 
 fold of tissue is present, and forms at each aperture an imperfect 
 kind of valve, and with this exception there are no valves in the 
 hepatic veins. In order to see these veins, after the liver has 
 been removed from the body, the vena cava should be slit open 
 from behind, when the gaping openings of the hepatic veins will 
 be seen. In rare cases the hepatic veins have been seen to pierce 
 the diaphragm, and open separately by one or two trunks into the 
 right auricle. Breschet has described single hepatic openings 
 into both right and left auricles, and Eothe has seen a single 
 hepatic vein pierce the diaphragm, and open directly into the 
 left auricle, the aperture being guarded by a valve. When the 
 inferior vena cava passes upwards in company with the aorta, 
 and joins the superior vena cava, the hepatic veins unite and form 
 a single trunk, which passes through the diaphragm in the usual 
 position for the aperture of the inferior vena cava, and then joins 
 the right auricle. 
 
 Inferior vena cava. — The upper portion of the abdominal 
 vena cava is situated within a deep groove, which is occasionally 
 converted into a canal, on the posterior surface of the liver, 
 between the right border of the lobulus Spigelii and the left 
 border of the posterior surface of the right lobe. This groove 
 is wide and deep, and the vein is firmly fixed to the connective 
 
LYMPHATICS. 15 
 
 tissue capsule of the liver by the union of the outer coat of the 
 vein and the connective tissue of Glisson's capsule, and also by 
 the junction of the hepatic veins with the inferior vena cava. 
 The groove is generally deeper above than below, owing to the 
 fact that the vein passes slightly forwards before it pierces the 
 diaphragm to join the right auricle. The bridge of liver tissue, 
 which occasionally overlaps the vein and converts the groove into 
 a canal, is called the pontic ulus hepatis. The portion of the 
 inferior vena cava which lies in relation with the liver measures 
 from \\ to 2 in. in length. 
 
 Lymphatics. — The lymphatic vessels by which the lymph is 
 conveyed from the liver may be divided into two sets, («) an 
 external set, which lie upon the external surface of the liver, 
 underneath the peritoneal covering, and in or upon the connective 
 tissue of the capsule of Glisson ; (&) an internal set, which lie 
 within the substance of the liver, and accompany the branches 
 of the portal vein and the hepatic artery. The external set of 
 lymphatic vessels leave the liver at many points, and on this 
 account they can be subdivided into the following groups, namely, 
 (1) Those which pass upwards along the falciform ligament. 
 The lymphatics from the greater portion of the superior surface 
 and the upper part of the anterior surface of the liver all con- 
 verge towards and join together in the falciform ligament, between 
 the layers of which they pass to the aperture between the dia- 
 phragm and the ensiform cartilage, whence they run into the 
 thorax and open into the lower lymphatic glands in the anterior 
 mediastinum. (2) The lymphatics from the median portion of 
 the posterior surface. These vessels pass between the layers of 
 the coronary ligament, pierce the diaphragm, and then join the 
 lymphatic glands around the thoracic portion of the inferior vena 
 cava. The lymphatic vessels from the left part of the posterior 
 surface join the lymphatics around the oesophagus. (3) The 
 lymphatics from the lower portion of the posterior surface, from 
 the greater part of the inferior surface, and from the lower portion 
 of the anterior surface, pass to the transverse fissure, where they 
 join some of the deep lymphatics, and then pass into the glands 
 which lie in the gastro-hepatic omentum. (4) The lymphatics 
 from part of the right lateral surface pass between the layers of 
 the right lateral ligament, and then generally pierce the diaphragm 
 and join the glands in the mediastinal space, or cross the crus of 
 the diaphragm, and empty themselves into the receptaculum 
 
1 6 ANATOMY. 
 
 chyli. (5) The lymphatics from the apex of the left lobe pass 
 between the layers of the left lateral ligament, and join the 
 oesophageal lymphatics around the oesophageal opening in the 
 diaphragm, or they pierce the diaphragm and join the glands in 
 the anterior mediastinum. 
 
 The internal set. of lymphatics emerge from the liver at two 
 points, and on this account are divided into portal and hepatic 
 groups — (1) The portal group pass out from the liver at the 
 transverse fissure, and run into the gastro-hepatic omentum, where 
 they are joined by some of the external set, and then empty into 
 the hepatic glands, whence they pass into the coeliac glands and 
 the thoracic duct. (2) The hepatic group emerge from the liver, 
 along with the hepatic veins, in the groove for the inferior vena 
 cava, and then pierce the diaphragm, along with that vessel, and 
 enter the glands around its thoracic portion, whence vessels pass 
 over the thoracic aspect of the diaphragm and join the lower 
 portion of the thoracic duct. 
 
 Nerves. — At the portal fissure of the liver there is a dense 
 plexus of nerves which surrounds the portal vein, the hepatic 
 artery, and bile ducts, and is called the hepatic plexus. It 
 receives branches from the solar plexus, some branches from the 
 right vagus, and a larger number from the left. Nerves pass 
 inwards from this j)lexus and accompany the branches of the 
 hepatic artery and the portal vein. The ultimate distribution of 
 these nerves is not exactly known, but ganglia have been described 
 as occurring upon them in their course within the liver. Pfliiger 
 has described some of these nerve fibres, and asserts that they 
 terminate in the hepatic cells. MacCallum -^ says that an inter- 
 lobular plexus of non-medullated fibres is formed, from which pass 
 perivascular and intercellular plexuses. Korolkow^ and Berkley^ 
 have recently confirmed and extended MacCallum's observations. 
 
 Biliary (qji^aratus. — The biliary apparatus, formed by the 
 excretory ducts of the liver, consists of (a) the right, left, and 
 common hepatic ducts ; (&) the gall bladder and cystic duct ; and 
 (c) the common bile duct. The right hepatic duct commences 
 near the right extremity of the transverse fissure, and passes 
 slightly downwards and towards the left, where it joins the left 
 hepatic duct coming from the left extremity of the transverse 
 
 J MacCallum, Quart. Jovrn. Mkr. Sc, London, 1887, p. 439. 
 '- Korolkow, Anat. Anz., Jena, 1893, s. 751. 
 3 Berkley, ibid., 1893, s. 769. 
 
BILIARY APPARATUS. 
 
 ^7 
 
 fissure, to form the common hepatic duct. The common hepatic 
 duct measures about 3 c.c. in length, and is situated between 
 the layers of the gastro-hepatic omentum, where it is directed 
 downwards and to the right. It lies in front of the portal vein, and 
 has the hepatic artery on its left (Fig. 8). At its lower extremity 
 it is joined on its 
 right side by the cystic 
 duct, which comes from 
 the gall bladder. The 
 duct which is formed 
 by the union of the 
 cystic duct and the 
 common hepatic duct, 
 is called the common 
 bile duct, or the duc- 
 tus communis chole- 
 dochus. 
 
 The gall bladder 
 is a hollow sac, pyri- 
 form in shape, which 
 lies in a fossa on the 
 inferior surface of the 
 liver between the 
 quadrate and right 
 lobes. The sac measures 
 about 10 cm. in 
 length, 3 cm. in width 
 at the base, and it has 
 a capacity of about 
 20 c.c. The gall 
 bladder consists of a 
 fundus, a body, and a 
 neck. The fundus is 
 the lowest portion, 
 and is directed down- 
 wards, forwards and towards the right, and when it is 
 distended it lies behind the ninth right costal cartilage, pro- 
 truding a little beyond, so as to come into contact with the 
 posterior surface of the anterior abdominal wall. This part is 
 completely covered with peritoneum. The body is that part of 
 the gall bladder which lies between the fundus and the neck. 
 
 Fig. 5. — The gall bladder and biliary ducts, a, cavity 
 of gall bladder ; h, neck of gall bladder ; c, cystic 
 duct ; d, spiral valve of cystic duct ; e, common 
 hepatic duct ; /, common bile duct ; (j, duct of 
 pancreas ; /i, ampulla of Vater ; t, second portion 
 of duodenum ; j. biliary papilla. (After Testdt. ) 
 
i8 ANATOMY. 
 
 It lies in the fossa for the gall bladder, and is attached on its 
 upper and anterior surface by connective tissue to the inferior 
 surface of the liver. The lateral, inferior, and posterior surfaces 
 are covered with peritoneum, which is reflected on to the 
 inferior surface of the liver. The lower surface of the gall 
 bladder is in contact with the first part of the transverse colon, 
 
 Fig. 6. — Portion of the riglit lobe of the liver, the gall bladder, and tlie colon, 
 showing the mesentery which occasionally fixes the gall bladder to the colon. 
 
 the first portion of the duodenum, and occasionally with the 
 pylorus. The gall bladder may be fixed to the transverse colon 
 by a fold of peritoneum, extending from the inferior aspect of 
 the former viscus to the upper border of the latter. This 
 condition is illustrated in Fig. 6. In rare cases the gall bladder 
 has a mesentery, and when this is present it is suspended to the 
 
BILIARY APPARATUS. 
 
 19 
 
 inferior surface of the liver. Hochstetter -^ has recorded a case in 
 which the gall bladder was attached to the liver on the left side 
 of the middle line, and in v/hich there was no transposition of 
 viscera. The mucous membrane of the gall bladder, when seen 
 from the interior, is thrown into a number of folds which give 
 it a honeycombed appearance (Fig. 7). As the body of the 
 gall bladder nears the transverse fissure of the liver, it becomes 
 narrower, and passes into the constricted portion or neck. The 
 neck becomes narrower as it passes backwards, and is folded 
 upon itself in an S-shaped manner, and when it reaches the 
 transverse fissure it passes into the cystic duct. The cystic 
 duct is a small canal, 
 2'5 to 3"5 c.c. in 
 length, which passes 
 backwards and tow^ards 
 the left in the gastro- 
 hepatic omentum,wdiere 
 it joins at an acute 
 angle the common 
 hepatic duct on its 
 right side, so as to 
 form the common bile 
 duct. The mucous 
 membrane of the cystic 
 duct is thrown into a 
 number of folds, which 
 are called the valves of 
 Heister. These valves 
 usually have a spiral 
 arrangement. The common bile duct measures about 7 '5 c.c. 
 in length, and in diameter 5 to 6 mm. It passes down- 
 wards, first between the layers of the gastro-hepatic omentum, 
 lying to the right of the hepatic artery and in front of 
 the portal vein, then behind the first portion of the duodenum, 
 and finally between the left aspect of the second part of the 
 duodenum and the right margin of the head of the pancreas, to 
 terminate in the lower part of the descending portion of the 
 duodenum. After passing for three-quarters of an inch obliquely 
 through the intestinal wall, it opens into the duodenum on the 
 top of a small eminence, which is called the biliary papilla, and 
 
 1 Hochstetter, Arch. f. Anat. «. Entwcklnrjsrjesch., Leipzig, 1886, s. 369. 
 
 Fig. 7. — Mucous membraue of gall bladder as seeu 
 from the iuterior. (After Testut.) 
 
20 ANATOMY. 
 
 is situated on the posterior and left aspect of the intestine. As 
 the common bile duct passes through the wall of the duodenum, 
 it is joined on its left side by the duct of the pancreas, and then 
 becomes dilated so as to form a small fusiform sac, which is 
 called the ampulla of Vater. There is a slight constriction in 
 the lumen of the duct at its point of entrance into the duodenum. 
 The cystic duct and the gall bladder receive a small arterial 
 branch from the right hepatic artery, wdiich is called the cystic 
 artery, and this vessel ramifies in the walls of both these 
 structures. The cystic vein opens into the portal vein or into 
 its right division. Purser ^ has described a case in which two 
 gall bladders were met with, each sac having a distinct duct 
 which joined the hepatic duct separately. 
 
 Hcixtto-cystic duds. — It occasionally happens that small bile 
 ducts pass directly from the liver substance to the gall bladder. 
 When these are present they are called hepato-cystic ducts. 
 They have, however, only very rarely been observed in man. 
 
 Topographical anatomy of the liver. — The liver, as we have 
 already seen, lies in close contact with the lower surface of the 
 diaphragm ; and below, it is in relation with the stomach, the 
 first and second portions of the duodenum, the right kidney and 
 suprarenal capsule, and the hepatic flexure of the colon. The 
 liver, in an adult who is in the erect position, extends only a 
 very short distance below the costal margin ; usually it extends 
 about one-third or half an inch below the ribs, from the ninth 
 to the twelfth, upon the right side. The apex of the left lobe 
 of the liver is situated in the left side of the abdomen, about 
 two or two and a half inches from the middle line of the 
 sternum, and lies behind the lower border of the junction of the 
 sixth rib with its cartilage. Behind, the liver extends down- 
 wards as far as the first lumbar spine. Hence the lower border 
 of the liver will be represented by a line which commences 
 behind at the spine of the first lumbar vertebra, and passes 
 forwards and upwards to the lower part of the eleventh rib, and 
 thence along the costal margin of the right side to the ninth 
 costal cartilage, whence it crosses the subcostal angle to the 
 eighth costal cartilage of the left side, and is then continued to 
 the apex which lies behind the junction of the sixth rib with its 
 cartilage at its lower border. The upper border of the liver is 
 represented by a lino wln'ch conmiences opposite the lower 
 
 ^ Purser, Trims. Acrul.. Mai. Irelinid, Duliliii. vol. v. ]>. 24-3. 
 
GALL BLADDER — COMMON BLLE DUCT. 21 
 
 border of the sixth rib, at tlie junction with its cartilage, and 
 passes to the right across the middle line just above the 
 junction of the gladiolus sterni with the xiphoid cartilage, and 
 thence to the junction of the fifth rib with its costal cartilage, 
 from which point tlie line is carried first downwards and to the 
 right, and then abruptly downwards to the spine of the first 
 lumbar vertebra. 
 
 The height of the liver varies with the movements of 
 respiration ; thus, during inspiration, the lower border is somewhat 
 below the above-mentioned line ; whilst during expiration it lies 
 above that level. In the recumbent position the greater portion 
 of the liver recedes underneath the ribs, and only a small part 
 in the subcostal angle can be felt. 
 
 The liver is proportionately much larger in children, 
 especially in infants, than in the adult. On this account the 
 lower margin of the gland extends a variable distance below the 
 costal border. It may be felt in some cases to extend one-third 
 of the way towards the umbilicus. The left lobe also is com- 
 paratively much larger in children, and on this account it 
 extends beyond the nipple line, and passes towards the 
 neighbourhood of the spleen. 
 
 The gall Madder lies in the right hypochondriac region, its 
 fundus being situated immediately behind the ninth right costal 
 cartilage. In the erect position the fundus projects a little 
 below the costal margin, but in the recumbent position it usually 
 lies completely hidden by the ribs and their costal cartilages. 
 The main part of the vesicle lies at a higher level and in a 
 much deeper plane. 
 
 The common hile d.uct lies at first in the gastro-hepatic omen- 
 tum, a little to the right of the middle line, and the last part 
 behind the duodenum, and slightly more to the right. It must be 
 remembered that the common bile duct is in very close relation 
 with the portal vein, which lies immediately behind it and to 
 the left ; whilst the hepatic artery is just to the left, and in the 
 same plane. Immediately behind these structures, and only 
 separated by the two layers of peritoneum which are the bound- 
 aries of the foramen of Winslow^ there lies the inferior vena 
 cava, and a little further to the left the abdominal aorta (Fig. 8). 
 
 The devehprnent of the liver. — In early foetal life the 
 stomach and duodenum are connected with the anterior body wall 
 by a mass of mesoblastic tissue, which has been termed, the 
 
2 2 ANATOMY. 
 
 ventral alimentary mesentery. In this run the two vitelline veins, 
 bringing the blood from the yolk sac. The body cavity is in 
 this early condition bilaterally symmetrical. There arises from 
 the fore-gut in the human embryo, before the fifteenth day, a 
 short hollow diverticulum, and shortly afterwards a second 
 diverticulum appears. A close network of anastomosing rods of 
 cells is formed from these rudiments. The arrangement of the 
 gland at this stage resembles the permanent condition in the 
 reptile and amphibian. This development of cell cylinders, 
 
 m j h I 
 
 Fig. 8. — Diagram of a section through the gastro-hepatic omentum, at the level 
 of the foramen of Winslovv. a, Lesser omentum or gastro-hejiatic omentum ; 
 b, common bile duct ; c, hepatic artery ; d, portal vein ; e, foramen of 
 Winslow ; /, lesser sac of peritoneum; g, lobulus Spigelii ; h, twelfth 
 dorsal vertebra ; i, inferior vena cava ; j, abdominal aorta ; k, right kidnej' ; 
 /, right suprarenal caj^sule ; m, left suprarenal capsule ; n, left kidney. 
 
 derived, of course, from the hypoblast, occurs in the veutral 
 alimentary mesentery. At the same time, the vessels in this 
 tissue multiply, and thus furnish a blood supply to the primitive 
 liver, which has, however, a somewhat complicated arrangement. 
 The original hollow diverticula from the fore-gut represent the 
 right and left hepatic ducts. Where they open into the 
 duodenum an outgrowth gradually develops, and in this way the 
 bile duct is formed. In the second month a subordinate out- 
 growth from this occurs to form the cystic duct and the gall 
 bladder. The bile capillaries arise by a canalisation of the 
 
DEVELOPMENT. 23 
 
 primitive cell cylinders ; and, as the tubular arrangement of the 
 liver gradually becomes lost, these bile capillaries are found to 
 be bounded simply by two liver cells. These bile capillaries 
 branch freely and anastomose laterally, and thus an individual 
 liver cell comes to have a bile capillary on more than one 
 aspect. At first the liver is symmetrical, but after the fourth 
 month the right lobe begins to preponderate. At the end of 
 the second month the liver forms a large part of the weight of 
 the whole embryo — roughly, one-half ; and this predominance 
 of the organ naturally suggests important functions during early 
 embryonic life. It presumably modifies the nutrient matter 
 brought by the allantoic (umbilical) veins, and during embryonic 
 and foetal life acts also as an excretory organ. The size of the 
 liver, compared with the rest of the body, gradually diminishes 
 as gestation proceeds, so that at birth the proportion is 1 to 18. 
 The ventral alimentary mesentery also conducts the 
 allantoic veins to the liver. One of these disappears later, and 
 only the left persists as the umbilical vein till birth, w^hen that 
 also becomes obliterated. The suspensory ligament is finally 
 derived from that portion of the ventral alimentary mesentery 
 which is between the liver and the anterior body wall. That 
 portion between the liver and the stomach and duodenum 
 {i.e. dorsal to the liver) becomes the gastro-hepatic omentum. 
 The vascular arrangement in the liver develops in man some- 
 what differently from the course in most other mammals. It 
 must be remembered that at one time three pairs of veins are 
 emptying into the sinus venosus of the heart — (<x) the 
 Giiviericm, returning blood from the embryo itself ; (&) the 
 vitelline, returning the blood from the yolk sac ; and (c) the 
 allantoic, returning blood from the placenta. The Cuvierian 
 veins have no special significance as regards the liver. It is, 
 however, necessary to follow out the changes in the other two 
 pairs. The vitelline veins are closely associated with the liver, 
 and become lost in it as development proceeds. Early in the 
 fourth week these veins become interrupted in their course through 
 the liver by the establishment of a set of capillaries. In this 
 way are formed veins supplying blood to the liver substance and 
 conducting blood from the liver substance. These are the 
 venm advehentes and the vence revehentes. The right and left 
 vitelline veins become connected by three commissural vessels 
 just before they enter the liver, one of these being dorsal to 
 
24 ANATOMY. 
 
 the gut, and the other two ventraL Two vascular rings or 
 sinus annulares are thus formed. The afferent hepatic vessels 
 arise from the upper of these rings. The right and left 
 vitelline veins later unite to form a single vein, and connected 
 with this vein are vessels bringing blood from the intestine, and 
 thus the portal vein originates. With respect to the two 
 annular sinuses, the left half of the upper and the right half of 
 the lower become obliterated ; a single vessel thus becomes 
 formed, having a spiral course round the gut. The allantoic 
 veins during the fourth week lose their connection with the 
 sinus venosus. The only important remnant of these is the 
 left allantoic vein, which joins the upper sinus annularis as this 
 is breaking up in the liver substance. At a certain stage in the 
 human embryo, at about the twenty-third day, the blood 
 returning to the heart by the vitelline and allantoic veins must 
 necessarily pass through the capillaries of the liver. But, later, 
 a direct passage to the heart becomes formed between the 
 developed portal vein, just as this is breaking up into the liver 
 substance, and the right hepatic vein (the proximal portion of 
 the right vitelline vein). This is known as the ductus venosus 
 or vena aurantii. This appears to be a new vessel in the 
 human embryo, though in the rabbit it corresponds to a portion 
 of the paired vitelline veins. The left hepatic vein subsequently 
 loses its direct connection with the heart, and a new com- 
 munication with the sinus venosus becomes established. The 
 posterior vena cava develops later by joining the sinus venosus. 
 This is formed by the junction of the iliac veins, and is at 
 first quite insignificant. During foetal life, therefore, the blood 
 which has come to the liver by the umbilical vein has two 
 alternative routes open to it. A part may go by the afferent 
 hepatic vessels through the substance of the liver, the larger 
 part goes direct through the ductus venosus to the heart. The 
 ductus venosus disappears at birth with the obliteration of the 
 umbilical vein. The blood passes to the liver by the portal 
 vein only, and is able to reach the heart only by traversing the 
 substance of the liver. The umbilical vein and the ductus 
 venosus are generally obliterated by the sixth or seventh day. 
 
 The Stkucture of the Liver. 
 
 The mammalian liver at first sight bears but little re- 
 semblance to the usual plan upon which a gland is arranged. 
 
STRUCTURE. 25 
 
 In lower animals the typical glandular arrangement is more 
 apparent, and in its early development, even in the mammal, it is 
 more easily seen. The reason for the departure from the typical 
 form is probably to be found in the fact that with higher 
 animals the functions of the organ have become modified, so that 
 its primitive function of the secretion of bile becomes less 
 conspicuous, and its adaptation to that function alone less 
 obvious. 
 
 In the frog, and to some extent in the mammalian embryo, 
 we find a simple tubular liver, consisting of cells arranged 
 around a lumen, into which is poured the secretion of those 
 cells. The liver of such an animal may be aptly compared to 
 the secretory portion of the mammalian pancreas, and betrays 
 apparently more resemblance to this than to the mammalian 
 liver. The fundamental difference, however, between the liver 
 of the amphibian and the mammal lies in the fact that the 
 lumen into which the bile is secreted is in the latter a mere 
 chink between two hepatic cells, whereas in the former it is a 
 definite passage bounded by many hepatic cells. These narrow 
 passages are called bile capillaries, and they show considerable 
 anastomosis. This, however, is also the case in the simple tubular 
 liver of the amphibian. 
 
 The cells of the mammalian liver are massed into lobules. 
 They have a definite arrangement in these lobules, being dis- 
 posed as rods or columns of cells, set in a radial manner from 
 the centre of the mass. Between the columns, blood vessels 
 pass from the periphery towards the centre. Between the 
 cells also, there are the narrow passages forming the bile 
 capillaries, which anastomose freely, but pass the bile to the 
 periphery of the lobule, where it is received in larger vessels, 
 the bile ducts. The lobules are sometimes definitely separated 
 from one another by septa of areolar tissue, continuous with the 
 external fibrous covering of the liver. This occurs in the pig 
 and the camel. In the rabbit the lobules are not so definitely 
 bounded, in man they are even more confluent. 
 
 Around the lobule are numerous blood vessels. These are 
 either branches of the portal vein, branches of the hepatic vein, 
 or branches of the hepatic artery. The branches of the portal 
 vein and hepatic artery, as they ramify through the organ, receive 
 together with the bile ducts a loose but strong sheath of areolar 
 tissue, enclosing the three vessels together, and forming what 
 
26 
 
 ANATOMY. 
 
 are termed yortal canals. This capsule of areolar tissue is 
 frequently called Glissons capsule. The hepatic veins are in- 
 vested by a small amount of areolar tissue, which binds them 
 to the glandular substance, and prevents their collapsing after 
 becoming empty. These have been called hepatic canals. In 
 the loose areolar tissue investing the vessels are numerous 
 lymphatics. From the branches of the portal vein, as they 
 ramify around the lobules, being then called interlobular 
 
 Fig. 9. — Diagrammatic section of a lobule of the liver. «, interlobular vein ; 
 b, intralobular vein ; c, intralobular capillaries ; d, interlobular artery ; 
 e, branches of interlobular artery ; /, interlobular biliary canal ; g, branches 
 of biliary canal in the lobule, forming the intercellular canaliculi ; h, biliary 
 caualiculi in transverse section ; i, hepatic cells ; j, interlobular lymphatic 
 vessels ; k, intralobular lymphatic vessels ; /, intralobular connective tissue. 
 (After Testut.) 
 
 veins, numerous vessels proceed gradually between the columns 
 of hepatic cells towards the centre of the lobule, or towards one 
 particular radius, along which the efferent vein of the lobule 
 conducts the blood. The finer lobular vessels anastomose, and 
 form a capillary network in the lobule, the distance apart of two 
 adjacent capillaries being no greater than the diameter of two 
 liver cells. The capillary vessels themselves are comparatively 
 
STRUCTURE. 27 
 
 large. The central vessel into which the blood is poured is 
 called the intralobular vein, and proceeds along one of the 
 radii of the compressed sphere to which the lobule may be 
 compared, to a vein at the periphery of the lobule called the 
 siMobular vein. The sublobular veins, by confluence, gradually 
 form the larger branches of the hepatic veins. 
 
 The hepatic artery finally terminates in three sets of vessels, 
 entitled the vaginal, capsular, and interlobular. The first supply 
 the portal canals, the second spread out in the fibrous coat on 
 the surface of the liver, the last supply blood to the walls of the 
 interlobular veins and bile ducts, and possibly to the extreme 
 peripheral parts of the lobule. 
 
 The hepatic cells are polyhedral in form, and have a dia- 
 meter varying from '01 7 mm. to "022 mm. They have no 
 cell membrane. They frequently contain granules in their cell 
 substance. The nuclei are round and clear, and have generally 
 one or two nucleoli. After fatty diet the cells may be found to 
 contain fat, more conspicuously seen in those cells near the 
 periphery of the lobule. 
 
 The cells frequently contain glycogen, and after the glycogen 
 is dissolved out the cell may show a vacuolated appearance. In 
 the frog, where one aspect of the cell is connected with the 
 blood supply and another with the bile capillary, it is easy to 
 make out that the glycogen is laid down in that part of the cell 
 nearest the blood supply. In the mammal this is not so easily 
 shown, as the same face of the cell may be in one part connected 
 with the bile capillary and in another with the blood vessels, but 
 the irregularity seen after dissolving out the glycogen probably 
 depends upon the same arrangement. 
 
 The bile capillaries between the cells can be demonstrated, 
 either by the silver-chromate method, or by killing the animal, 
 an appropriate time after the administration of sulphindigotate of 
 soda. They are probably channels grooved out between the 
 cells, as far as their origin is concerned, and possibly have 
 connection, at certain times, with other vacuoles which form 
 within the cells. 
 
 The bile ducts, as observed between the lobules, have walls 
 composed of a fine fibrous tissue, with a lining of columnar 
 epithelium. They have both longitudinally and circularly dis- 
 posed muscle fibre in their walls. In the bile ducts of 
 intermediate size numerous openings are to be observed, but 
 
28 ANATOMY. 
 
 these are the mouths of simple tubular recesses rather than 
 of glands. In the laro-er bile ducts a considerable amount of 
 elastic tissue occurs, and in the main ducts mucous glands are to 
 be found. 
 
 The gall bladder possesses a peritoneal investment, a mus- 
 cular and connective tissue coat of much strength, and a mucous 
 lining. This is found, after death, elevated into numerous ridges 
 with corresponding depressions (Fig. 7). The whole is covered by- 
 columnar epithelium, and mucous glands are present in the walls. 
 The hepatic duct, the cystic duct, and the common bile duct, 
 have the ordinary characters of the larger bile ducts. 
 
 The nerves of the liver, derived mainly from the left pneumo- 
 gastric and the solar plexus, are described as terminating in fine 
 arborisations, and distributed to the walls of the blood vessels 
 and biliary ducts, and also between the hepatic cells. It is also 
 said that such medullated nerves as enter the liver are dis- 
 tributed to the liver cells, whilst the non-medullated supply 
 almost exclusively the blood vessels. 
 
 The " aberrant ducts," described by Eerrein, and later by 
 Kiernan, represent portions of liver which were of importance at 
 an earlier period of development, but which have since under- 
 gone atrophy. 
 
CHAPTER 11. 
 
 THE FUNCTIONS OF THE LIVEE. 
 
 Though in earlier times, from its connection with a disordered 
 state of the bodj, the secretion of bile was considered the 
 function of the liver, at the present day we are disposed to 
 consider the formation of bile as less important than other 
 fmictions. Probably of greater importance to the animal body 
 is the influence the liver brings to bear upon carbohydrate foods, 
 upon proteid foods, and upon the formation of substances ex- 
 creted in the urine. Of much importance, also, is this organ in 
 changing such substances as probably result from muscular 
 metabolism ; and in proportion to its metabolic activity 
 and absolute bulk its relation to the heat formation of the 
 animal body must be duly estimated. Though the bile, then, 
 is to be looked upon as a " comparatively insignificant bye- 
 product," its formation may be conveniently considered before 
 other functions of the liver. 
 
 The secretion of bile by the liver. — Though, in general, the 
 rate of secretion of a gland depends upon the demand made 
 periodically for the secretions, yet in the case of the liver we 
 have a secretion of bile which is continuous, though subject to 
 alteration of rate influenced by the progress of digestion in the 
 alimentary canal. We can in this sense compare the secretion 
 of bile rather with the secretion of the kidney than with that of 
 other glands opening into the alimentary canal. As, however, 
 the constant inflow of bile to the alimentary canal might be 
 somewhat harmful to the organism, we have (at any rate in 
 carnivora) an apparatus in which the bile secreted in the intervals 
 of digestion may be conveniently stored. The quantity of bile 
 secreted by man has been estimated in cases of biliary fistulse, 
 some of which, however, occurred in patients so far removed from 
 the normal condition as to make any exact conclusion drawn 
 from them extremely hazardous. Nevertheless, other cases. 
 
30 THE FUNCTIONS OF THE LIVER. 
 
 though permitting observation by reason of the fact that a 
 biliary fistula existed, yet showed the patients to possess, in 
 the main, all the signs of health, so that deductions as to the 
 absolutely normal condition of the secretion of bile might be 
 made without any large error being included. 
 
 Such a case is that recorded by Copeman and Winston,^ in 
 1889. Here occlusion of the common duct, due to a calculus, 
 existed, the patient showing the usual symptoms of jaundice. 
 The gall bladder was opened, and a fistula resulted, through 
 which the whole of the bile formed was passed. The jaundice 
 gradually disappeared, the urine lost its bile reaction, but the 
 stools remained greyish and free from bile. This case, then, 
 affords an example of the way in which the possible purposes of 
 the formation of bile might be separated. As far as bile con- 
 stitutes a discharge of waste material, its function was not inter- 
 fered with, but any powers it possesses of influencing digestion 
 were lost. 
 
 From the observations of Copeman and Winston it was 
 found that the quantity of bile secreted in twenty-four hours 
 averaged 779'6 c.c. This agrees fairly closely with a series of 
 observations made about the same time on a patient of Mayo 
 Eobson,^ in which the quantity was found to average 85 c.c. in 
 twenty-four hours. In the first case the solids per diem were 
 11 "09 grms. ; in the second, 15 "2 8 grms. 
 
 As regards variation in the rate of secretion, it seems that 
 there is an increase soon after a meal is taken, then a diminution, 
 followed by a subsequent minor increase. 
 
 We proceed next to a consideration of the different influences 
 which affect the secretion of bile. The first question that may 
 be asked is. How far does the absorption of bile in the intestine 
 influence the further secretion ? 
 
 It was pointed out by Schiff^ that withdrawal of bile leads 
 to a diminution in the secretion, but if bile be allowed to flow 
 into the intestine the secretion is increased again. From this 
 he argued that a portion of the secretion absorbed in the in- 
 testine furnishes material for further secretion. This has been 
 confirmed by Prevost and Binet,^ and Wertheimer,'' who, on inject- 
 
 1 Copeman and Winston, Journ. Anat. and Pluj.'iuiL, London, vol. ix. p. 213 et seq. 
 
 2 Mayo Rob.son, /Voc. lioi/. Soc. London, vol. .xlvii. p. 499 et tteq. 
 3Schiff, Arch./, d. r/es. Physiol., Bonn, 1870. iii. s. 098. 
 
 * Pri'vost and Binet, Rev. nikl. de la Suisse Rom., Geut've, 1888, No. 520. 
 ' Wertheirner, Arch, de physioL, norm, etpath., Pari.s, 1891, pp. 724 et seq. 
 
THE SECRETION OF BILE. 31 
 
 ing foreign bile into the blood vessels or into the stomach of an 
 animal, found the characters of the foreign bile in the secretion 
 of the animal. It seems, therefore, possible that the secretion 
 of bile depends to some extent upon absorption from the alimen- 
 tary canal, and thus a kind of circulation of biliary constituents 
 occurs. 
 
 The next question that arises is, How far does the secretion 
 of bile depend upon the circulation of blood through the liver ? 
 
 Cases have been cited, such as those of Abernethy,^ in which 
 the portal vein opened into the vena cava inferior below the 
 liver, yet the secretion of bile was not apparently interfered 
 with. Experimentally, the portal vein has been ligatured, and 
 a connection made between the vena cava inferior and the portal 
 vein. Here no arrest of secretion of bile was observed. We 
 may suppose, therefore, that in cases of occlusion of the portal 
 vein, the hepatic artery can supply the liver with the essentials 
 for the formation of bile. 
 
 Finally, with respect to the influence of the nervous system 
 upon the secretion of bile, a general fall of blood pressure, brought 
 about by nervous agencies, affects the secretion of bile adversely. 
 Section of the splanchnic nerves, causing a dilatation of the 
 blood vessels of the abdominal area, also causes an increase in 
 flow of bile. We have evidence, then, that the secretion of bile 
 depends, within limits, upon the blood flow through the liver, 
 but at present we are without evidence as to any direct central 
 or local nervous mechanism affecting the secretion of bile. 
 
 The pressure of the secretion of bile, though low as com- 
 pared with that of saliva, yet is higher than that of the portal 
 vein. 
 
 If the outflow of bile be prevented, the secretion becomes 
 reabsorbed, and the constituents, or at any rate the pigments, are 
 excreted by the urine. The fact that the bile salts are not in- 
 variably associated with the pigments in icteric urine, suggest 
 that they are not so conspicuously waste substances as the latter 
 are. The reabsorption of the bile that occurs is through the 
 medium of the lymphatics with which the liver is plentifully 
 supplied. 
 
 The composition of the hilc. — The composition of bile, as 
 obtained from the cases of biliary fistulte previously referred 
 to, does not show any great variation. 
 
 1 Abernetliy, Phil. Trans., London, 1793, p. 61. 
 
32 THE FUNCTIONS OF THE LIVER. 
 
 One example may therefore be taken as indicative of the 
 several observations. 
 
 Water 98-4:74 per cent. 
 
 Solids :— 
 
 Glycocholate of soda 
 
 Taurocholate of soda . . \ '349 
 
 •075 
 
 Soaps 
 
 Cliolesterin 
 
 Lecithin 
 
 Fats . 
 
 Mucinoid matter, pigments, etc. "461 
 
 Inorganic salts . . . '641 
 
 1-526 
 
 100-000 
 
 The characters and significance of these constituents require 
 some comment. 
 
 The bile of all animals contains either glycocholic or tauro- 
 cholic acid, or both. In herbivora, glycocholic acid is the more 
 important ; in carnivora, taurocholic acid. In man, glycocholic 
 acid is predominant ; taurocholic acid being frequently absent. 
 
 The bile salts may be prepared as follows in the form of 
 Platner's " Crystallised Bile." The bile is mixed with animal 
 charcoal, and evaporated to dryness in a water bath. When 
 completely dry, an extract is made with absolute alcohol. To 
 this extract anhydrous ether is added, and a white amorphous 
 precipitate forms, wdiich after a day or so shows masses of 
 crystals. These crystals are the salts of glycocholic and 
 taurocholic acids. 
 
 These two acids are recognised by means of Pettenkofer's 
 reaction. The solution supposed to contain the acid is freed 
 from albuminous matter, and a few drops of a strong solution 
 of cane sugar are added, and the mixture well shaken. Strong 
 sulphuric acid is added, drop by drop, and a purple colour is 
 developed. It has been shown that this reaction depends upon 
 the formation of furfurol, and Mylius modifies the test by 
 substituting a solution of furfurol for cane sugar. In connec- 
 tion with Pettenkofer's reaction, it must be remembered that 
 other substances besides bile salts give a somewhat similar 
 result with the reagents used in the test. To completely 
 
THE COMPOSITION OF THE BILE. ^i 
 
 identify the bile salts, it is necessary to confirm by means of 
 spectroscopic examination of the colour produced in the Petten- 
 kofer reaction. Two marked absorption bands occur if bile salts 
 are present, the centres of the bands corresponding to Xo27 and 
 X487. 
 
 With respect to the nature of these bodies, by decomposition 
 glycocholic acid yields cholalic acid and glycin (amido-acetic 
 acid), whilst taurocholic acid yields cholalic acid and taurin, this 
 latter being a sulphur-containing body. 
 
 The colouring matters of bile attracted attention for obvious 
 reasons earlier than the other constituents. In the commence- 
 ment of the present century, Gmelin pointed out the effect of 
 nitric acid in producing changes in the colour of bile. 
 
 To the pigment causing the orange or golden-yellow colour 
 of the bile of man and carnivorous' animals the name bilirubin 
 has been applied. It is also found in the blood serum of the 
 horse, in gall stones, and in old blood extravasation it exists as 
 microscopic crystals, to which the name of heematoidin was 
 applied by Virchow. Biliverdin imparts the green colour to the 
 bile of herbivorous animals, and it is presumably identical with 
 the green pigment obtained by the action of oxidising reagents 
 on bilirubin. 
 
 The presence of these pigments is usually ascertained by 
 means of nitric and nitrous acids (Gmelin's reaction). If such 
 acid be allowed to come into contact, avoiding mixing, with the 
 solution of the pigments, a series of colours will be seen. In 
 the case of bilirubin, zones of green, blue, violet, red, and reddish 
 yellow will be seen in order, the latter being nearest the acid. 
 To be certain that the pigment is really a bile pigment, the 
 whole series of colours must be seen, or the colour change 
 examined spectroscopically. The substances formed giving the 
 reddish yellow colour and constituting the last of the oxidation 
 changes, have applied to them the single name choletelin. 
 
 There are also certain chromogens existing in the bile of 
 some herbivora, which, under the influence of the decomposition 
 occurring when the bile is exposed to the air, yield pigments 
 with well-marked absorption spectra. Such a body is cholo- 
 hccmatin, obtained from the bile of oxen and sheep. 
 
 The mucinoid substance of bile demands a brief reference. In 
 the ox the so-called mucin is mainly nucleo-proteid ; in human bile 
 there is very little nucleo-proteid and a large amount of mucin. 
 
 3 
 
34 THE FUNCTIONS OF THE LIVER. 
 
 The cholesterin that occurs in bile may be looked upon as 
 the excess separated from the blood, which has arisen from 
 metabolic changes in nervous tissues. 
 
 Finally, as far as the composition of bile is concerned, it 
 must not be lost sight of that iron is a constant constituent. 
 
 The origin of the hile acid. — Glycin and taurin probably 
 arise from proteid metabolism in the body generally. Yet they 
 by no means represent the entire amount of the proteid decom- 
 position that occurs. An increase in the supply of proteid food 
 to an animal does not proportionately increase the nitrogen and 
 sulphur of the bile. The cholalic acid which unites with these 
 bodies is probably furnished by the liver cells, but the nature of 
 the process whereby this is brought about we are ignorant of. 
 We do not know why taurocholic acid is predominant in the 
 bile of one animal, whilst glycocholic is of greater importance in 
 another. It may, however, be pointed out that, agreeable to the 
 larger consumption of proteids in the carnivorous animal, we 
 have taurocholic acid which contains sulphur, as would naturally 
 be expected. Nevertheless, the glycin also is a product of 
 proteid decomposition. 
 
 The origin of the hile lyigments. — Virchow, about 1850, 
 pointed out the resemblance of the hcTmatoidin found by him in 
 old blood clots to the bile pigment. Precise experiments have 
 been performed often since then, all tending to prove the change 
 of blood pigments into bile pigments. Moreover, the formulae of 
 hfematin and bilirubin have a very close relationship, and 
 hamatin deprived of its iron (htematoporphyrin) is apparently 
 of the same percentage composition as bilirubin. 
 
 Amongst vertebrates, Amphioxus alone does not possess 
 red blood, and forms no bile-colouring matters. If the haemo- 
 globin becomes changed into bilirubin, the iron element must be 
 separated before bilirubin is formed. This is found to be the 
 case ; the liver cells contain iron in combination, and in excessive 
 destruction of red corpuscles the iron is present in large quantity 
 in the liver. 
 
 Tlic nature of jaundice. — We now look upon jaundice as 
 invarial)ly produced by causes wliich obstruct the outflow of bile, 
 or in some way n)odify the pressure under which it passes along 
 the bile ducts. The bile in tliese cases is partially reabsorbed by 
 the lymphatics, passed to the thoracic duct, and thence into the 
 blood. If the amount is such that the kidneys cannot secrete 
 
THE NATURE OF JAUNDICE. 35 
 
 it entirely, it is found staining the tissues and giving the 
 characteristic colour to the skin. That the bile is reabsorbed 
 from the bile ducts in this manner, is proved by simultaneously 
 ligaturing both the common bile duct and the thoracic duct. 
 It is then found that the bile pigments no longer colour the 
 urine, and no jaundice is obvious. 
 
 In earlier days it was thought that the liver acted rather as 
 a separator than as a producer of the bile. It was thought that 
 two forms of jaundice could occur, the jaundice from suppression 
 of the liver function in separating, and the jaundice from ob- 
 struction of the outflow of bile from the liver. But it has now 
 been conclusively proved that if the liver be extirpated, or 
 rendered functionless by isolation, no accumulation of biliary 
 constituents results. 
 
 From researches of Kiihne and others, about 1860, it was 
 thought that jaundice could have a double origin, that there 
 could be a hcematogenic as well as a hepatogenic jaundice. The 
 injection of blood pigments into the circulation caused at one 
 time the presence of haemoglobin in the urine, at another of 
 bilirubin. The latter resulted if a bile acid was simultaneously 
 injected. It was necessary to . see whether this change of 
 haemoglobin into bilirubrin really occurred in the blood. The 
 evidence adduced by many observers was, however, in favour of 
 the change occurring actually in the liver. The experiments of 
 Minkowski and Naunyn practically settled this question. In- 
 halation of arseniuretted hydrogen causes the appearance of 
 bile-colouring matters in the urine in ducks and geese. If the 
 liver were isolated by ligature, heemoglobin was found replacing 
 the bile pigment. In order that bile pigment should be pro- 
 duced, the haemoglobin set free in the blood by the action of 
 arseniuretted hydrogen must be acted on by the liver. If not 
 so acted on, it appears as simply blood pigment. All the 
 evidence, indeed, tends to indicate that there is no such 
 occurrence as hEematogenic jaundice. 
 
 The modificatio7i of tile in abnormal conditions. — After the 
 administration of certain drugs, phenylhydrazin, toluylenediamin, 
 pyrogallol, etc., oxyhsemaglobin may occur in the bile. This 
 seems to depend upon insufficient elimination by the kidneys. 
 In obstructed venous circulation, albumin may be found in the 
 bile. Sugar occurs in diabetes, urea is frequently found after 
 death in the bile, when Bright's disease or cholera have proved 
 
^6 THE FUNCTIONS OF THE LIVER. 
 
 fatal. Leucin and tyrosin have been found after death from 
 acute yellow atrophy. 
 
 In pyrexia the quantity of bile is diminished, and the bile 
 pigments may be so much diminished as to leave the bile 
 practically colourless. This has been noticed to occur during 
 that part of the day when the temperature was highest. 
 
 Occasionally a calculus may be impacted in the cystic duct, 
 and acting as a valve may permit of the exit but not of the 
 entrance of fluid into the gall bladder. A fluid may then be 
 passed from the gall bladder, which is colourless, highly viscous, 
 and of alkaline reaction. It is a secretion of the gall bladder. 
 A calculus may completely occlude the gall bladder, which then 
 becomes distended, sometimes enormously, by such a fluid, causing 
 the so-called dropsy of the gall bladder, or hydrops cystidis fellece. 
 We must not, however, regard this as a normal secretion of the 
 gall bladder. 
 
 Cholagogues. — It has been long known clinically that certain 
 drugs cause an increase in the amount of bile secreted. 
 Eutherford investigated this question very elaborately. He 
 found that many drugs might be classed as " hepatic stimulants." 
 Amongst the more powerful of these are sodium phosphate, 
 mercuric chloride, ipecacuanha, colchicum, jalap, aloes, colocynth, 
 sodium benzoate, and salicylate ; much feebler are rhubarb, nitro- 
 hydrochloric acid. Some investigators have denied that any 
 true cholao-ogic action is to be ascribed to these drugs. Positive 
 results have, however, been attained by Eosenberg, who said 
 that olive, oil, bile and sodium salicylate, were true cholagogues. 
 Santonin is also said to be of this character. The great flaw in 
 Eutherford's experiments, and in those of many others, lies in 
 the fact that the bile had been entirely diverted from the 
 intestinal canal, and thus the re-absorption of some of the con- 
 stituents which normally occurs was prevented, and thus an 
 abnormal condition of the animal ensued. 
 
 To whatever extent the secretion of the bile may be aflected 
 by the administration of certain drugs, there is no doubt tliat 
 the bile may act as a vehicle for the elimination of certain 
 metallic poisons. But as long as the hepatic membranes are 
 complete and impervious, probably even when the blood is 
 teeming with micro-organisms, none of these will pass into the 
 biliary secretion. 
 
 The (jlycogenic function of the liver. — There seems little 
 
THE FORMATION OF UREA IN THE IIVER. 37 
 
 doubt that a large proportion of the carbohydrate material 
 of food is not made use of immediately in the body, but 
 that, passing by the portal vessels to the liver as dextrose, 
 it is stored up in the hepatic cells as glycogen, to be 
 drawn upon as required by the animal. A hot-water extract, 
 made from the liver of an animal immediately after death, 
 contains a large quantity of glycogen ; similar extracts made 
 some hours after death contain no glycogen, but sugar. 
 Apparently, therefore, the glycogen is not in a stable condition, 
 but is easily changed in the body into sugar. 
 
 After much hard work, an animal is found to have but 
 a small amount of glycogen in its liver, unless at the same time 
 it is plentifully fed ; and this food need not necessarily be 
 carbohydrate, proteid food will also result in glycogen being 
 stored. We may say that the great weight of evidence is that 
 glycogen leaves the liver as sugar, though it is at the same time 
 possible that some proportion may pass out in other com- 
 binations. 
 
 The, formation of urea in the liver. — It is not possible to 
 trace the urea present in the urine, from any other important 
 source than the liver. It is probable that not only is the 
 excess of nitrogenous food passed out from the liver as urea, 
 but also that the nitrogenous waste derived from various parts 
 of the body receive, by the metabolic activity of the liver, a 
 final fashioning into urea. 
 
 If an excised liver have passed through it, under appropriate 
 conditions, ammonium carbonate, urea is formed. This is not 
 the case if it be passed through the kidney or the muscles. 
 
 If blood from an animal killed in digestion be passed 
 through the liver, urea is found, and this cannot be referred to 
 washing out urea from the liver. In acute yellow atrophy of 
 the liver, urea may be replaced by leucin and tyrosin in the 
 urine. 
 
 Though one cannot give the stages passed through by 
 proteids towards urea with any definiteness, yet there seems 
 little doubt that the changes that occur in this direction take 
 place largely in the liver. 
 
CHAPTER III. 
 
 JAUNDICE. 
 
 Jaundice is essentially a symptom of a disease or diseases, and is 
 not a disease itself. It occurs in the course of many hepatic 
 and biliary affections, as well as in diseases which primarily and 
 chiefly involve organs other than the liver and the biliary system. 
 Jaundice can be defined as a condition or state in which bile- 
 colouring matters are present in the urinary excretion, and the 
 conjunctivae, skin, and mucous membranes are stained a more or 
 less pronounced yellow, brownish yellow, or greenish yellow, by 
 the deposit in their tissues of the biliary pigments. 
 
 Pathology of jaundice. — According to the results of a number of 
 recent researches concerning the pathology of jaundice, it appears 
 to be quite clear that the symptom is due in every case to the 
 presence of an obstruction, partial or complete, to the flow of the 
 bile along the intra- or extra-hepatic bile ducts. It has already 
 been stated that the bile pigments are physiological derivatives 
 of the pigment of the blood, that is to say of hcemogiobin ; and by 
 some authorities it is said that the pigment of the blood can be 
 transformed into bile-colouring matter by organs other than the 
 liver. This being assumed, it was supposed that a ha?matogenous 
 variety of jaundice could be produced, owing to the formation of 
 the bile-colouring matter in some part of the circulatory system 
 from the blood pigment. This view of the pathology of jaundice 
 has been shown to be incorrect by the recent experiments of 
 Fleischl,! Kunkel,^ Kufferath,^' and Vaughan Harley.^ Thus it 
 has been demonstrated conclusively by these experimenters that 
 no jaundice results if the common bile duct and the thoracic 
 duct of an animal be simultaneously ligatured. The work of 
 
 ' Fleischl, Arh. a. d. physiol. Anst. zu Leij/ziff, 1874, s. 24. 
 
 -' Kuiikel, ihid., 1875, s. 112. 
 
 3 KutlVratli, Arch./. Physiol., Leipzig, 1880, s. 92. 
 
 ■• Vaughan Harley, ibid., 1893, s. 29. 
 
PATHOLOGY. 39 
 
 Vaughan Harley upon this subject has clearly shown that the 
 above view is the only correct one. Minkowski and Naunyn ^ 
 have isolated the liver in birds by the application of ligatures to 
 the hepatic vessels and duct, and they have afterwards examined 
 the blood of the animal experimented upon, but in no case have 
 they been able to demonstrate the existence of any of the biliary 
 pigments in the blood. The statement that the bile pigments 
 are formed only in the liver, is supported clinically by a case 
 which has been observed and recorded by Hanot and Gombault. 
 The patient was a man who suffered from a chronic peritonitis, 
 and in whom the common bile duct and the vessels in the portal 
 fissure were slowly and gradually obliterated, owing to the inflam- 
 matory process. The secretion of bile gradually diminished as 
 the obstruction to the circulation increased, until finally the 
 production of bile pigment ceased. From these considerations 
 it appears to be certain that the mechanism of the production of 
 jaundice is as follows : an obstruction arises which impedes, re- 
 tards, or arrests the flow of bile along some portion of the biliary 
 ducts, and as a result the bile is secreted at a higher pressure 
 than normal. Next, the bile passes from the intra-hepatic bile 
 vessels into the small lymphatic vessels which lie in the im- 
 mediate neighbourhood of the bile capillaries, whence it is carried 
 into the larger lymphatic channels in the liver, and from these 
 into the thoracic duct and the general blood system. By the 
 blood stream the colouring matter is carried to the tissues of the 
 body generally ; when it reaches the kidneys part of it is ex- 
 creted by these organs and hence it is voided in the urine, whilst 
 a portion is deposited in the tissues, this deposit occurring first 
 in the conjunctivae and next in the skin. The first signs of 
 jaundice are the presence of bile pigments in the urine, next 
 pigmentation of the conjunctiva and skin, and last of all deposit 
 of pigment in the tissues generally. White fibrous tissue appears 
 to be the commonest tissue to be stained, whilst the teeth, hair, 
 cartilage, and the central nervous system do not become a seat 
 of the deposit of the pigment. Exudations from serous surfaces, 
 such as ascitic fluid and the fluid which is found in the peri- 
 toneum, pleura, and arachnoid, are usually stained with the bile 
 pigment. The physiological secretions of the salivary and lach- 
 rymal glands do not contain any bile-colouring matter during an 
 
 1 Minkowski and Naunyn, Arch. f. exper. Path. u. PharmakoL, Leipzig, Bd. xxi. 
 s. 1 et seq. 
 
40 J A UNDICE. 
 
 attack of jaundice. The secretion of the mammary gland 
 during lactation may be stained yellow, owing to the presence 
 of bile pigments ; this, however, is not constant, and it has only 
 occasionally been observed. The secretion of the sweat glands 
 becomes stained with the pigments during an attack of jaundice. 
 In order to allow the development of jaundice as a result of 
 biliary obstruction, it is requisite that the hepatic cells should 
 by their activity produce bile which contains the ordinary 
 pigments. 
 
 Causes of jaundice. — The morbid processes which may be the 
 cause of an attack of jaundice are rather numerous. They act 
 directly in some cases and in others indirectly, but in all it will 
 be found that a condition of obstruction to the flow of bile along 
 the ducts has been induced. These morbid processes may affect 
 the lumen of the biliary channel alone, or they involve the tissues 
 which form its walls, or they may be seated for the most part in 
 the anatomical structures which lie in the immediate neighbour- 
 hood of the ducts. In the first group we shall include gall stones, 
 parasites, and foreign bodies, which have gained an entrance into 
 the bile channels. When a gall stone is the cause, it will usually 
 be found to have become impacted in some part of the common 
 bile duct, or in the common hepatic duct. In the majority of 
 cases gall stones take their origin in the gall bladder, and as long 
 as they remain in this sac they do not produce biliary obstruction, 
 except under exceptional conditions, to which we shall refer later. 
 When they are expelled from the gall bladder, they pass along 
 the cystic duct, and thence into the common bile duct. The 
 stone may be arrested in some portion of the cystic duct, and 
 when this occurs it may or may not result in jaundice, according 
 to the amount of interference which is produced in the flow of 
 the bile along the common bile duct. The flow of bile along the 
 common bile duct is not usually affected in these cases. When 
 the calculus has passed into the common bile duct, it may either 
 pass along this canal into the duodenum, or it may be arrested 
 in some part of its course. The most common place for it to be 
 arrested is the portion of the duct immediately above its entrance 
 into the duodenum, since at this point the lumen of the duct is 
 narrower than at any other part. It is not, however, uncommon 
 to find the calculus arrested at other points, especially in the 
 gastro-hepatic omentum. In rare cases, the calculus, after it has 
 passed from the cystic duct into the common bile duct, slips 
 
CAUSES. 41 
 
 backwards along the common hepatic duct and is arrested in 
 some part of this canal. When a calculus has Ijeen arrested, 
 either in the common hepatic duct or the common bile duct, it 
 usually produces complete obstruction to the flow of Ijile. This 
 is effected partially by the mechanical obstruction of the calculus 
 itself, and partially by the swelling of the mucous lining of the 
 duct, owing to the irritation of the calculus. If a calculus 
 remains impacted at the same spot for a considerable period, it 
 commonly sets up a condition of local ulceration, which ulcera- 
 tion may at a later stage, when the calculus has passed into the 
 intestinal canal, be followed by cicatrisation and subsequent 
 narrowing or closure of the lumen of the duct. An attack of 
 jaundice which is due to gall stones, is usually sudden in its 
 onset, and is preceded by one or more attacks of biliary colic. 
 Parasites are an occasional cause of jaundice. Distomata, 
 ascarides, and echinococcus cysts have been met with in the 
 bile ducts as causes of obstruction. Distomata usually inhabit the 
 portal vein as it lies within the liver, but they have been known 
 to work their way through the walls of this vessel and gain an 
 entrance into one of the large bile ducts, and so become a cause 
 of mechanical obstruction to the passage of bile. Cases have 
 been recorded in which ascarides have passed from the intestine 
 through the aperture of the common bile duct (where it opens 
 into the duodenum), into the lumen of the common bile duct, and 
 there, becoming coiled up, they have produced sudden and com- 
 plete obstruction, which has been followed by an attack of 
 jaundice. It is very uncommon for round worms to become 
 impacted in this manner. When the liver is the seat of a 
 hydatid cyst, it occasionally happens that this cyst ruptures, and 
 one or more of the daughter cysts pass into one of the intra- 
 hepatic bile ducts and then pass along into the common bile duct, 
 where they become rolled up and cause mechanical obstruction. 
 As the cyst passes along the bile duct it gives rise to an attack 
 of biliary colic, which resembles that which is due to the passage 
 of a gall stone. Foreign bodies, such as the seeds of fruit, have 
 been known to pass from the duodenum into the common bile 
 duct, and there they have become impacted, causing obstruction 
 to the passage of bile into the duodenum. 
 
 In the second group of the pathological causes of jaundice, 
 are iiieluded those morbid processes which involve the tissues 
 forming the walls of the ducts themselves. The commonest is 
 
42 J A UNDICE. 
 
 an inflammatory condition of the mucous membrane which lines 
 the internal surface of the ducts. In the majority of cases the 
 inflammatory process spreads by direct continuity from the 
 mucous membrane of the duodenum, and it is often associated 
 with a gastro-intestinal catarrh. The inflammation is either 
 catarrhal or suppurative, usually the former. The inflammatory 
 process causes a swelling of the mucous membrane, which may 
 be so extensive as to obliterate the lumen of the biliary canal, 
 and hence induce jaundice by obstruction. This condition is one 
 of the common causes of jaundice, both in adults and in infants. 
 Stenosis of some portion of the common bile duct or common 
 hepatic duct, may be a cause of jaundice. The stenosis may 
 be either congenital or acquired in its origin. When it is con- 
 genital there may be complete obliteration of a portion of the com- 
 mon bile duct or the common hepatic duct. Most commonly that 
 part immediately above the duodenum is not patent. The 
 difierent varieties of congenital closure of the bile ducts are 
 described in the chapter upon malformations. When the 
 stenosis is of acquired origin it is most commonly due to the con- 
 traction of a scar which has been left by a previous condition 
 of ulceration. The ulcer in some cases is caused by the 
 irritation of a calculus which has been lodged there, or it may 
 follow a purulent catarrhal condition of the mucous membrane, 
 or it may be the result of syphilis, a gumma having developed 
 in the wall of the bile canal, and healed leaving a fibrous scar. 
 Tumours may grow from the tissues which form the walls of 
 the ducts, and when these extend in an inward direction they 
 obliterate, partially or completely, the lumen of the affected 
 portion of the duct. These tumours may be innocent or 
 malignant in nature. Among the innocent ones, fibromata, 
 lipomata, papillomata, and gummata have been met with. These 
 innocent grov/ths are, however, exceedingly rare. The malignant 
 formations are either carcinomata or sarcomata, the former 
 being the more common. Jaundice, which is due to the presence 
 of a tumour, is usually gradual in its onset, and persists. 
 
 The third group comprises a number of very different morbid 
 conditions. Chronic inflammatory processes which are located in 
 the neighbourhood of the bile ducts, may extend and involve 
 them, giving rise to the formation of cicatricial tissue, which 
 will contract and so cause diminution in the size of the lumen 
 of the biliary canal, and by this means bring about a biliary 
 
CA USES, 43 
 
 obstruction. Duodenal or gastric ulcers which have perforated 
 the walls of the alimentary canal, and set up a localised peri- 
 hepatitis, may be the cause of the production of scar tissue, 
 which at a later period contracts and causes an obstruction to 
 the flow of bile. A duodenal ulcer, which involves the mucous 
 membrane in the immediate neighbourhood of the opening of 
 the common bile duct into the intestines, may heal, and the scar 
 which results contract and cause stenosis of the biliary canal as 
 it passes through the wall of the duodenum. An inflammatory 
 process around the portal vein as it lies in the gastro-hepatic 
 omentum, or in the portal fissure, is liable to be followed by the 
 formation of scar tissue, which may cause narrowing of the 
 adjacent portion of the bile ducts, and in this manner set up 
 jaundice owing to the establishment of an obstruction to the 
 bile stream. Hydatid cysts of the liver or hepatic region can, 
 by direct pressure, obliterate the lumen of the bile ducts, either 
 partially or completely, and thus cause biliary obstruction. In 
 a similar manner an aneurism of the hepatic artery, of the 
 neighbouring portion of the abdominal aorta, or of the superior 
 mesenteric artery, may by pressure from without establish 
 biliary obstruction and cause subsequent jaundice. Tumours, 
 such as carcinomata of the gall bladder, duodenum, and the head of 
 the pancreas, frequently involve the common bile duct by a direct 
 extension of the morbid process, and cause partial or complete oblit- 
 eration of its canal, jaundice following as a result of this obstruc- 
 tion. In rarer cases, malignant growths, which may be primary or 
 secondary, of the colon, kidneys (especially the right),uterus, ovaries, 
 omentum, mesentery, or portal lymphatic glands, are the cause of 
 biliary obstruction, owing to pressure from without. 
 
 The intra-hepatic affections which cause obstruction to the flow 
 of bile along the bile ducts within the liver may be divided into 
 three groups, in the same manner as the extra-hepatic affections. 
 Thus intra-hepatic calculi, which may have been formed originally 
 within the liver, or which have migrated from the gall bladder 
 into an intra-hepatic bile duct, can cause obstruction, whilst 
 a distoma or a mass of inspissated bile may act in a similar 
 manner. Jaundice from these causes is not very common, since 
 only one of the smaller ducts is involved, and this is not 
 sufficient in most cases to set up this condition. The mucous 
 membrane which lines the internal surface of the bile ducts 
 within the liver may be the seat of a catarrhal or suppurative 
 
44 J A UNDICE. 
 
 inflammatory affection, which is due to the extension of a 
 similar process from the extra-hepatic ducts. This affection 
 results in the development of a catarrhal jaundice, but it only 
 occurs in association with a like condition of the larger ducts 
 outside the liver. Inflammatory processes in the interior of 
 the liver, which are either interstitial, parenchymatous, syphilitic, 
 tubercular, or suppurative, by exerting pressure upon the bile 
 ducts from without, can produce an obstruction to the free flow 
 of bile, and in this manner may be the cause of an attack of 
 jaundice. In a like manner, new growths, as carcinomata and 
 sarcomata, can give rise to jaundice, but these cases are not very 
 common. 
 
 The sym'ptom8 of jaundice. — At a very early period after 
 the obstruction to the free flow of bile along the biliary 
 ducts has been established, the urine becomes darker in colour 
 than is usual, owing to the presence of bile pigment. Pigment is 
 said to be present after the expiration of three hours, if the 
 common bile duct of a dog is ligatured. AVickham Legg '^ made 
 a similar experiment on cats, and found that a much longer 
 time was required before there were distinct signs of pigment in 
 the urine. He says that a pigment is very often present in 
 the urme of dogs under quite normal conditions, which it is 
 impossible to distinguish from bilirubin, by Gmelin's test ; 
 and on these grounds he throws doubts on the statement that 
 the pigment appears in the urine at the end of three hours. 
 In man it is not possible to say how soon the pigment appears 
 in the urine, after obstruction has taken place. Clinically, the 
 presence of bile pigments — that is to say, bilirubin in the urine — 
 is sought for by the application of Gmelin's test. In applying 
 this, a plate of white porcelain is taken, and upon it a small 
 quantity of the suspected urine is placed, and to it is added a 
 few drops of fuming nitric acid (nitric and nitrous acids mixed) ; 
 if any bilirubin is present, a play of colours is produced where 
 the liquids come into contact. Another test for bile pigments, 
 which is easy of application, is Marechal's test. A mixture of 
 tincture of iodine and alcohol, in the proportion of one part of 
 the former to ten of the latter, is added to the urine which is 
 supposed to contain bile, and if any bile pigments are present a 
 greenish-coloured ring will be seen where the two liquids come 
 into contact. After the urine, the conjunctiva.* next become 
 
 1 Wickliam Legg, "Bile, Jaundice, aud Bilious Diseases," 1880. 
 
SYMPTOMS. 45 
 
 stained with the bile pigment. This coloration apparently conies 
 on within twenty-four to forty-eight hours after the obstruction 
 has commenced. In man, however, it is very difficult to say 
 when the obstruction does commence. This coloration is 
 usually the first symptom of jaundice which is noticed by the 
 patient or his friends. The skin is the next tissue which 
 becomes stained, the coloration usually commencing in the face 
 and extending thence to the neck ; afterwards, the upper 
 extremities and upper portion of the trunk are stained ; and, 
 lastly, the lower portion of the trunk and the lower extremities. 
 This staining of the skin is more apparent, especially in the 
 early stages, when the amount of coloration is slight, in people 
 of light or fair complexions, whilst in dark people there may be 
 some difficulty in distinguishing it from the normal colour of the 
 skin. The staining in the early stages is nothing more than a 
 slight yellow colour, but as the pigmentation deepens the tint 
 becomes much darker, and in advanced cases it may be bronze 
 or almost green. When the pigmentation is very dark, the term 
 " black jaundice " is sometimes applied to these cases. In the 
 majority of cases it will be found that the jaundice involves the 
 whole surface of the body, and that the depth of the pigmenta- 
 tion does not vary in different parts. It occasionally happens 
 in slight cases, or in the early stages of an attack, that the upper 
 half of the body is alone pigmented. Cases have been described 
 in which the right or left half of the body has been alone 
 affected. I have not seen a case of this kind, and there does not 
 appear to be any record of any such case having been seen 
 during recent years. On this account it is very probable that 
 the older observers who described these cases were wrong in 
 their diagnosis. The mucous membranes become coloured owing 
 to a deposit of pigment. This is not at first apparent, but if 
 pressure be made on the part so as to drive out the blood, the 
 yellow tint will come visible. As has been mentioned, the 
 secretions of the mucous and serous glands, and the secretion of 
 the mammary gland, do not usually contain the pigments of the 
 bile during an attack of jaundice. In rare cases the secretion 
 of the salivary glands has contained a considerable amount of 
 bile pigment. This appears, from the cases which have been 
 recorded, to have occurred nearly always in patients who were 
 taking a preparation of mercury, and often in patients who were 
 salivated. The connection between the administration of 
 
46 JAUNDICE. 
 
 mercury and the excretion of pigment in this manner is not 
 clear. The secretions of the glands which open into the 
 alimentary canal (other than the liver) do not appear to contain 
 any bile pigment, as the faeces in cases of jaundice do not con- 
 tain any bile-colouring matter. The normal fluids which are found 
 as secretions, or rather exudations, in the serous cavities, are, in all 
 cases of jaundice, coloured with the bile pigment, and patho- 
 logical exudations into these same cavities are coloured in a 
 similar manner. 
 
 The urine. — -In addition to the presence of bilirubin, the 
 urine contains in many cases of jaundice the bile acids. In 
 order to detect their presence, it is necessary to separate them 
 from the urine before applying chemical tests which demonstrate 
 their existence. The bile acids are separated from urine by first 
 evaporating it to dryness over a water-bath, and then extracting 
 the residue with absolute alcohol, to which extract is added an 
 excess of ether, when the bile acids are precipitated as crystals. 
 These crystals must be decolorised with charcoal, and then a 
 small amount of the crystalline salt is dissolved in water, and 
 to it Pettenkofer's test is applied. This consists in placing a 
 little of the fluid containing the crystals upon a white porcelain 
 plate, and adding to it a drop of a solution of cane sugar and 
 then some sulphuric acid. If there are any bile salts present, 
 a rich purple colour will appear. It is not sufficient to apply 
 this to urine alone, as there are other substances in urine which 
 give the same reaction, and if they are present in considerable 
 quantity no reliable reaction will be obtained. Bile acids are said 
 to lower the surface tension of any liquid in which they are placed, 
 and if flowers of sulphur are added the powder at once sinks to 
 the bottom, which does not occur in the absence of acids (Hay). 
 If both Pettenkofer's and Hay's tests are applied to a specimen 
 of urine, and both give characteristic results, the urine in all 
 probability can be said to contain bile acids. As, however, the 
 bile acids are present in most cases in such small quantities, 
 Pettenkofer's test will not often be of value. In some cases of 
 jaundice the bile pigments in the urine undergo a process of 
 oxidation, in which case they cause a yellow coloration of the 
 fluid, but they do not give Gmelin's test. Some observers assert 
 that a small quantity of the bile acids is present normally in 
 urine, but this appears to be very doubtful. Golowin in man 
 and animals, and Pye Smith in man, have been unable to detect 
 
THE F^CES. 47 
 
 the presence of bile acids in the later stages of obstructive 
 jaundice, and they think that bile acids are not formed by the 
 liver in the later stages of jaundice. The amount of urea which 
 is excreted with the urine has been found to vary within very 
 wide limits in cases of jaundice. There does not seem to be 
 any direct connection between an attack of jaundice and the 
 amount of urea which is produced within the body. The quantity 
 of chlorides varies in a similar manner to that of the urea. 
 Leucin and tyrosin are only found in the urine in those cases of 
 jaundice which are due to acute yellow atrophy. 
 
 Tlu Fceces. — When no bile passes into the alimentary canal, 
 the fteces become pale or even white in colour, and generally 
 they are less consistent. In some cases they are said to be more 
 consistent, but in my experience this does not appear to be true ; 
 Wickham Legg has had the same experience. Occasionally the 
 fseces are coloured in one part and not in another, an appearance 
 which is probably due to small quantities of bile passing into 
 the intestinal canal, owing to the obstruction not being continuous 
 or complete. In some cases of jaundice the faeces apparently 
 retain their normal colour. This is due in most cases to the 
 administration of drugs or to the passage of blood into the 
 alimentary canal. In other cases it may be due to the passage 
 of a small quantity of bile into the intestine, in those cases where 
 the obstruction is not complete, although it is sufficient to cause 
 the development of jaundice. The faeces in jaundice usually 
 contain an excess of fat, which is due to the non-absorption of 
 the fat which is taken in along with the food. The want of 
 colour of the faeces is said to be due to the absence of stercorin, 
 a substance which is present in normal human faeces and which 
 is apparently a derivative from cholesterin. When the jaundice 
 is due to a catarrhal condition of the bile ducts, it is, as we have 
 seen, often associated with a similar condition of the upper 
 portion of the intestinal canal, and in these cases there is usually 
 diarrhoea, or attacks of diarrhoea alternating with constipation. 
 In chronic jaundice constipation is present in a certain per- 
 centage of cases, but in many cases there is persistent diarrhoea 
 or alternating diarrhoea and constipation. In one case, which 
 I had recently under my care, there was persistent diarrhoea, 
 which resisted most measures for its relief. The stools in cases 
 of jaundice usually have a very strong putrid or offensive odour. 
 The digestive processes in many patients are not impaired, but 
 
48 J A UNDICE. 
 
 in those in whom the jaundice has been induced by a catarrhal 
 condition spreading from the intestinal mucous membrane, digest- 
 ive troubles are commonly met with. Patients generally dislike 
 fatty food when they are the subjects of an attack of jaundice. 
 Flatulence and abdominal colicky pains may be present during 
 the course of an attack, but they are not common. The rate 
 of the pulse is often found to be diminished in the course 
 of the affection ; it will usually be found to be from forty 
 to sixty per minute, but in rare cases it may be only twenty. 
 This is said by Wickham Legg to be due to the action of the 
 bile acids upon the cardiac ganglia. The temperature in many 
 cases is raised, its course resembling that in an attack of malaria. 
 We shall deal with the temperature in detail later. When the 
 temperature is raised the pulse rate is increased in frequency, 
 but not to so great an extent as under similar conditions without 
 jaundice. The respiration is usually unaffected, but in a few 
 cases hiccup has been met with. 
 
 It has been said that a bitter taste in the mouth is a 
 frequent symptom of jaundice, and that this is due to the 
 excretion of the bile acids in the saliva. This symptom appears 
 to be present very rarely, and I have not met with a case 
 in which it was present. Xanthopsia, or yellow-coloured vision, 
 used to be looked upon as a constant symptom in an attack 
 of jaundice. This may have been so in former times, but at the 
 present time it is undoubtedly a very rare phenomenon. Wick- 
 ham Legg relates three cases in which he found this symptom, 
 whilst Frerichs says that he has never met with such a case. 
 White substances alone are in the majority of cases seen yellow, 
 but all things may appear to have a yellow tinge. The symptom, 
 when present, usually comes on in the later stages of chronic 
 jaundice, and only lasts for a short time, not more than two or 
 three days at the most. The pathology of this symptom is not 
 known. 
 
 Xanthelasma. — When an attack of jaundice has persisted for 
 a considerable period, it is not uncommon to find, from six to 
 twelve months after the commencement of the attack, that spots 
 of xanthelasma develop. These commence usually on the skin 
 of the eyelids, and later they may affect other parts. The 
 affection is characterised by the formation of small, rounded, or 
 oval patches, resembling pieces of wash-leather implanted in the 
 skin. This condition seems to be due to the growth in the 
 
XANTHELASMA. 49 
 
 affected part of connective tissue cells, which afterwards undergo 
 fatty degeneration. There are two chief varieties of the disease, 
 the plane and the tuberous. The plane variety involves chiefly the 
 eyelids, but it may be found in other parts, — as, the skin of the 
 face and ears, and sometimes upon the mucous membrane of the 
 mouth. In one case which I saw some time ago, both eyelids 
 were affected, and there were a few patches about the shoulder. 
 The patient was a woman about fifty, who had been jaundiced 
 for a long time. The tuberous variety takes the form of small 
 soft tuberous swellings, which may be grouped together, and are 
 found about the body often around the anus and in the neigh- 
 bourhood of the genitals. Most cases occur in association with 
 chronic jaundice, but this is not invariable, and occasionally the 
 affection appears to be congenital. Itching of the skin is 
 a not unfrequent symptom of jaundice, and when present it 
 may be very troublesome. It is said to be caused by the 
 presence of bile pigments, which act as irritants, but others 
 maintain that it is the bile acids which are the cause of this 
 symptom. 
 
 Drowsiness is an occasional symptom, and a condition of slight 
 lethargy is said to be common. Patients who are the subjects 
 of jaundice do not commonly suffer from sleeplessness, except 
 when itching of the skin is present, or during attacks of pain, 
 such as those due to the passage of a gall stone. In a certain 
 number of cases of chronic jaundice, and occasionally in very 
 acute cases, haemorrhages are liable to occur. They may be 
 subcutaneous, from the mucous membranes or into the tissues. 
 In the chronic form they come on usually towards the end 
 of the affection, that is, shortly before the fatal termination. 
 Petechiae in the skin are not uncommon, but probably the 
 commonest seat of the haemorrhage is from the mucous mem- 
 brane of the nose, which results in epistaxis. Haemorrhages 
 into the stomach, or some part of the intestinal canal, are 
 common. Haematuria, owing to haBmorrhage from the kidney, is 
 not very common. Almost any part of the body may be the seat 
 of haemorrhage in jaundice, but those mentioned above are the 
 most frequent. The cause of the ha?morrhage is not very clear. 
 Some have suggested that it is due to the presence of bile acids, 
 in the blood ; but if this were the case we should expect to have 
 frequent haematuria, such as takes place when a quantity of bile 
 acids is injected into the circulation. Possibly it may be induced 
 4 
 
50 J A UNDICE. 
 
 by a diseased condition of the blood vessels, as the arteries have 
 been found to be atheromatous in some cases. 
 
 In all cases of jaundice which go on for some time, there is 
 gradual wasting of the tissues, with accompanying weakness. 
 The cause of the wasting which takes place when the bile ducts 
 are obstructed, has been said by Wickham Legg ^ to be due to 
 the alteration of the glycogenic function of the liver. There are, 
 however, a certain number of cases of jaundice which last for a 
 long time without the patient losing weight or being incon- 
 venienced in any way beyond the pigmentation of the skin. 
 
 1 Wickliam Legg, op. cit. 
 
CHAPTER ly. 
 
 THE DIAGNOSIS OF DISEASES OF THE LIVER AND 
 BILIARY SYSTEM. 
 
 The diagnosis of many of the diseases of the liver and biliaiy 
 system often requires a very careful examination of the patient, 
 together with a knowledge of the exact history of the different 
 stages of the affection, as they have manifested themselves in the 
 individual case which is under consideration. 
 
 Previous history. — A history of the previous illnesses and 
 diseases from which a patient has suffered, as well as an account 
 of the time and manner of development of the different signs 
 and symptoms which are met with during the course of an 
 examination, often give important indications in the diagnosis of 
 the nature and complications of a case of biliary or hepatic 
 disease. Thus the previous occurrence of an attack of dysentery 
 or of ulceration of the rectum, or of septic affection of any of the 
 abdominal viscera, will be of value when a supposed case of 
 hepatic abscess is under consideration; whilst the occurrence 
 of attacks of pain which were most intense in the right 
 hypochondriac region, of jaundice, or the passage of gall stones 
 per anum, are facts of great importance in the diagnosis of the 
 existence of biliary calculi. The exact sequence of the symptoms 
 of the present affection should also be carefully inquired into, as 
 not uncommonly important facts are elicited in this way. 
 
 Sex. — The sex of the patient is of importance when we 
 are dealing with supposed cases of either gall stones or carcinoma 
 of the gall bladder, since in these affections women are found to 
 be much more commonly afflicted than the opposite sex. 
 
 Age. — Hepatic or biliary diseases are extremely rare in 
 young people of either sex, and it is found that the majority 
 of cases occur in people who are over forty ; but certain classes of 
 disease, such as hydatid cysts, abscesses, and jaundice which 
 is due to catarrhal conditions of the mucous membrane of the 
 
52 DIAGNOSIS OF DISEASES OF THE IIVER, ETC. 
 
 bile ducts, or to the presence of round worms in these ducts, 
 may occur in people of all ages, whilst those affections which are 
 dependent upon or due to imperfect or abnormal development, 
 are met with at birth, or soon afterwards. Traumatic affections 
 may occur in children, but they are far more commonly met 
 with in adults. 
 
 Climate. — Hepatic abscesses, that is to say, the tropical 
 variety or those which are due to dysentery, are much more 
 frequently seen in persons who have lived in trox3ical countries, 
 and they are especially liable to develop in those people who 
 have had an attack of dysentery at some former date. Con- 
 gestive affections of the liver also are more common in hot 
 climates. G-all stones appear to be met with more frequently in 
 some countries than in others. 
 
 Suhjedive symptoms. — Symptoms of a gastro-intestinal dis- 
 turbance are in many cases either directly associated with, or are 
 the precursors of, an attack of hepatic or biliary disease. Thus 
 it not uncommonly happens that a series of symptoms, due 
 to the existence of a gastro-intestinal catarrh, precedes the 
 development of an attack of jaundice which is due to an 
 inflammatory and catarrhal condition of the mucous membrane 
 of the bile ducts, which has spread by direct continuity from the 
 duodenum to the mucous lining of the common bile duct, and 
 from this to the other bile ducts. In a similar manner, an 
 empyema of the gall bladder may be directly caused by an 
 extension of a septic inflammatory process from the mucous 
 lining of the intestine ; and this condition will also in most cases 
 be preceded by the occurrence of symptoms of gastro-intestinal 
 disturbance. The presence of gall stones in the gall bladder, or 
 in one of the bile ducts, may be associated with a series of 
 symptoms which are due to chronic lithiemia. Symptoms of 
 toxaemia may become manifest in cases of acute yellow atrophy, 
 in advanced cirrhosis, and in the later stages of carcinomatous 
 disease of the gland, owing to the fact that the liver cells are 
 unable to perform their normal physiological functions, and 
 destroy or convert into innocuous compounds the various toxines, 
 ptomaines, and leucomaines which have been absorbed from the 
 alimentary canal, or have been produced in the tissues of the 
 body generally, as the result of normal or pathological processes. 
 
 Pain is a frequent symptom of hepatic and biliary disease, 
 and it varies in severity and nature according to the character of 
 
SUBJECTIVE SYMPTOMS. 53 
 
 the pathological condition which is the cause of its appearance. 
 A dull, heavy pain, or feeling of uneasiness and fulness, in 
 the right hypochondriac region, is very common, and when 
 present is often associated with pain which is referred to the 
 inferior angle of the right scapula. This variety of pain is 
 met with in cases of congestion of the liver, in abscesses which 
 have not extended to the surface, and in some patients who 
 suffer from gall stones. The referred pain in the region of the 
 right scapula may extend across the spine to the inferior 
 scapular region of the opposite side. Continuous severe pain 
 in some portion of the hepatic area, which is increased on 
 pressure and accompanied by localised tenderness, is usually met 
 with in cases of perihepatitis. This may be due to the existence 
 of a localised peritonitis, in connection with the surface of the 
 liver, or to the presence of an abscess which has extended to the 
 surface. A shoulder-tip pain may occur in these cases, and 
 when it is met with it indicates that the inflammatory process 
 has extended to the upper surface of the liver and the inferior 
 aspect of the diaphragm, and has irritated the branches of the 
 phrenic nerve. The pain of perihepatitis is usually sudden in 
 its onset, and accentuated by local pressure or by movements. 
 Stabbing, darting, and lancinating pains in the hepatic region are 
 often associated with the existence of cancer of the liver. 
 Acute pain in the right hypochondriac region, usually opposite 
 the cartilages of the seventh, eighth, and ninth ribs, which 
 occurs in paroxysms, and may last for several minutes or even 
 hours, denotes the existence of gall stones, one or more of which 
 has passed into the cystic duct. This calculus may pass back- 
 wards into the gall bladder, or onwards into the common bile 
 duct, in which case the pain will cease for a time, but will 
 return when the stone reaches the orifice of the bile duct into the 
 duodenum, or when the same or another calculus passes into the 
 cystic duct. In these cases the pain may be very severe, so as 
 to cause the appearance of a certain amount of collapse and 
 shock, and occasionally it has been known to cause death, in 
 which case a calculus has been found to be partially extruded 
 from the orifice of the common bile duct, where it opens into the 
 second portion of the duodenum. These paroxysms of pain are 
 known as biliary or hepatic colic. When an attack of severe 
 abdominal pain comes on suddenly, commences in the right 
 hypochondriac region, and from there extends to other parts of 
 
54 DIAGNOSIS OF DISEASES OF THE IIVER, ETC. 
 
 the abdomen, and is accompanied by the development of shock, 
 collapse, and other signs of acute peritonitis, rupture of the gall 
 bladder, one of the bile ducts, a hepatic abscess, or hydatid cyst, 
 may be suspected, especially when there have been symptoms 
 which connect the affection with the region of the liver. When 
 patients are being examined, who are the subjects of pain in the 
 region of the liver, it must be remembered that pleurisy and 
 basal pneumonia may give rise to the appearance of symptoms 
 which simulate hepatic affections. 
 
 Objective symptoms. — In dealing with all cases of diseases of 
 the liver or the biliary system, a careful physical examination 
 should be made in every case. 
 
 (1) Inspection or adspection. — The superficial veins in 
 the subcutaneous tissues which overlie the hepatic region 
 and adjacent parts of the abdominal wall may be seen 
 to be enlarged and dilated, in which case the existence 
 of an obstruction to the free flow of blood through the portal 
 vein or the inferior vena cava will be indicated. This symptom 
 is often met with in patients suffering from advanced alcoholic 
 cirrhosis of the liver. Jaundice is a frequent symptom in both 
 hepatic and biliary disease ; but, owing to its great importance, 
 it is considered in a separate chapter. A localised swelling or 
 prominence may be evident in some portion of the hepatic area, 
 and cause a projection of the upper part of the abdominal wall, 
 or the lower portion of the thorax. This condition has been met 
 with in hydatid disease of the liver, in cases of hepatic abscess, 
 in cancer of the liver, and also in enlargements of the liver which 
 are due to fatty, amyloid, or syphilitic disease. When the gall 
 bladder is very much enlarged or distended, it may give rise to 
 the appearance of a prominence which extends downwards for a 
 variable distance below the costal margin, reaching beyond the 
 umbilicus, and even as low as Poupart's ligament. Several 
 nodular prominences may be apparent externally in rare cases, 
 and when met with they usually indicate the presence of multiple 
 cancerous growths, or occasionally multiple cysts. Xanthelasma, 
 both the tuberous and flattened varieties, may be met with as a 
 concomitant of hepatic disease, especially in those cases in which 
 jaundice has existed for a long time. 
 
 (2) Fcdpation. — When the surgeon examines the hepatic 
 region, the patient should be instructed to lie in the dorsal 
 position, with the thighs partially flexed, so as to relax the 
 
PALPATION. 55 
 
 abdominal muscles; the shoulders should be elevated, and 
 the breathing should be deep and quiet. The palmar surfaces 
 of the surgeon's fingers are then laid upon the skin of the 
 right hypochondriac region, a short distance below the costal 
 margin, with the finger-tips somewhat flexed, so that 
 they look upwards and towards the middle line of the 
 body. Firm but gentle pressure is then made during an inspira- 
 tion, and if the liver is enlarged it can be distinguished as it 
 passes downwards underneath the fingers. In children, in those 
 who have thin and lax abdominal walls, or in women who have 
 pendulous abdomens as the result of frequent child-bearing, the 
 lower margin of the liver can be felt in a state of health. In 
 some cases in which it is wished to palpate the liver, it may be 
 necessary and advisable to place the patient in a sitting posture, 
 with the trunk bent slightly forwards, so as to relax the 
 abdominal walls as much as possible. In this case the surgeon 
 stands a slight distance behind the right side of the patient, and 
 applies his hand and fingers as directed above, the finger-tips 
 being pressed well inwards. The liver may then be felt to 
 descend during deep inspiration, and the shape and form of its 
 lower and anterior portions can be made out. When the 
 abdomen is distended with ascitic fluid, or by intestines dilated 
 with gas, the tips of the fingers should be suddenly pressed 
 downwards into the hepatic region, and the liver, if it is enlarged, 
 may then be felt as a solid resisting body, after the fluid or the 
 distended intestines have been pushed to one side. Palpation 
 over the surface of a swelling which lies in close relation to the 
 posterior aspect of the abdominal wall, may detect the presence 
 of fluctuation, in which case the existence of an abscess or a fluid- 
 containing cyst, such as a hydatid, will be suggested. When the 
 liver is the seat of much enlargement, the characters of this 
 enlargement can usually be made out by a careful palpation. 
 When the gall bladder is distended with bile or pus, or is 
 enlarged owing to the presence of large calculi or of a malignant 
 growth, it can be felt to protrude below the costal margin, 
 opposite the ninth costal cartilage of the right side. It is said 
 that a distended gall bladder tends to extend downwards in the 
 abdominal cavity, in a line directed towards the centre of 
 Poupart's ligament on the left side. This, however, is not the 
 invariable direction which an enlarged gall bladder takes, since 
 its course may be altered by the formation of adhesions, and by 
 
56 DIAGNOSIS OF DISEASES OF THE LIVER, ETC. 
 
 the weight of its contents. The enlargement of the liver may 
 be general or localised, and in the latter case there may be 
 several eminences or irregularities upon its surface. In all cases 
 of hepatic tumours and enlargements, movements which are 
 synchronous with those of respiration can be made out. The 
 movements of a displaced or of an enlarged liver can generally be 
 distinguished by careful palpation, especially in those patients 
 who have lax abdominal walls. It is found to be necessary to 
 anaesthetise the patient in some cases, in order to render the 
 abdominal walls flaccid, and enable the surgeon to detect those 
 signs which can be distinguished by palpation. In some cases 
 of perihepatitis it is possible to distinguish fremitus with the 
 palpating finger. 
 
 (3) Percussion. — The height to which the liver extends 
 upwards on the right side can be mapped out by per- 
 cussion, but on the left side of the body the liver dulness is 
 continuous with that which is due to the presence of the heart, 
 whilst the lower border of the organ in the abdomen can be 
 readily made out. Growths from, and enlargements of, the right 
 kidney may simulate hepatic enlargements ; but usually percus- 
 sion in the latter class of cases will succeed in defining an area 
 of resonance between the upper margin of a renal swelling and 
 the lower border of the liver, owing to the presence of the colon 
 in the groove between the tw^o viscera. In order to obtain this 
 resonance, or to prove its absence in those cases in which con- 
 siderable doubt exists, it may be requisite to distend the colon 
 with gas from the anus by the introduction of a tube into which 
 gas is pumped. 
 
 (4) Auscultation. — In the majority of cases of hepatic 
 tumours, auscultation is of very little service in assisting the 
 surgeon to make a diagnosis. Occasionally, however, friction 
 can be heard in the hepatic area, due either to a localised 
 perihepatitis, or to the bruits of a hepatic or an aortic aneurism. 
 This method of examination is of great value in those cases 
 of basal pneumonia of the lung which simulate affections of the 
 liver. 
 
 (5) ExjAoratory pitncturc with the needle of an aspirator. — 
 In many cases of a fluid swelling in connection with the liver or 
 the gall bladder, it is necessary to obtain some of the fluid 
 contents before it is possible to make an exact diagnosis of the 
 nature of the disease from which the patient is suffering. It is 
 
EXPLORATORY PUNCTURE. 57 
 
 not advisable, however, to adopt this method of examination in 
 a routine fashion, as it has been followed by fatal results in 
 several recorded cases. In those cases in which an abscess has 
 been proved to be present by aspiration with the needle of an 
 exploring syringe or an aspirator, the surgeon should always be 
 prepared to perform an operation for the evacuation of the pus, 
 since it is liable to leak into the peritoneum along the track of 
 the needle, and set up a general septic peritonitis. 
 
CHAPTER V. 
 
 MALFOEMATIONS. 
 
 Malformations of the liver and the biHary system are not 
 common, and they have only occasionally been observed. The 
 biliary ducts or the gall bladder are more frequently involved 
 than the liver itself. These affections may conveniently be 
 divided into two groups, according to their mode of origin, namely, 
 (a) those of congenital origin, and (b) those of acquired origin. 
 The liver is more often the seat of acquired than congenital 
 malformations, whilst in the biliary system congenital mal- 
 formations are more frequent than the acquired. These different 
 classes of deformities will be considered separately. 
 
 Congenital Malformations of the Liver. — The congenital 
 malformations of the liver are exceedingly rare, and do not call 
 for a detailed description, since, in the majority of cases, they do 
 not give rise to a definite train of symptoms by which their 
 presence can be recognised. The condition of hepatomphalos is, 
 however, of surgical importance, and will be described in more 
 detail. The existence of all the varieties of malformation ought 
 to be known to the surgeon ; as, in dealing w^ith obscure cases 
 of hepatic disease, a knowledge of these malformations may 
 materially assist in the establishment of a correct diagnosis, or, 
 at least, may aid in x^i'eventing errors. The most important 
 congenital malformations of the liver are the following, namely — 
 
 (1) Complete transposition of the wliole viscus, in which case 
 the large lobe of the gland is situated in the left hypocliondriac 
 region and the smaller lobe in the right hypochondrium. 
 When this condition of affairs obtains, it will, as a general rule, 
 be found that there is a transposition of the whole of the viscera, 
 the heart lying in the right side of the thoracic cavity, and the 
 spleen in the right hypochondrium. I have not met with any 
 cases, nor seen the records of any, in which this malformation of 
 the liver was not associated witli a transposition of the viscera. 
 
ACCESSORY LOBES. 59 
 
 This form of malformation of the hver is the most important 
 from the point of view of diagnosis. 
 
 (2) The, 'presence of accessory lohes. — This \^ariation is 
 occasionally met with during post-mortem examinations. The 
 lobes are usually very small, and situated upon or in co^nnection 
 with the inferior surface of the gland. In the post-mc^rtem 
 room of St. Bartholomew's Hospital I have several times seb^n 
 these accessory lobes, but in every case they have been small, 
 and not larger than a pea or small hazel-nut. In the museum 
 of the Hospital there is a drawing of a liver with a small 
 pedunculated lobe attached to the inferior surface of the right 
 lobe. I have occasionally observed the presence of additional 
 fissures upon the surface of the liver, especially in some part of 
 the right lobe, which have caused an appearance of accessory 
 lobes, bat in no case have these fissures completely separated 
 a portion of the gland. Dickinson ^ has described the liver 
 of a patient which was the seat of extensive lobulation, and in 
 appearance resembled the liver of a rabbit. Other observers 
 have occasionally met with similar appearances. The abnormal 
 lobes cannot usually be distinguished clinically during life, and 
 it is only when the post-mortem examination is made that the 
 differences in form become apparent. 
 
 (3) Left lobe, long and thin. — The left lobe has been met 
 with as a long, thin, tongue-like process, which extended down- 
 wards and towards the left into the left hypochondrium, or even 
 into the left lumbar region as far as the spleen, or even below 
 this viscus. When this form of lobulation is present it may be 
 mistaken for an enlarged spleen, but usually its easily definable 
 connection with the liver, and its very free movements during 
 respiration, will indicate the nature of the enlargement or 
 swelling in the left hypochondrium. 
 
 (4) Absence of left lobe. — In a few cases the left lobe is 
 found to be entirely absent, or merely represented by a small 
 mass of fibrous tissue. This variation gives rise to no symptoms 
 which suggest the presence of the deformity. 
 
 (5) Liver ?^07mdcd in form. — Occasionally the whole liver 
 may be rounded in form and have no easily definable lobes, or it 
 may have the form of a quadrilateral or quadrangular body. In 
 the former of these varieties the inferior border may not be so 
 easily palpable as when it has the ordinary conformation ; but as 
 
 1 Dickinsou, Trans. Path. Soc. London, vol. xvii., p. 160. 
 
6o MALFORMATIONS. 
 
 in many instances the lower edge cannot be felt in normal cases, 
 this fact is of no importance ; the quadrangular form cannot be 
 distinguished by palpation. 
 
 (6) D'iep fissures. — The normal fissures- of the gland are 
 deeper ■'chan usual in some cases, or there may be one or more 
 addi*Jional grooves, especially upon the inferior surface of the 
 ^ight lobe. None of these conditions occasion any symptoms, 
 and they are of very little clinical interest. They are, however, 
 of a certain amount of pathological interest, since they explain 
 the presence of grooves and additional fissures which are found 
 in some cases post-mortem, and in which there are no other 
 signs of disease of the liver. This is especially the case in 
 connection with the livers of children. The exact cause of the 
 formation of additional lobes and fissures has not been explained 
 from a developmental point of view. Possibly some of the cases 
 may have been caused by an intra-uterine perihepatitis. This, 
 however, will not explain the presence of the small pedunculated 
 lobes which have already been described. 
 
 (7) Congenital apertures in diapliragm. — It happens in rare 
 cases that some portion of the diaphragm is congenitally absent, 
 so that there are one or more apertures through which a portion 
 of the upper surface of the liver may extend into the thoracic 
 cavity, either into the pericardium or into one of the pleural 
 cavities, forming a diaphragmatic hernia. This condition is very 
 rare, and it does not appear to be possible to diagnose its 
 existence during life. When, however, there is an area of the 
 chest wall, which is persistently dull to percussion, and which is 
 not associated with a train of symptoms attributable to a patho- 
 logical condition of one of the thoracic viscera, the possilDle 
 presence of a diaphragmatic hernia must be borne in mind. 
 
 (8) HepatompJialos. — When the abdominal wall fails to be 
 completely closed in at the umbilicus and in the median line 
 immediately above it, a portion of the liver may protrude, or if 
 a hernia arises in this situation as a result of imperfect develop- 
 ment, the liver may form the whole or a part of the contents of 
 such a hernia. This condition is known as hepatomphalos. 
 Albert Wittig has recorded a case of this kind.^ The patient 
 was a child Ijorn at the full term of pregnancy, with a tumour of 
 the umbilical region. This tumour had the characteristics of a 
 so-called funicular hernia, and its contents consisted of a con- 
 
 1 Alljert Wittig, " Hepatoiuplialos," Iiiaug. Diss., Kdiiigsberg, 1888. 
 
HEPATOMPHALOS. 6i 
 
 siderable portion-of the liver. When this condition is present it 
 is charcacterised by the following symptoms. At birth a tumour 
 projects from the region of the umbilicus, or through the middle 
 line of the abdominal wall between the umbilicus and the lower 
 extremity of the ensiform cartilage, the contents of which are in 
 part or entirely solid, smooth to palpation, dull to percussion, and 
 continuous with the lower part of the liver above. The tumour 
 moves upwards and downwards synchronously with the move- 
 ments of respiration. 
 
 Diagnosis. — The diagnosis of hepatomphalos will easily and 
 readily be made by paying attention to the existence of a series 
 of physical signs similar to those described above, and by 
 ascertaining by palpation the presence of a tumour which is in 
 direct connection with the liver. 
 
 Treatment. — If it is found to be impossible to reduce the 
 herniated portion of the liver into the abdominal cavity, it may 
 be requisite to remove the protuberant portion by a surgical 
 operation. The method of performing such an operation is 
 described in the chapter upon operations. 
 
 Acquired Malformations of the Liver. — The acquired 
 malformations of the liver, which are not due to disease, are in 
 nearly all cases caused by the practice of wearing tightly-laced 
 corsets. In the majority of instances the affection is found in 
 persons of the female sex, but the practice of wearing tightly- 
 fitting belts has been known to produce a similar affection in 
 men. In all cases, as a result of the pressure which is exerted 
 upon the liver from without, the gland tends to become com- 
 pressed, and to be partially subdivided into two superimposed 
 halves. In the slighter cases, and in the early stages of the well- 
 marked ones, a circular depression is formed upon the external 
 surface of the liver, a short distance above its inferior border. 
 The earliest result of tight-lacing appears to be the pressing 
 inwards of the lower part of the costal arch and forcing down- 
 wards of the liver. Next, the liver itself becomes compressed, 
 and acquires upon its external surface a horizontal depression, 
 which is most marked upon the right lobe. In the more marked 
 cases the liver projects downwards a variable distance below the 
 costal margin, often extending as far as the umbilicus, or even 
 lower. In the Museum of St. Bartholomew's Hospital there 
 is a specimen of the liver and gall bladder of a female ^ who was 
 
 1 St. Barth. Hosp. Museum, Spec. 2114. 
 
62 MALFORMATIONS. 
 
 admitted into the Hospital for symptoms of strangulated hernia. 
 When the operation for the relief of this condition was performed, 
 the hernial sac was found to be occupied by the fundus of 
 the gall bladder, and the liver was felt to extend as far down- 
 wards as Poupart's ligament. This condition has been caused by 
 wearing very tightly-laced corsets, the liver being very much 
 constricted. In addition to the lower portion of the liver being 
 pressed downwards into the abdomen, the upper part of the gland 
 may be pressed upwards in a similar manner, so as to encroach 
 upon the thoracic space, owing to the elevation of the diaphragm. 
 These abnormal conditions do not in the majority of instanises 
 give rise to the appearance of many symptoms. The symptoms 
 which are present are due more to the obstruction to the free 
 movements of respiration, and to pressure upon the heart and 
 pericardium. This form of malformation of the liver is said to 
 predispose to the development of gall stones in the gall bladder, 
 and also to explain to a certain extent the greater frequency 
 of these concretions in the female sex. By some authors the 
 practice of tight-lacing is said to predispose the patient to attacks 
 of " biliousness." As regards the treatment of this class of case, 
 the best method is that of removing the exciting cause. All 
 tightly-fitting garments must be prohibited, especially any which 
 tend unduly to constrict the waist. If these injunctions are 
 carried out, the liver will, to a certain extent, recede upwards 
 beneath the ribs, and resume somewhat its original form. If, 
 however, the practice of wearing tightly-fitting corsets has been 
 made use of for a long time, so that the costal arches have 
 become much deformed, it is not probable that they will return 
 to their pristine shape, but usually improvement will take place. 
 It is quite common in the post-mortem room to find evidence of a 
 constricted liver, which during life had not given rise to any 
 definite train of symptoms. 
 
 Congenital Malformations of the Biliary System. — The 
 congenital malformations of the biliary system, especially when 
 affecting the gall bladder or the common bile duct, are of 
 considerable surgical importance, since it appears to be possible 
 that, in the future, some of them will be amenable to direct 
 surgical interference. The varieties and forms of these mal- 
 formations wliich have been described are tlie following, namely — 
 
 {a) Total absence of the gall hi adder and the cystic duct. — When 
 this deformity is present, the common bile duct is usually found 
 
ABSENCE OF THE COMMON BILE DUCT. 
 
 63 
 
 to be enlarged a short distance above the entrance into the 
 duodenum, so as to form a fusiform sac, which may serve to a 
 certain extent as a substitute for the gall bladder in the storage 
 of the bile which is secreted between the periods of digestion. 
 No definite set of symptoms are attributable to this condition 
 alone, and its existence only becomes apparent at a post-mortem 
 
 Fig. 10. — Congenital obliteration of the ductus communis clioledochus. a, gall 
 bladder ; 6, unobliterated portion of common bile duct ; c, obliterated 
 portion ; d, portal vein ; e, hepatic artery ; /, duodenum. — Museum, Royal 
 College of Surgeons. (For description see Trans. Path. Soc. London, 1895, 
 p. 76.) 
 
 examination, or when the abdominal cavity has been opened for 
 some other affection. 
 
 {h) Obliteration, stenosis, obstruction, or abserice of the common 
 bile duct. — This is perhaps the commonest form of congenital 
 malformation which is met with in the biliary system, and it is 
 one which possibly may be relieved by a surgical operation, if 
 it is not associated with a similar condition of the hepatic or 
 
64 MALFORMATIONS. 
 
 cystic ducts. It is characterised by the existence of a constric- 
 tion in the course of the common bile duct, generally a short 
 distance beyond its commencement, that is, beyond the union 
 of the common hepatic duct and the cystic duct. The duct 
 at the constricted portion has in most cases the appearance of 
 a fibrous cord, extending towards the duodenum, and in which 
 there is no trace of a lumen. In some cases all trace of a 
 fibrous cord has disappeared, and the patent part of the bile 
 passage has no connection with the duodenum, and in others the 
 constriction may be incomplete, so that a small lumen is left in 
 the centre of the fibrous cord, through which bile may pass into 
 the duodenum. The length of the obliterated or constricted 
 portion is not generally more than a half or three-quarters of an 
 inch. 
 
 Pathology. — The exact cause of this condition does not 
 appear to be very clear, although several theories have been 
 advanced which may explain it. We have already seen that the 
 liver is developed from a solid outgrowth of the epithelium which 
 lines the primitive alimentary canal, and that this outgrowth 
 becomes hollowed out at a later period. It seems possible, and 
 in a few cases even probable, that these malformations may be 
 due to arrested, defective, or abnormal development. It has 
 been thought by some observers that the hollowing out of the 
 solid outgrowth has failed to take place at that part of the bile 
 duct which is impermeable. In the majority of these cases, 
 however, the meconium is found to be coloured at birth, a fact 
 which is in favour of the previous existence of a communication 
 of the bile duct with the duodenum which allowed the bile to 
 pass along. It is more probable, as has been suggested by John 
 Thomson,^ that the hollowing out of the solid outgrowth only 
 takes place to a limited extent, and that a congenital narrowness 
 or irregularity of the lumen of the duct is first produced, which 
 is of such a nature as to render it especially liable to the develop- 
 ment of pathological conditions, which bring about its obliteration. 
 Arrested development appears to be the explanation of the 
 absence of the gall bladder in a certain number of the cases. In 
 others, however, where the gall bladder is represented by a 
 quantity of fibrous tissue, it is more probable that its obliteration 
 lias Ijcgu V>rought about liy some infiammatory process. The 
 congenital narrowness which is due to defective developmental 
 
 1 Thomson, Kdin. Med. Journ., vol. .\xxvi. p. 523 et seq. 
 
Pathology. 65 
 
 processes, may involve a considerable length of the bile ducts, 
 and cause the varieties of malformation which are enumerated 
 next. Localised peritonitis occurring in the early stages of 
 intra-uterine life has by some authors been thought to be the 
 cause of these affections. This, however, is supported by very 
 few definite observations. If this were the pathology of the 
 disease, we should expect to find adhesions of the bile ducts to 
 the surrounding structures, and that the external portions of the 
 obliterated ducts were most involved in the pathological process. 
 Adhesions are present in some of the cases, but in these the 
 constricting process does not appear to have extended from with- 
 out, but from within. Syphilis has also been said to be the 
 cause in some of the recorded cases. There is not much evidence 
 in favour of this suggestion, and of the cases which have been 
 described, in only a small percentage has syphilis been stated to 
 have been present either in the child itself or in the parents. 
 The cirrhosis of the liver which is found in most of the cases has 
 been attributed without sufficient reason to syphilis, but in most 
 it will be found that this condition is really one of biliary cir- 
 rhosis, which has been induced by the biliary obstruction. Intra- 
 uterine affections of the walls of the biliary ducts have been 
 thought to be the important etiological factors in the establish- 
 ment of the malformations. Thus, gall stones have, in one case 
 which has been recorded by Lieutaud, been met with. Inflam- 
 mation of the mucous membrane of the duct is a possible cause, 
 but there is no evidence in favour of this. It seems more 
 probable, when inflammation is present, that it has been induced 
 by the previous formation of stenosis of the duct, and that the 
 inflammation has expedited the complete obliteration of the 
 lumen. Beck has described a case in which the blocking was 
 apparently due to the formation of localised gummata. It has 
 been found that in some of the recorded cases more than one 
 member of the same family has been similarly affected. Binz^ 
 and Gould ^ have both described cases in which two children of 
 the same parents have been affected. Many cases have also 
 been placed on record where other children have either suffered 
 from jaundice soon after birth, or have died from diseases in 
 which jaundice was a marked symptom. These facts seem to 
 be more in favour of the malformations being the result of 
 
 1 Binz, Yirchoio's Archir, Bd. xxxv. s. 296. 
 
 - Gould, Boston Med. and S. Journ., 1855, p. 109. 
 
6 6 MALFORMA TIONS. 
 
 defective development. The total obliteration of the lumen of 
 the ducts occurs at a variable period. In most cases it is com- 
 plete in the early stages of intra-uterine life, but occasionally it 
 does not take place till later, and there are a few cases in which 
 it apparently did not take place till a short time after birth. 
 When the ducts have become blocked, accumulation of bile 
 behind the seat of the obstruction occurs, and this soon sets up 
 biliary cirrhosis, which increases and causes interference with the 
 functions of the liver. Cholsemia is induced, and, along with it, 
 its characteristic symptoms. In a few cases the inflammatory 
 process which follows the establishment of obstruction spreads to 
 the adjacent portion of the peritoneum, and sets up a localised 
 peritonitis. 
 
 Symptoms. — At birth the child is in most cases found to be 
 jaundiced, but in a few the skin is quite free from yellow dis- 
 coloration, and the jaundice comes on shortly afterwards. The 
 discoloration of the skin gradually increases in intensity ; the 
 urine is dark, owing to the presence in it of bile pigments, and 
 the child suffers from constipation. The first stools which are 
 passed, and which consist of meconium, vary as regards their 
 colour. In some cases the meconium is coloured green, owing to 
 the presence of pigments derived from the bile, whilst in others 
 it is white or almost colourless. In the former cases the oblitera- 
 tion of the duct only took place after a certain amount of bile 
 had been secreted by the liver, and had been poured into the 
 duodenum ; in the latter, the obliteration probably became com- 
 plete at an early period of intra-uterine development. In some 
 cases the jaundice, after it has been established, may decrease in 
 intensity and the child undergo an apparent improvement. This, 
 however, is only of temporary duration, and soon the jaundice 
 again deepens and further symptoms develop. Nutritional dis- 
 turbances manifest themselves at a variable date after the 
 appearance of jaundice ; in some they are apparent after a few 
 weeks, whilst in others they do not become well-marked until 
 after the expiration of one or two months. In the advanced 
 stages attacks of vomiting and convulsions are frequent, and are 
 probably due to the occurrence of a species of blood-poisoning. 
 Enlargement of the spleen has also been noted as a common 
 symptom in the later stages. Spontaneous hicmorrhages occur 
 in nearly all cases which last for a few months. Hiemorrhage 
 from the umbilicus is the most frequent, but epistaxis, hiemor- 
 
S YMPTOMS—DIA GNOSIS. 6 7 
 
 rhage into the tissues and into the alimentary canal, are not 
 uncommonly met with. The hiemorrhage is in all probability 
 induced by the condition of the tissues, owing to their impregna- 
 tion with the non-eliminated biliary excretion. When hemor- 
 rhages occur they are very persistent, and cannot be arrested by 
 ordinary measures. Usually they continue until death, and in 
 many cases they are its immediate cause. The duration of life 
 in children suffering from congenital obliteration of the common 
 bile duct varies between a few weeks and several months. John 
 Thomson ^ collected forty-nine cases of congenital obliteration of 
 the bile ducts, and found that out of these, eleven lived less than a 
 week, eight more than a week and less than a month, fourteen 
 from one to four months, and sixteen more than four months, two 
 of these having lived until the eighth month. In one case of 
 obliteration of the common bile duct, which has been recently 
 reported by Francis Hawkins,^ the child lived for four and a half 
 months (Fig. 10). In a few of the recorded cases a green 
 coloration of the fa^,ces has been noted during the later stages 
 of the affection. This appears to have been due to mercury 
 having been administered ; which substance has formed green- 
 coloured compounds with some of the contents of the bowel. 
 
 Diagnosis. — Absence of coloured matter in the intestinal 
 excreta of a child at birth, or coming on soon afterwards, which 
 is co-existent with, or immediately followed by, the appearance of 
 jaundice, which is persistent and increases in intensity, points to 
 the existence of some obstruction to the flow of bile from the biliary 
 passages into the duodenum. It is not uncommon, however, for 
 a young child to suffer from jaundice, owing to the blocking of 
 the common bile duct by a catarrhal condition of the mucous 
 membrane, or by a plug of mucus which has become inspissated 
 and impacted at the entrance of the duct into the duodenum. 
 In both of these classes of cases the meconium is dark-coloured, 
 owing to the presence of biliary pigments, and the condition 
 clears up spontaneously in a few days, or yields to medical treat- 
 ment. Icterus neonatorum, which comes on shortly after birth, 
 lasts for a short time, and is due to change of the blood pigments 
 in the skin, must not be mistaken for the jaundice of oblitera- 
 tion. This variety only lasts for a short time, and soon clears 
 up spontaneously. All cases of jaundice occurring in the newly- 
 
 1 John Thomson, Edin. Med. Journ., vol. xxxvi. p. 523 et seq. 
 
 2 Hawkius, Trans. Path. Soc. London, 1895, p. 76. 
 
68 MALFORMATIONS. 
 
 boru, require to be watched for some days before it can be 
 definitely stated whether the jaundice is due to permanent 
 blocking of one or other of the bile ducts, or is due to other less 
 persistent causes. 
 
 Treatment. — When the existence of a permanent congenital 
 obstruction of the entrance of the bile into the duodenum has 
 been diagnosed with a fair amount of certainty, there appears to 
 be only one method of treatment which offers a possibility of 
 relief to the condition being afforded. An exploratory laparotomy 
 should be performed, the incision being made in the middle line 
 above the umbilicus, or in the right liuea semilunaris, commencing 
 at the lower margin of the costal arch. In most cases it will be 
 better to make the median incision, but if a localised swelling can 
 be distinguished, which extends more to the right, then it will 
 be advisable to make the incision in the right linea semilunaris. 
 The structures in the portal fissure of the liver and its neigh- 
 bourhood should be carefully examined, together with the 
 gastro-hepatic omentum and the duodenum. If it is found 
 that the common bile duct is obliterated above its entrance into 
 the duodenum, that the gall bladder is present and of normal 
 size, and its cystic duct is patent and communicates wdth the 
 hepatic ducts, which also are patent, then a fistulous communica- 
 tion should be made between the gall bladder and the duodenum. 
 This can be done best by the use of a small "anastomosis 
 button," assisted by a few stitches. The details of this operative 
 procedure are described later. If the gall bladder is absent and 
 the common bile duct obliterated, then the only thing which can 
 be attempted will be to establish a communication between the 
 lower extremity of the dilated portion of the bile duct and the 
 duodenum. In the majority of cases this will in all probability 
 be found to be almost impossible. 
 
 Prorjnosis. — If the patients with congenital obliteration of the 
 common bile duct are left untreated, they all die ; but as yet no 
 cases have been recorded which have been treated in the manner 
 which is advocated above. It seems, however, to be quite 
 possible, and even probable, judging from the result of cholecyst- 
 enterostomy in older people, that there is a chance of the pro- 
 cedure proving successful in suitable cases. It must be 
 I'emenibered that there is only a limited number of these 
 congenital cases which will be found to be suitable. In most 
 cases, in addition to obliteration of the common bile duct, there 
 
OBLITERATION OF COMMON HEPATIC DUCT. 69 
 
 are other more extensive lesions which do not lend themselves 
 to successful operative interference. In John Thomson's ^ paper, 
 already referred to, diagrams are given of twenty-nine of the re- 
 corded cases, and out of these only six appear to have been suit- 
 able for the application of this method of treatment. Giese has 
 recently collected twenty -seven cases, and out of this number he 
 found that only three were suitable for the performance of an opera- 
 tion which would have a fair chance of being successful. The suit- 
 able cases are those described by Kostlin," Eoth,^ and Legg.* To 
 this list may be added the case of Francis Hawkins ^ (Fig. 10). As, 
 however, the affection if left alone is necessarily fatal, it appears 
 to be quite justifiable to attempt to relieve it by surgical 
 measures. 
 
 Congenital obliteration of the common hepatic duct. — This is 
 a very rare condition, and when it is met with it gives rise to 
 a train of symptoms which are indistinguishable from those 
 which occur when the common bile duct is obliterated. In 
 some cases it is associated with obliteration of the common bile 
 duct or the gall bladder, and its existence can only be definitely 
 diagnosed after an exploratory examination of the biliary passage 
 has been carried out. The common hepatic duct and the right 
 and left hepatic ducts are usually represented by solid white 
 cords of fibrous tissue, which extend into each extremity of the 
 portal fissure. In some cases the common hepatic duct has 
 alone been found to be obliterated, and in others the right and 
 left hepatic ducts are closed as well, whilst occasionally the 
 right or left hepatic duct, or both, have been obliterated. The 
 left duct may be obliterated alone, and give rise to no symptoms, 
 but this is very unusual. When the hepatic ducts are obliterated, 
 it does not seem to be possible to perform any surgical opera- 
 tion which will be of avail in rectifying the condition. All 
 these cases must apparently terminate fatally. If the gall 
 bladder and the cystic and common bile ducts were normal, and 
 there were also present hepato-cystic ducts, which have occasion- 
 ally been met with, it seems to be possible that the bile might 
 pass into the intestine by this route from the liver, but no case 
 of this nature has been recorded. 
 
 1 Thomson, loc. cit. 
 
 2Kostlin, Med. Qor.-Bl. d. wurttemb. iirzil. Ver., Stuttgart, 1862, Bd. xxxii. 
 
 3 Roth, Virchmv's Archiv, Bd. xliii. s. 296. 
 
 ■* Legg, loc. cit. ^ Hawkins, loc. cit. 
 
CHAPTER VI. 
 
 ABSCESS OF THE LIVEK. 
 
 An abscess of the liver may arise as the direct or indirect result 
 of a considerable number of different pathological conditions. 
 In each case a localised hepatic inflammation is induced, which 
 terminates in the formation of a collection of pus. This condition 
 is usually associated with the entrance of a quantity of septic 
 material into some portion of the liver. The resultant abscesses 
 may be either multiple or single, those of pysemic origin being 
 almost invariably multiple. A special variety of the affection is 
 known as tropical abscess, and occurs in individuals who reside 
 or have resided in hot climates. 
 
 Etiology. — The etiology of inflammation of the liver and 
 hepatic abscesses may be considered under many distinct head- 
 ings, but for convenience of description, these will be separated 
 into the following seven groups, viz. : — 
 
 1. Traumatism. — Some portion of the liver may receive an 
 injury from without, such as a blow, or a fall against an obstacle, 
 and as a result of this the liver tissue at the point of reception 
 of the force undergoes a solution of continuity, and a rupture 
 occurs, either superficially or into the substance of the gland. 
 The damaged part may undergo resolution and no serious com- 
 plication follow, or micro-organisms may be carried to it by the 
 blood stream, which grow and multiply so as ultimately to lead 
 to the development of an abscess. The formation of abscess may 
 be delayed until some time after the injury. Severe and exten- 
 sive ruptures of the liver are quickly fatal in the majority of 
 instances, and it is only the slighter varieties which may become 
 the seat of the development of an abscess. Haspel ^ has 
 described the case of a soldier who received a severe blow in the 
 right hypochondriac region, and died from a hepatic abscess 
 eleven days afterwards. Cases have also been described in 
 
 ^ Haspel, "Henoch's Unterleibskrankheiten," 1864. 
 
TRAUMATISM— GALL STONES. 71 
 
 which children have died from hepatic abscesses caused by falls 
 from a height. Fish bones, pins, and needles which have been 
 swallowed, have been found in the interior of a hepatic abscess, 
 having perforated the walls of the stomach and then passed into 
 the liver. Abscesses of the liver, as the result of non-perforating 
 injuries, are exceedingly rare, and, according to C. Langenbuch,^ 
 only thirty-nine cases are recorded in surgical literature. Per- 
 forating wounds of the liver are more commonly followed by the 
 formation of an abscess than the non-perforating ones. These 
 wounds may be due to stabs with sharp instruments, or blunt 
 bodies may be driven through the abdominal or thoracic walls 
 into the liver substance, or the perforating body may be the pro- 
 jectile of a firearm. In all these cases, if the injury is not very 
 extensive, the development of an abscess may follow. Septic 
 matter may be introduced either at the time of injury or later, 
 by means of the blood stream or by unclean instruments which 
 are used to examine the wound. Portions of the perforating 
 body may be detached and left in the bottom of the wound, or a 
 piece of the clothing may be carried in. All cases of abscess of 
 the liver which are caused by perforating wounds are associated 
 with the presence of the micro-organisms of suppuration. A 
 foreign body which has been introduced into the liver in the 
 manner described above is not always immediately followed b}^ 
 the formation of an abscess, since the foreign body may become 
 encapsuled in the liver substance and surrounded by a layer of 
 dense fibrous tissue, when it remains quiescent for a long time. 
 When an encapsuled body is located within the liver, it is liable 
 at any time to become the seat of an inflammatory process which 
 may terminate in the formation of an abscess. An hepatic 
 abscess may thus occur after the lapse of a considerable length 
 of time from the introduction of the foreign body. 
 
 2. Gall stones. — Gall stones are not unfrequently the cause of 
 hepatic abscess in non-tropical climates, and they can produce 
 this result in several ways. When the gall stones are located 
 within the gall bladder, they are liable, by a process of constant 
 irritation, to cause inflammation and ulceration of the mucous 
 membrane which lines the internal aspect of the sac, and if this 
 inflammatory condition extends to the neighbouring portion of 
 the liver, it becomes the direct cause of the formation of an 
 abscess. In other cases the gall stones may be impacted in the 
 
 1 LaBgenbncli, "Deutsche C'hiraraie." Lief. 45 c, Thei]. i. s. 205. 
 
72 ABSCESS OF THE LIVER. 
 
 cystic duct, or in some part of the intra-hepatic bile ducts, and 
 by a similar process of irritation, inflammation, and ulceration, 
 induce the development of an abscess. The gall stones which 
 are found in the intra-hepatic ducts may have arisen within the 
 liver, or they may have migrated there from the gall bladder 
 along the cystic and hepatic ducts. The micro-organisms of 
 suppuration play a very important part in the development of 
 abscess dependent upon gall stones. The Bacterium coli commune 
 has not uncommonly been found in the pus of abscesses which 
 have arisen in this manner. This micro-organism is always to 
 be found as an inhabitant of the human alimentary canal, and 
 when it is found in connection with inflammatory processes due 
 to the presence of gall stones, it has, in all probability, in most 
 cases reached the liver by passing along the bile passages from 
 the duodenum. Gall stones which haA'^e become impacted in 
 some portion of the common bile duct have been found to be the 
 cause of the formation of an hepatic abscess in a small proportion 
 of cases. It has been suggested with a very fair amount of 
 reason, that in these cases the gall stone, when impacted, causes 
 ulceration of the mucous membrane, and the ulcerated surface 
 becomes the seat of growth of suppurative micro-organisms, which 
 have migrated from the adjacent portion of the intestine ; 
 colonies of these micro-organisms then enter the small veins or 
 capillaries which return the blood from the walls of the common 
 bile duct, and pass along with the blood stream into the portal 
 vein and thence into the liver, where they are arrested in the 
 intra-hepatic capillaries of the portal system, and give rise to the 
 development of abscesses in the manner described in connection 
 with portal pytemia. Gall stones have been found in the interior 
 of abscesses which have arisen according to the two first of the 
 above ways, either post-mortem, or when the abscess has opened 
 externally and discharged its contents, or when it has ben incised 
 and evacuated by the surgeon. Cases have been described in 
 which the abscess has opened into some part of the alimentary 
 canal and the pus and gall stones have been passed per anum, or 
 vomited up when the stomach has been the seat of the perforation. 
 
 3. Parasites {animal). — Several varieties of animal parasites 
 have been met with, as the direct cause of the development of 
 an abscess of the liver. 
 
 (a) Ascaridcs, or round worms, may inhabit the upper 
 part of the intestine in man, and cases have been recorded 
 
ANIMAL PARASITES. 73 
 
 in which they have passed through the aperture of the 
 common bile duct into the duodenum, and thence along the 
 biliary passages to the gall bladder, or to the intra-hepatic 
 portions of the bile ducts. When they have gained an entrance 
 into the bile ducts or gall bladder, they usually become coiled up 
 and soon die, owing to the poisonous effect of the bile upon them. 
 They act as irritants to the mucous membrane lining the in- 
 terior of the bile passages, and induce the formation of an abscess 
 in a manner similar to gall stones, but as they have passed 
 directly from the small intestine, suppuration commences at an 
 early period, owing to the presence of the micro-organisms which 
 they have carried with them. The formation of an abscess is 
 not the invariable result of the passage of a round worm into 
 the biliary ducts. When the parasite has been killed by the 
 action of the bile, it may be extruded into the duodenum by the 
 contraction of the muscular walls of the ducts. Cases have been 
 met with and described where a dead ascaris has been passed 
 externally, either when a hepatic abscess has opened spontaneously 
 on the surface of the body, or has been evacuated by the surgeon. 
 The formation of a hepatic abscess as the result of the j)i'esence 
 of an ascaris within the liver is a very rare condition, and when 
 present it can scarcely be distinguished clinically from an abscess 
 which is due to a gall stone. This condition, however, is liable 
 to occur in children and young adults, and if the patient is 
 known to be suffering from ascarides, and the formation of a 
 hepatic abscess has been preceded by attacks of violent biliary 
 colic, this cause must be taken into consideration when making 
 a diagnosis. It usually happens that a single ascaris finds its 
 way into the liver, and a single abscess is the result. Cases, 
 however, have been recorded in which multiple abscesses have 
 formed after several of the parasites have passed into the bile 
 ducts. Bargioni ^ has described a case in which sixteen round 
 worms were found in the liver of a patient after death. In the 
 Dupuytren Museum in Paris there is a human liver into which 
 eleven adult round worms have passed along the course of the 
 bile canal. According to Davaine ^ an ascaris does not live more 
 than twenty hours after it has obtained an entrance into the bile 
 ducts. Nearly all the recorded cases have occurred in children or 
 young adults. 
 
 1 Bargioni, quoted by Langeiibiicli, op. cit., s. 207. 
 - Davaine, "Traite ties entozoaires," 1877. 
 
74 ABSCESS OF THE LIVER. 
 
 (b) A hydatid cyst of the liver may become the seat of 
 a suppurative process which terminates in the establishment 
 of a hepatic abscess. The inflammation and suppuration may 
 commence in the liver tissue which immediately surrounds 
 the cyst, so that the parasite lies in a bed of pus, but sooner or 
 later the cyst itself is involved, and its interior becomes filled 
 with the products of suppuration ; in other cases the cyst and 
 its contents are first affected in the inflammatory process, and 
 the neighbouring portion of the liver is involved afterwards. 
 The exciting causes of suppuration of a hydatid cyst are not 
 always apparent. An exploratory puncture with the needle of 
 an aspirator has been the direct cause of the introduction of 
 septic micro-organisms, and a blow or contusion in the hepatic 
 region has preceded the occurrence of this complication. Often, 
 however, it is not possible to refer it to any definite cause. 
 The symptoms are those of an ordinary hepatic abscess, preceded 
 by those of hydatid disease, if the hydatid cyst has attained 
 any considerable size or has commenced to exhibit pressure 
 symptoms. A small hydatid cyst may become the seat of an 
 inflammatory process which terminates in abscess without having 
 previously exhibited any symptoms by which its existence can 
 be surmised. 
 
 (c) Distomata. — In tropical and subtropical countries the 
 Distoma hcematohium has been found in the liver, occupying 
 the portal canals, and, in rare cases, causing an abscess of the 
 liver. This appears to be an occasional cavise of hepatic abscess 
 in Egypt. Arnold ^ has recorded a case of abscess of the liver, 
 which he opened by operation, and in the pus which was evacu- 
 ated he found an adult distoma. In the Museum of St, Barth- 
 olomew's Hospital^ there is a preparation of a human liver, in 
 which are seen a number of specimens of Distoma liciMtimtm ; 
 the liver was taken from the body of a countryman. The abscesses, 
 which are due to the presence of these parasites, appear to be 
 usually small and multiple. This condition is an extremely rare 
 one, and when present it does not appear to be possible to dis- 
 tinguish it from other varieties of multiple small abscesses. 
 
 {d) Ooccidia. — According to the researches of Podwyssozki,^ 
 coccidia may very rarely cause the formation of small localised 
 
 1 Anwhl, Arrh. de rued. vav.jFa.niij'NQV. 1889. " Museum, St.Barth.Hosp., Spec.2238. 
 3 Podwyssozki, Vrach, St. Petersburg, 1890 ; and Centra/hi. f. kUn. Med., Bonn, 1890, 
 No. 48, s. 807. 
 
ABSCESSES OF PYEMIC ORIGIN. 75 
 
 abscesses in the liver of man. The affection is quite common in 
 rabbits. The parasite is a small unicellular organism, belonging to 
 the group of Sporozoa. Poclwyssozki says that the coccidia spores 
 are, in many cases, introduced into the body of man along with un- 
 cooked eggs. He asserts also that in one sample of eggs which 
 he examined in the summer, 10 per cent, were affected with 
 the spores of coccidia. The abscesses which are produced by 
 these parasites are small, multiple, and of slow growth. They 
 may cause considerable enlargement of the liver, but the diagnosis 
 of the affection is practically impossible until the contents of the 
 abscess have been evacuated by operation and examined. 
 
 4. By direct extension from ivflammatory foci in adjacent 
 tissues. — Inflammatory and suppurative processes in the neigh- 
 bourhood of the liver may, by direct extension, involve the 
 liver itself and give rise to the formation of an abscess. 
 Thus any form of localised perihepatitis, such as subphrenic 
 abscess, an empyema of the base of the right pleural 
 cavity, an empyema of the gall bladder, a localised purulent 
 peritonitis, or suppuration in the region of the right kidney, 
 may each be the immediate cause of an abscess of the liver. A 
 tubercular cavity in the base of the right lung has been known 
 to cause the formation of an abscess of the upper portion of the 
 right lobe of the liver, by obliterating the lower part of the 
 pleural cavity and extending through the diaphragm to the 
 underlying portion of the liver. 
 
 5. Abscesses of pymmic origin. — These abscesses are in 
 nearly every case multiple, and they result from a variety of 
 pathological causes and conditions (Fig. 11). The essential 
 factor in the establishment of the affection, in a considerable 
 proportion of cases, is the conveyance to the liver, by one of its 
 blood vessels, of colonies of micro-organisms which are associated 
 with, and the cause of, a suppurative process in some other part of 
 the patient. These micro-organisms can reach the liver by means 
 of the portal vein, the hepatic artery, and the inferior vena cava. 
 
 (a) The "portal vein. — Any process of suppuration in con- 
 nection with the anatomical structures from which blood 
 is taken to the liver by the portal vein, may be the immediate 
 cause of an abscess of the liver. Ulcers of the stomach and 
 duodenum, which are either simple or malignant in character, 
 may be the cause of an embolic process, and become the start- 
 ing-point in the development of an abscess in the liver. In the 
 
76 
 
 ABSCESS OF THE LIVER. 
 
 same manner ulcerations in 
 
 Fig. 11. — Pyfemlc abscess of the liver. 
 Section of a liver, diaphragm, and 
 lower portion of right lung. Tlie liver 
 substance is riddled with numerous 
 cavities of varying size, which have 
 destroyed a considerable amount of 
 the hepatic substance. These cavities 
 were originally filled with thick 
 mucoid pus. The suppuration had 
 extended upwards, lea^ling to the 
 formation of a sub-diai)hragmatic 
 abscess and an empyema of the right 
 pleural cavity. This condition had 
 foUoweil a perforation of the vermi- 
 form appendix, caused by a pin. Be- 
 fore death the seventh rib was resected 
 so as to ail'ord an outlet for the jnis. 
 
 able that in all these cases 
 
 any part of the small or large 
 intestine may be followed by the 
 same result. Inflammatory pro- 
 cesses in or around the vermiform 
 appendix are especially liable to 
 lead to the development of an 
 abscess. Abscesses which are 
 primary in the spleen and pan- 
 creas have been known to cause 
 a similar condition of the liver. 
 Dysenteric ulcers of the large 
 intestine give rise to abscesses of 
 the liver which are often single, 
 or possibly there may be two or 
 more. Operations for hitmor- 
 rhoids, rectal prolapse, or for 
 cancer and other affections of the 
 pelvic viscera, have been directly 
 followed by hepatic abscess. Local- 
 ised peritonitis in the pelvis, 
 especially after a septic labour, is 
 liable to give rise to the same 
 condition. Septic inflammation 
 of the stump of the umbilical cord 
 and the umbilical region have 
 caused hepatic abscess in infants. 
 The occurrence of a gastro-intes- 
 tinal catarrh, in which there has 
 been no apparent abrasion of the 
 mucous membrane, has been 
 immediately followed by the 
 development of suppurative hepa- 
 titis. The simple operation of 
 ligature of piles has been known 
 in several instances to be the 
 cause of an abscess of the liver, 
 and operations upon the urinary 
 bladder from the perineum have 
 had the same sequel. It is prob- 
 septic emboli, which consist of 
 
 colonies of some variety of the micro-organisms of suppuration, 
 
THE HEPATIC ARTERY. 
 
 77 
 
 have passed from the seat of ulceration into the radicles of 
 the portal vein, and have been carried by the blood stream 
 to the liver, where they have been arrested in the portal 
 capillaries, and then by their growth and multiplication have 
 caused inflammation and 
 localised necrosis, which has 
 terminated in the formation 
 of one or more abscesses. 
 It is not clear how these 
 colonies gain an entrance 
 into the lumen of a blood 
 vessel in the case of simple 
 catarrh, but possibly there 
 may be in this condition 
 small abrasions of the mucous 
 membrane which have not 
 been recognised. The micro- 
 organisms which have been 
 met with and described are 
 those of ordinary suppura- 
 tion, such as the pyogenic 
 streptococci and staphy- 
 lococci, and also the Bac- 
 terhtm coli commune. In 
 hepatic abscesses of dysen- 
 teric origin an organism has 
 been met with which is called 
 the amreba coli, but the 
 exact connection of this 
 micro-organism with the sup- 
 purative processes has not 
 been definitely established. 
 No micro - organisms have 
 been detected in some cases 
 of hepatic abscess, even after 
 the most careful examination. 
 
 (h) The hepatic artery. — When septic emboli reach the liver by 
 means of the hepatic artery, they usually come from some distant 
 focus of disease, and not from any of the structures within the 
 area of the portal vein. Head injuries, which have become the 
 seat of a septic process, are very frequently followed by the 
 
 Fig. 12. — Pylephlebitis. Section through the 
 right lobe of a liver which was the seat of 
 a septic pylephlebitis, secondary to an 
 affection of the vermiform appendix. 
 Numerous small abscesses are seen on the 
 surface of the section, situated along the 
 course of the branches of the portal vein. 
 
78 ABSCESS OF THE LIVE JR. 
 
 development of metastatic abscesses in the liver. The septic 
 emboli from the cranium in these cases must pass through the 
 capillaries of the lung before they obtain an entrance into the 
 main arterial system, whence they pass into the hepatic artery 
 and are carried to the liver, where they are arrested in some of 
 the hepatic capillaries. In some of the cases there are no 
 metastatic abscesses in other organs, but in many it is found 
 that the lungs are also the seat of similar abscesses. Other 
 parts of the body, such as the spleen, kidneys, and brain, may 
 also become the seat of these secondary abscesses. The liver 
 and the lungs, however, are the organs which are the most 
 frequently involved. It has been the subject of much specula- 
 tion and controversy as to why septic emboli pass from the 
 cranium and other organs, when they are affected with septic 
 inflammations, through the lungs, and are not arrested there, or, 
 if they are arrested there, they do not cause the development of 
 metastatic abscesses. No clear explanation of this pathological 
 condition has as yet been given. It may be possible that the 
 micro-organisms which cause the abscess in the liver will not 
 grow and multiply in the lung tissue, owing to the large amount 
 of oxygen which is always present in these organs. No one has 
 demonstrated, however, that the micro-organisms which are found 
 in abscesses of the liver, due to septic emboli from a distant 
 source, and not associated with abscesses in the lungs, are 
 different from those which are found when the abscesses are 
 present in both the liver and lungs or other organs. Septic 
 inflammations in connection with diseases of bone are not 
 uncommonly the cause of liver abscesses, the emboli being carried 
 to the organ by the hepatic artery. The various forms of acute 
 infective periostitis and osteomyelitis, as well as the septic 
 affections which involve the portions of bone enclosing the organs 
 of hearing, are especially liable to be followed by these sequela-. 
 A case has been described by Fontan,-^ in which an ordinary boil 
 in the temporal region was followed by the development of an 
 abscess of the liver, and the Stapliylococcm ijyngencs aureus was 
 found both in the boil and in the hepatic abscess. Ulcerative 
 endocarditis has been the cause of a secondary abscess of 
 the liver in a certain number of cases. Thierfelder,- Meyer,^ 
 
 1 Foiitiin, Semaine med., Paris, 1893. 
 
 2 Tliierfeldcr, " Zieiii.ssen'.s lianill>ucli," Bil. vii. 
 
 3 Meyer, " Ueber endocarditis ulcerosa," Zurich, 1870. 
 
THE INFERIOR VENA CAVA. 79 
 
 Chvostek/ and Buckling - have described such cases. Forty- 
 eight fatal cases of ulcerative endocarditis are recorded in 
 the statistical tables of St. Bartholomew's Hospital for the 
 years 1885—1894, and of those cases which were examined 
 post-mortem, abscesses of the liver were found to be present 
 in only one case, and in this there were also abscesses 
 in other viscera. Gangrene of the lung, purulent bronchitis, 
 and tubercular disease of the lung, in which the caseous 
 portions have undergone disintegration, have all been followed 
 not unfrequently by secondary abscesses in the liver, the septic 
 emboli having been carried to the liver by the branches of the 
 hepatic artery. In the tubercular cases the abscesses in the 
 liver may be either tubercular in nature, or, as more frequently 
 happens, they may contain the micro-organisms of suppura- 
 tion. Eoss and Osier ^ have described a case of aneurism 
 of the hepatic artery, which was followed by the develop- 
 ment of numerous secondary abscesses in the liver, owing to the 
 interior of the aneurismal sac becoming the seat of a septic 
 process, and septic emboli being detached therefrom and carried 
 thence to the liver by the hepatic artery. Chronic pyaemia, 
 which is characterised by the appearance of abscesses in various 
 parts of the body, frequently affects the liver ; and in nearly all 
 cases which are fatal, this viscus sooner or later becomes the seat 
 of abscesses. Patients who are the subjects of septic thrombosis 
 of the lateral sinus not uncommonly develop signs of secondary 
 abscesses in the liver. In two cases of this kind which I had 
 recently under treatment, both patients died, and in each 
 abscesses were fomid in the lungs and liver. 
 
 (c) The inferior vena cava. — Some observers, as Magendie and 
 Meckel, have asserted that a septic infection may spread back- 
 wards from the blood in the right auricle, along the inferior cava 
 and the hepatic veins to the liver tissue, and give rise to the develop- 
 ment of abscesses, the manner of extension apparently taking the 
 form of a thrombus in the veins. The septic material in these 
 cases reaches the right auricle by veins which return blood from 
 other septic foci. There does not appear to be any definite 
 evidence that this is a method by which septic material can 
 reach the liver and cause hepatic abscesses, and from a practical 
 
 1 Chvostek, Wun. Klinik, 1881. 
 
 - Biickling, Inaug. Diss., Berlin, 1868. 
 
 3 Ross and Osier, Canada Med. Journ., Montreal, vol. vi. p. 1. 
 
8o ABSCESS OF THE LIVER. 
 
 point of view it can be disregarded. Some surgeons have main- 
 tained, but without sufficient reason, that abscesses of the liver 
 which follow suppurating head injuries, and thrombosis of the 
 various cranial venous sinuses, may arise in this way, especially 
 when the lungs are not simultaneously affected. 
 
 {d) We have already seen, in the chapter on the functions 
 of the liver, that the liver plays an important part in destroying 
 or rendering innocuous the toxines and ptomaines, which are 
 produced by the growth and activity of the various micro- 
 organisms which are concerned in the processes of suppuration. 
 It is possible, when an excessive amount of these substances is 
 produced, that the cells of the liver may be overworked in their 
 attempts to destroy them, and, as a result, their vitality may be 
 so much impaired that they become the seat of growth of 
 suppurative micro-organisms, which have been deposited from the 
 blood either of the portal vein or the hepatic artery. If this is 
 found to be true, it will afford an easy explanation of the fact 
 that, in some cases, abscesses occur only in the liver in certain 
 varieties of septic affections, especially in head injuries. 
 
 G. In connection with acute specific fevers. — The liver has 
 been found to be the seat of an abscess in a few cases of typhoid 
 fever. According to Eomberg, this condition can arise in three 
 different ways — 
 
 (a) By extension along the tile ducts. — An inflammation and 
 ulceration of the biliary ducts or gall bladder, which has 
 been caused by an extension of the typhoid bacillus to these 
 structures, is met with in very exceptional cases of typhoid 
 fever. When it occurs, the ulcerative process may, by direct 
 extension, spread to the adjacent portion of the liver and be the 
 exciting cause of an abscess. Klebs ^ has described a case of 
 this kind in which the ulceration involved the intra-hepatic 
 ducts. 
 
 (h) As the result of a supijurative pylephlelitis. — The mode 
 of origin in this class of case is similar to that which has 
 been described in connection with ulcers of the intestine and 
 portal vein pyaemia. The septic material obtains an entrance 
 through the tissues in the floor of the typhoid ulcers, and is 
 carried by the portal vein to the liver. In a case of this kind 
 recorded by Eomberg,^ the pus in the liver contained 
 
 1 Kkihs, " Handbuch f. Patli. Anat," 1868. 
 - Koiiiburg, Bed. Min. Wchnschr., 1890, No. 9. 
 
TROPICAL ABSCESS. 8i 
 
 staphylococci. Blickling/ Tungel,^ and Bernhardt have de- 
 scribed similar cases. Schlier* and Futterer^ have discovered 
 colonies of the typhoid bacillus (Eberth) in the biliary ducts. 
 
 (c) In the third class of cases are included those abscesses 
 of the liver which are supposed to be due to an infection from 
 a localised suppuration occurring in the course of an attack of 
 typhoid fever. Chvostek ^ and Leudet '^ have described cases 
 which have followed perichondritis and necrosis of the laryngeal 
 cartilages, occurring as the result of typhoid fever. Louis ^ has 
 recorded a case in which the abscess followed a suppurative 
 condition of the parotid gland and the submaxillary region. It 
 is probable in these cases that the formation of an abscess 
 in the liver is due to absorption of septic material from the 
 typhoid ulcers in the intestine, although it is possible that 
 the septic material may have the origin attributed to it by 
 Eomberg. 
 
 The affection of the liver in most of the recorded cases 
 appears to have developed in the later stages of the fever. In 
 one of the cases mentioned by Bertrand and Fontan ^ the 
 affection was associated with the onset of a typhoid state. 
 
 The occurrence of this condition in the course of typhoid 
 fever is very rare ; and, according to Langenbuch,^*^ only about 
 twenty cases has been placed on record. 
 
 Influenza appears to be almost the only one of the other 
 acute specific fevers which has given rise to hepatic abscess. 
 Cimbali ^^ has recorded the case of a man who died from an 
 abscess of the liver which followed an attack of this affection. 
 
 In the Museum of Guy's Hospital ^^ there is a specimen of a 
 liver containing an abscess which occurred as the result of an 
 attack of scarlatina. 
 
 7. Tropical abscess. — Tropical abscess of the liver is the 
 term which is applied to a variety of hepatic suppuration which 
 
 I Buckling, Inaug. Diss., Berlin, 1868. 
 
 - Tuugel, Klin. Mitth. v. d. med. Abth. d. Allg. Krankenh. in Hamburg, 1864. 
 3 Beruhard, Jahj-b.f. Kinderh., Leipzig, 1886, s. 303. 
 ■* Schlier, Munchen. med. Wchnschr. , 1891. 
 
 5 Fiitterer, ibid., 1888, No. 19, s. 317. 
 
 6 Clivostek, Allg. Wien. med. Ztg., 1866, No. 37. 
 ' Leudet, Clinique medicale, Paris, 1874. 
 
 8 Louis. " Reclierclies anatomiques, etc., sur fievre typhoide," Paris, 1841, vol. i. p. 118. 
 
 9 Bertrand et Fontan, " L'Hepatite Suppuree,' Paris, 1895. 
 10 Laugenbucli, "Deutsche Chirurgie," Lief. 45 c, Theil. 1. 
 
 II Cimbali, Sperimentale, Firenze, 1890. 
 12 Guy's Hosp. Mus., Spec. 1294. 
 
 6 
 
82 
 
 ABSCESS OF THE LIVER. 
 
 occurs for the most part, although not entirely, in people who 
 live in tropical and subtropical regions, or who, at some time, 
 have lived in hot climates. The abscesses are either single, or 
 not more than two or three in number. Fig. 13 is an illustra- 
 tion of a large single abscess. 
 
 Geographical distribution. — The disease appears to exist as 
 
 an endemic affection in 
 many countries which lie 
 within 45 degrees north 
 and south of the eqviator, 
 whilst those cases which 
 occur in more temperate 
 climates are of a sporadic 
 character. In Europe the 
 disease occurs most com- 
 monly in those countries 
 which lie on the northern 
 coast of the Mediterranean. 
 The southern parts of 
 Spain, France, Italy, and 
 Greece, together with the 
 islands which lie in the 
 Mediterranean (Sardinia, 
 Sicily, Malta, the Balearic 
 Isles, and the Ionian 
 Islands) are the places in 
 which the disease occurs 
 as an endemic afiection. It 
 has been said by some 
 authors that no cases have 
 occurred in England except 
 in people who have been 
 in hot climates. This is 
 probably incorrect. Accord- 
 ing to Hilton Fagge/ be- 
 tween 1(SG0— 1880, there were fifteen fatal cases of large 
 single abscess (one was double) in Guy's Hospital, and in 
 these cases in five only was there a history that the patients 
 had lived out of England. In most of the remaining ten it was 
 definitely stated that tliey had never been out of England. A 
 
 1 Hilton Fagge, " Principles and Practice of Medicine," vol. ii. 
 
 Fig. 13. A largejsingle abscess of the lower portion 
 of the right lobe of the liver. The volume of 
 the liver is only slightly enlarged, although 
 there is considerable destruction of the hepatic 
 tissue. 
 
GE O GRAPHICAL DISTRIB UTION. 
 
 83 
 
 patient whom I have seen in St. Bartholomew's Hospital died 
 from a large single abscess of the liver, and he stated that he 
 had. never been out of England, 
 and also that he had never had 
 any dysenteric symptoms. Post- 
 mortem, several small dysenteric 
 ulcers were found in the colon. 
 Similar cases have been met with 
 in other places in Northern 
 Europe. From these facts it 
 seems that cases of true tropical 
 abscess can occur in England, 
 and other places with a tem- 
 perate climate. In Asia the 
 disease is endemic in India, Bur- 
 mah, Southern China, Southern 
 Japan, the East Indies, especially 
 Java, Sumatra and Borneo, 
 Ceylon, and the southern parts 
 of Arabia and Persia, especially 
 along the coasts of the Eed Sea 
 and the Persian Gulf. Fayrer ^ 
 says that, between the years 
 1850-1879, 2-19 per thousand 
 on an average died each year 
 from hepatic abscess among the 
 British troops, the mean strength 
 during the period mentioned 
 being 57,742 men. The mor- 
 tality varied in the different 
 presidencies. In Madras it was 
 3-31; in Bengal, 2-04; and in 
 Bombay, I'll, per thousand men. 
 From these observations of 
 Fayrer, and also those of 
 Chevers,'^ it seems that the 
 disease is more frequent in 
 Madras, especially on the Coro- 
 
 mandel Coast and in the Eastern Ghats. In Bombay it is 
 most frequent in the Ghat Mountains, and in Bengal in the 
 
 1 " Hygiene and Diseases of Warm Climates, 1893, p. 648 et seq. " Clievers, ibid. 
 
 Fig. 14. Large single abscess of the liver. 
 A liver containing a large abscess 
 situated in the right lobe near the 
 convex surface. The walls of the 
 abscess are irregular, and it has pene- 
 trated for some distance into the sub- 
 stance of the organ, causing destruction 
 of the hepatic tissue, so that its internal 
 aspect is rough and shaggy. The 
 abscess communicated with a circum- 
 scribed portion of the peritoneal 
 cavity. In the transverse colon the 
 scars of three ulcers are visible. — St. 
 Barth. Uosp. Museum. 
 
84 ABSCESS OF THE LIVER. 
 
 North-West Provinces. (Compare Hirsch, vol. iii.) These 
 statistics apply only to the British troops, and not to the 
 native population. According to Morehead/ the admissions for 
 hepatitis during the period of six years at the European Civil 
 Hospital of Bombay averaged 3 '7 per cent., and at the 
 Native Hospital, 1'5 per cent., of the total admissions. Waring ^ 
 says that abscess of the liver is met with in a considerable 
 number of cases in the native and foreign population, although 
 not so frequently as among the British troops. In Ceylon, 
 according to the observations of Marshall,^ the disease is as 
 common in the English troops as it is in India. In Africa the 
 disease is met with in the countries which form the coast of the 
 Mediterranean from Morocco on the west to Egypt in the east. 
 In Madagascar, Mozambique, Mauritius, Eeunion, Senegambia, 
 the Slave Coast, the Gold Coast, and Fernando Po, the disease 
 is said to be almost as frequent as in India; whilst on the 
 coasts south of these places it occurs, but much less commonly. 
 In America, the affection is said by most observers to be quite 
 rare in the West Indies, and in the United States it is very 
 rarely seen. It is very common in Chili, especially in the 
 north, and it is of frequent occurrence in Panama, Costa Pica, 
 Guatemala, Salvador, and the western coast of Mexico, whilst 
 on the eastern coast of Mexico it is less frequently met with. 
 In the Western Hemisphere, the northern coast of the Gulf of 
 Mexico forms the limit of the disease as a widespread affection. 
 (Hirsch.^) In Australia hepatic abscess is met with, but far less 
 frequently than in India. 
 
 Predisposing causes. — The predisposing conditions of tropical 
 hepatic abscess are fairly numerous, and deserve careful atten- 
 tion. 
 
 {a) Climate. — It has been shown by Mouat ^ and other 
 observers, that the frequency of the occurrence of tropical 
 abscess of the liver does not depend entirely upon the tempera- 
 ture alone, but that it varies to a considerable extent in tropical 
 places which have approximately the same mean annual tempera- 
 ture. In Algiers, Mauritius, Chili, where the climate is moderately 
 mild, the affection is far more prevalent than in such places as 
 
 1 MorL'liead, " Clinical Researches on Disease in India," 1S56. 
 
 - Waring, "Statistics and Pathology of Abscess in the Liver," 18.54. 
 
 •■' Marshall, " Notes on Medical Topography of Ceylon," London, 1821. 
 
 * Hirsch, "Geographical Pathology," vol. iii. 
 
 5 Mouat, Madras (Juart. Med. ./ourn., 1839. 
 
PREDISPOSING CAUSES. 85 
 
 Jamaica, Southern China, and Guiana, where the temperature 
 is much more tropical in character. In the North-Western 
 Provinces of India, and the higher parts of Madras, hepatic 
 abscess is more frequent than in Lower Bengal and Bombay, 
 where the climate is hotter. The rainy and cold seasons appear 
 to be the part of the year when the greatest proportion of cases 
 occur. Out of 243 deaths from abscess of the liver, which have 
 been analysed by Waring, 101 happened in the cold season, 
 seventy-nine in the rainy season, and sixty-thr^e in the hot 
 season. It seems from these facts, and the recorded observations 
 of many other writers, that the affection commences in the 
 greatest percentage of cases when the daily variations of the 
 temperature are the most considerable, that is when cold nights 
 follow very hot days. When we discuss the relation of tropical 
 abscess of the liver with malaria, it will be seen that the season 
 of greatest prevalence of the two affections is not quite the same. 
 In general terms it can be stated that the disease is most 
 prevalent when the atmosphere contains the greatest amount 
 of moisture, and the daily variations of temperature are the 
 most marked. 
 
 (&) Locality. — Some authors have maintained that tropical 
 abscess of the liver is more frequently met with in low-lying 
 marshy regions, and in those countries which have low, flat coasts, 
 than in elevated mountainous places and countries with steep 
 coasts, but there does not appear to be very much evidence in 
 support of this statement. In Madras and Bombay the disease 
 is more common in the elevated regions than in the low-lying 
 plains and on the coasts. 
 
 (c) PMce. — There is no doubt that the white members of the 
 population, that is to say Europeans, are most frequently 
 the victims of the disease in all countries in which tropical 
 abscess of the liver occurs, According to the statistics which 
 have been collected, concerning the prevalence of the affection in 
 the army in India, the ratio of the percentage of Europeans to 
 natives affected is from one to a little over two. A similar pro- 
 portion has been observed in other countries where the disease 
 is endemic, but according to Hirsch,^ the natives of these 
 countries, especially negroes, are more frequently the subjects 
 of the affection than the natives in India. People who have 
 recently arrived in a tropical country from a temperate one are 
 
 1 Hirsch, " Geographical Pathology," vol. ii\ 
 
86 ABSCESS OF THE LIVER 
 
 more liable to be affected than those who have lived in a hot 
 climate for some time. 
 
 {d) Sex. — The great majority of cases of tropical abscess of the 
 liver occur in the male sex. In 300 fatal cases collected by 
 Waring/ 291 were males and nine females. Of these latter, three 
 were Europeans and six native Indians. De Castro ^ tabulates 
 170 cases occurring in Egypt, and among these eight were 
 females. ZancaroH has recently published a record of 157 
 cases, which comprised 145 males and 12 females. It is evident 
 from these statistics that many more males were attacked than 
 females. 
 
 (e) Age. — Tropical abscess of the liver does not occur in young 
 children, and in old people it is only occasionally met with. 
 Eouis * says that amongst soldiers the most common age is 
 between 23 and 27, and in civil life between 30 and 45. 
 Poiret gives the years between 20 and 25 as the most frequent. 
 
 (/) Constitution. — The affection seems to be the most common 
 in persons of a strong constitution. Saux says that out of fifty-two 
 cases forty-seven were strong and healthy previously, and Eouis 
 asserts that in 116 patients 102 were of good constitution. 
 
 (g) Mode of life. — The mode of life has a strong influence in the 
 predisposition to the development of a tropical abscess of the liver. 
 The abuse of alcoholic liquors appears to be of very great im- 
 portance, and some authors have stated that alcoholic drink 
 constitutes a very important factor in every case of tropical 
 abscess of the liver. This is, however, probably too sweeping a 
 statement, as there are without doubt cases which arise quite 
 independently of alcohol. The number of cases of hepatitis has 
 been said to have diminished during recent years among the 
 soldiers in India and on the West Coast of Africa, and this 
 diminution has been attributed to the more sober habits of the 
 men and the smaller amount of alcohol consumed by them. 
 It is quite possible, however, that this diminution has been 
 partially brought about by improved sanitary conditions and 
 surroundings. Daniell asserts that since alcoholic liquors have 
 become a regular article of commerce among the natives of the 
 West Coast of Africa, hepatitis has become much more prevalent 
 
 1 Waring, loc. cit. 
 
 - D(! Castro, " De.s abcts du foie iles pays chauds, et de leur traiteiiient chirurgical," 
 Paris, 1870. 
 
 3 Zancarol, "Traitement chirurgical <lc.s aliccs du foie de.s pays cliauds," Paris, 1893. 
 •* Kouis, " Traitc pratique des iiiahulies des pays cliaud." 
 
RELATION TO OTHER DISEASES. 87 
 
 among them. The greater amount of intemperance among males 
 may explain to a certain extent their greater liability to tropical 
 abscess. Injudicious and indigestible food, together with luxurious 
 and idle habits, may be predisposing causes. Bad hygienic sur- 
 roundings, with such hard work and exposure as is met with in a 
 soldier's life, may also act in the same manner. 
 
 Relation to other diseases. — (a) Malaria. — Some observers, 
 such as Haspel,^ Annesley,^ and Dutroulau,^ have thought that 
 an inflammation of the liver leading to hepatic abscess, is one 
 of the manifestations of a malarial infection. When malaria 
 affects the liver, the gland becomes enlarged, and also undergoes a 
 certain amount of sclerosis ; but it does not appear that the 
 development of a tropical abscess has been directly induced 
 by the malarial poison. It is, however, possible that by causing 
 sclerosis the malarial poison may act as a predisposing cause in 
 hastening the formation of an abscess. It has been conclusively 
 shown that the countries, or parts of countries, where malarial 
 fevers are the most prevalent, are not those where hepatic 
 abscesses are the most common. In Algiers tropical abscess of 
 the liver is most common in the province of Oran, a region 
 where malaria is not very prevalent ; whilst in Constantine 
 (especially at Bona), which is the region where malaria is the 
 most frequent, hepatic abscess is uncommon. In Chili abscess 
 of the liver is a frequent affection, but malarial fevers are 
 unknown. Malarial fevers are very prevalent in the low-lying 
 lands in the basin of the Danube and the Mississippi, but abscess 
 of the liver is almost unknown in these areas. Malarial fevers 
 are most common in the hot seasons, and we have already seen 
 that this is not the time when hepatic abscess is most frequently 
 met with. 
 
 (h) Yellow Fever. — Kallies and Helfft have suggested that 
 yellow fever may act as a predisposing factor in the etiology of 
 hepatic abscess. 
 
 (c) Dysentery. — In a very considerable proportion of 
 cases of abscess of the liver, it is found that the patients 
 have suffered from dysentery. According to Kiener and 
 Kelsch,^ out of 314 cases of tropical abscess of the liver, 8 5 '5 per 
 
 1 Haspel, loc. cit. 
 
 " Annesley, " Diseases of India," 1841. 
 
 3 Dutroulau, " Traite des maladies des Europeens dans les pays chauds," Paris, 1868. 
 
 * Kiener et Kelsch, " Traite de maladies des pays chauds," 1889. 
 
88 ABSCESS OF THE LIVER. 
 
 cent, were associated with dysentery. Manson^ says that " it 
 may safely be asserted that in 75 per cent, of cases of hepatic 
 abscess a history of some degree of dysentery — not necessarily of 
 a very urgent character — can be elicited." Hirsch - has collected 
 a number of tables relating to death from dysentery, and out of 
 2377 cases there were 457 cases of concurrent abscess of the 
 liver, being 19 '2 per cent. Some authors have said that the 
 hepatic abscess may be the cause of an attack of dysentery, and 
 there is no doubt that in some cases an abscess of the liver has 
 apparently immediately preceded an attack of dysentery. An 
 organism which is known as the amoeba coli has been found in 
 the pus of a certain number of these cases. Kartulis^ found this 
 organism in the pus of several hepatic abscesses, and also in the 
 hepatic tissue forming the abscess wall; whilst Osier* found it in 
 the pus removed by operation from such an abscess. The same 
 organism has been found in a large number of cases of dysentery 
 in which the ulcers have been examined, and also in the stools 
 of patients suffering from this disease. It is not clear what is 
 the exact connection between the amreba coli and dysentery and 
 hepatic abscess, but possibly further investigations may throw 
 more light on the subject. Some observers have stated that 
 they have discovered the amoeba coli in the fteces of healthy 
 persons. 
 
 The micro-organisms of hepatic abscess. — As we have already 
 seen, there are a number of micro-organisms which have been 
 found in the pus of hepatic abscesses. In those abscesses which 
 arise as the result of pysemic processes, the organisms of ordinary 
 suppuration have been found. Thus the Staphylococcus pyogenes 
 cdbus and aureus have not unfrequently been found in the pus 
 of hepatic abscesses. In other cases Streptococcus pyogenes has 
 been apparent, whilst the Bacterium coli commune has occasionally 
 been demonstrated. We have seen that the amoeba coli has been 
 found alone or accompanied by micrococci in some of the cases 
 of tropical abscess. The pus from an abscess has occasionally 
 been found to be quite sterile and devoid of organisms. When 
 this condition is met with, tlie absence of organisms is to be 
 explained either by the incompleteness of the examination, or by 
 
 1 Manson, " Abscess of Liver," Quaiii's "Diet. Mediciue." 
 
 - Hir.sch, "Geographical Pathology," vol. iii. p. 412. 
 
 •' Kiirtnlis, Virchmv's Arrhir, 1889, Bd. cxviii. s. 97. 
 
 •* Osier, Centralbl.f. Jiakteriol. it. I'arasitenk., Jena, 1890, s. 736. 
 
PATHOLOGY OF HEPATIC ABSCESS. 89 
 
 the assumption that in the earlier stages of the affection they 
 were present, but that at a later period they died, owing to an 
 accumulation of the products of their vitality and growth, and 
 subsequently underwent disintegration. The specific organisms 
 are always present in cases of coccidial disease. In actinomycosis 
 of the liver, an affection which we shall deal with separately, the 
 specific organism of this affection is constantly met with. From 
 these facts it is apparent that an abscess of the liver may be 
 associated with a variety of micro-organisms, the individual form 
 varying to a certain extent with the pathological cause of the 
 disease. 
 
 Pathological anatomy of hejjatic abscess. — An abscess of the 
 liver may be single or multiple, as many as ninety having been met 
 with in the liver of the same patient. It is most usual to find 
 a single abscess, or at most not more than two or three, in those 
 cases which are the result of injury, or are included in the list 
 of tropical abscesses. In Waring's list of 300 cases, there was 
 a single abscess in 177 cases, two in thirty-three, three in eleven, 
 four in seventeen,and five in five cases. Eouis,Dutroulau,and Castro 
 give similar tables, and from an examination of all of these it appears 
 that in tropical cases the abscess is single in from 73 to 75 per 
 cent, of cases. Some of the cases which are due to gall stones or 
 ascarides, or which arise by direct extension from neighbouring 
 foci of suppuration, have only a single abscess, or not more than 
 two or three. Abscesses of the liver which are due to other 
 causes, in the great majority of cases are multiple. Fig. 11 
 shows a section of a liver in which there were multiple pya?mic 
 abscesses following a localised suppuration in the vermiform 
 appendix, as the result of a pin becoming lodged there. An 
 abscess of the liver which is of pytemic origin is single in a very 
 small number of cases. If a liver is examined post-mortem in 
 the early stages of the suppurative process, one or more small, 
 somewhat circular patches may be seen, of a grey or yellowish 
 colour, and having around them a ring of congested liver tissue. 
 The hepatic cells in the centre of these areas may be seen to be 
 undergoing a process of disintegration, by which means a small 
 cavity is formed which contains pus cells and tissue debris, and 
 is the commencement of the formation of the definite abscess. 
 Several small abscesses of this kind may form in immediate 
 proximity, and as they enlarge they open into one another, so as 
 to form one large abscess cavity. An abscess of the liver may 
 
90 ABSCESS OF THE LIVER. 
 
 enlarge in two ways. It may either increase in size by a 
 molecular disintegration of the tissue which forms its walls — that 
 is, by a variety of ulceration — or small abscesses may be formed 
 in the hepatic tissue which bounds it ; and as these secondary 
 abscesses increase in size they break through into the cavity of 
 the parent abscess and thus become an integral part of it. If 
 the tissue which forms the boundary of an abscess be examined, 
 it wiU be found in all acute abscesses to be infiltrated with 
 leucocytes, blood cells, and micro-organisms, and it is at the 
 expense of this infiltrated tissue that an abscess enlarges. The 
 internal wall of an acute abscess is usually somewhat irregular, 
 and a number of small portions of necrotic tissue are attached to 
 it. When an abscess becomes subacute or chronic, its internal 
 wall becomes thickened owing to an increase of the fibrous tissue 
 elements, and in some cases the purulent collection becomes 
 almost encysted. The contents of the abscess or abscesses vary 
 considerably. In cases of tropical abscess they are often reddish 
 or red-brown in colour and thick in consistency, the material 
 resembling to a certain extent a quantity of anchovy sauce. The 
 odour of these cases is said to be peculiar and distinctive. 
 Portions of necrotic tissue may be seen in many cases, or small 
 quantities of blood ; whilst in others the contents sometimes have 
 the appearance of laudable pus, or the pus may be thin and 
 watery. In the pysemic cases, the abscesses contain a thick and 
 mucoid substance ; but in some cases the pus is more like 
 laudable pus. When the abscess has been caused by a sup- 
 purating hydatid cyst, or by the presence of gall stones, or 
 ascarides in the liver substance, then these bodies may be found 
 as part of the contents of the abscess, and in the same manner 
 foreign bodies which have been the cause of the abscess may be 
 present. In a few cases the contents of the abscess have been 
 found to be stained with bile, but this is not of common occur- 
 rence. When the purulent material from an abscess of the liver 
 is examined, it is found to contain pus cells, broken-down and 
 disintegrating hepatic cells, blood corpuscles, fatty debris, 
 pigments, and the various kinds of micro-organisms which have 
 been mentioned already as occurring in the different forms of 
 abscess. An abscess not uncommonly forms communications 
 with the different viscera and serous spaces which lie in the 
 neighbourhood of the liver. Some part of the abdominal 
 aliuKMitary canal, or one or other of the thoracic viscera, are most 
 
SYMPTOMA TOL OGY. 91 
 
 commonly involved in this way. Langenbuch^ says that in 170 
 collected cases in which these complications occurred, in seventy- 
 four the abscess burst into the lung, in twenty-six into the right 
 pleural sac, in twenty-three into the peritoneal cavity, in thirteen 
 into the stomach, in four into the pericardium, and in one into 
 the pelvis of the right kidney. Cyr- has collected the records 
 on this subject, and he finds that out of a total of 563 cases, 
 fifty-nine opened into the lungs, thirty-nine into the peritoneal 
 cavity, thirty-one into the pleura, thirteen into the colon, eight 
 into the stomach or duodenum, four into the biliary passages, three 
 into the inferior vena cava, two into the kidneys, two upon the 
 external surface of the body, and one into the pericardium. Of 
 this number, 311 were not opened, whilst eighty-three were opened 
 by operation. From these statistics it is evident that the lungs, 
 pleura, peritoneum, and the alimentary canal are the anatomical 
 structures to which abscesses most frequently spread. 
 
 The size of hepatic abscesses varies from one which is only 
 a few millimetres in diameter to one containing several litres of 
 pus. In nearly all cases of this affection the liver is increased 
 in bulk. Dutroulau ^ says that in sixty-six cases, which he had 
 observed, the size was increased in fifty-nine, unchanged in five, 
 whilst in two the gland was smaller than normal. Any part 
 of the liver may be the seat of an abscess, but it is found that 
 the right lobe, especially at its posterior and upper portion, is 
 most frequently involved. Waring* says that out of 240 cases 
 the right lobe was affected alone in 163, the left lobe alone in 
 sixteen, and both lobes in ten. These statistics relate to 
 tropical abscess only. The right lobe of the liver is four or five 
 times the size of the left lobe, hence it is only natural that 
 this lobe should be more commonly affected. 
 
 Symptomatology. — The clinical symptoms which result from 
 the presence of the different varieties of abscess of the liver do 
 not differ essentially in their nature, and on this account they 
 can be considered together. Many cases run a latent course, 
 and this is especially the case with tropical abscess. According 
 to Eouis,^ 13 per cent, of cases of tropical abscess are latent. 
 Many observations have been recorded of cases which were 
 
 1 Langenbucli, loc. cit., p. 276. 
 
 ■2 Cyr, " Traite pratique des maladies de foie," Paris, 1887. (These statistics include 
 those made by Wariug, Dutroulau, Roux, Haspel, aud Cam bray.) 
 
 3 Dutroulau, loc. cit. "^ Wariug, loc. cit. ^ Rouis, loc. cit. 
 
92 ABSCESS OF THE LIVER. 
 
 latent for some time, and then terminated with severe symptoms, 
 owing to rupture of the abscess into one of the neighbouring 
 organs, most commonly into the lung or peritoneal cavity. One 
 case has been described by Maclean, in which an old abscess 
 suddenly burst into the pericardium, after the patient had been 
 taking exercise, and terminated fatally. Another case has also 
 been recorded, in which the abscess burst into the pericardium 
 when the patient was straining at stool. When the abdominal 
 region of a patient, who is suffering from an abscess of the liver, 
 is examined, some part of the hepatic area may be seen to bulge 
 somewhat, or present a definite localised prominence. This, in most 
 cases, appears immediately below the right costal margin, either in 
 the hypochondrium or in the epigastric region. When the left lobe 
 of the liver is the seat of the abscess, a prominence may be seen in 
 the left hypochondrium, and extending into the epigastric region ; 
 or the lower two or three intercostal spaces of the right side may 
 bulge slightly, so that they are a little wider than usual, and the 
 respiratory movements are restricted or absent in these spaces. 
 
 Some observers have laid stress upon the appearance of 
 rigidity in the upper portion of the right rectus abdominis 
 muscle, but this condition is not confined to cases of 
 abscess of the liver, and may be met with in any case 
 where there is a suppurative or inflammatory process in the 
 upper portion of the abdominal cavity. Whenever there is a 
 fulness or swelling of the epigastrium and the adjacent portions 
 of the hypochondriac regions in a patient who may be the 
 subject of hepatic suppuration, and especially in those who are 
 emaciated, the probability of an abscess must always be borne 
 in mind when making a diagnosis. The skin over the localised 
 prominence may be slightly reddened, but usually nothing more 
 than a faint oedema can be discerned ; but if this can be seen and 
 recognised, it is a fact of much importance, since it points to the 
 existence of pus in the neighbourhood. Tlie patient often 
 complains of pains in the epigastric or right hypochondriac 
 regions, these pains being either sharp and cutting, or more 
 frequently heavy and dull in character, and occasionally amount- 
 ing to nothing more than a sense of heaviness and uneasiness. 
 When they are sharp and darting, they usually indicate that the 
 inflammatory affection has spread to the peritoneal surface of the 
 liver, causing some perihepatitis. If the abscess is entirely confined 
 to the interior of the gland, no pain of any kind may be noticed. 
 
S YMPTOMA TOL OGY. 
 
 93 
 
 An enlargement of the liver can generally be made out on 
 palpation of the hepatic region. This enlargement may be 
 either localised or general, most usually the former ; it may be 
 considerable or only slight, and it may extend upwards or 
 downwards, or in both directions. The localised swelling, when 
 present, usually feels smooth and somewhat rounded. Occasion- 
 ally it is possible to detect signs of friction, owing to the 
 inflammation having extended to the peritoneal covering, and so 
 produced rough surfaces which rub together, especially during 
 the respiratory movements, but this friction can only be felt in 
 rare cases. On careful examination, it is sometimes possible to 
 detect fluctuation in the hepatic swelling. When this can be 
 done with certainty, it is definite evidence that the swelling 
 contains fluid, and if there is also local tenderness and pain, or 
 oedema and redness of the overlying tissue, then it is probable 
 that an abscess is present. During the movements of respira- 
 tion, a swelling, which is either in close connection with the 
 liver or within it, can be felt to ascend and descend synchron- 
 ously with the respiratory movements. If the skin over a swelling 
 of the liver is red, owing to the abscess pointing in that area, the 
 central portion will usually be soft, and the tissues around hard 
 and indurated. This condition is not common, and is only seen 
 in the later stages of those cases which approach the surface. 
 
 Auscultation in the majority of cases is of little value in 
 the diagnosis of hepatic abscess. If the inflammatory pro- 
 cess has extended to the surface of the gland, so as to cause 
 perihepatitis, it is possible to hear friction sounds over the 
 region of the liver. In a similar manner, if the inflammatory 
 process extends through the diaphragm and causes a pleurisy, then 
 friction sounds may be heard over the base of the right lung. 
 Crepitations may also be heard in the base of the lung — more 
 often the right — when the inflammatory process has extended 
 to the lung, or perforation of the abscess into the lung has taken 
 place. In those cases in which an abscess has ruptured into the 
 lung, and a portion of the contents has been evacuated, and the 
 space which was occupied with purulent matter becomes filled 
 with air from the lung, it is possible to hear a curious bruit 
 synchronous with the systole of the heart, which is caused by 
 the entrance and exit of air through a small aperture from the 
 lung to the abscess cavity at each contraction of the ventricles 
 of the heart. From a similar reason, it has been said that a 
 
94 ABSCESS OF THE LIVER. 
 
 SLiccussion splash may occasioually be heard on shaking the 
 patient. The exact area of the hepatic duhiess can be definitely 
 mapped out by percussion, except where it passes into the 
 cardiac dulness above, and into the dulness which is present in 
 consolidation of the base of the lung, or into the area of dulness 
 of a pleural effusion. 
 
 The enlargement of the hepatic dulness, which is present 
 in cases of abscess, will frequently be found to extend upwards, 
 whilst the lower border of the gland will be found to be more 
 or less normal, and less commonly the hepatic dulness may be 
 increased in a downward direction, or even both upwards and 
 downwards. When an abscess is present, the area overlying it 
 is often found to be tender, and in some cases acute darting 
 pain is induced on percussion. If the normal outline of the 
 liver is found to be altered, this must be regarded as important 
 evidence in making a diagnosis regarding the presence of an 
 abscess, especially if the abnormal part gives signs of fluctuation. 
 In a few cases the lower outline of the liver has been found 
 almost as low as Poupart's ligament, but this is unusual in 
 cases of abscess. Displacements of adjacent viscera may 
 occasionally occur in an abscess of the liver, owing to the local 
 enlargement pushing the viscera aside. The heart may be 
 found to be displaced upwards and to the left, or if the enlarge- 
 ment is chiefly in the upper part of the right lobe it is dis- 
 placed towards the left alone. The right dome of the diaphragm 
 and lung may be pushed upwards at the same time, or even 
 without any displacement of the heart. The stomach and colon 
 and the right kidney may also be pushed downwards, owing to 
 the enlargement of the liver in this direction. Patients often 
 suffer from pains in the region of the shoulder and over the 
 scapula, and in nearly all cases it is the right scapular region 
 and shoulder ; but occasionally the left side is involved, and 
 when this is the case it is said that the left lobe of the liver 
 is the seat of the abscess, as has been demonstrated post-mortem 
 by several observers (Chvostek, Gintrac, Broussais). In some 
 the shoulder pain has been bilateral. The pain in these cases 
 is most intense over the angle of the scapula and at the tip of 
 the shoulder, and it has been supposed to be due to irritation of 
 the branches of the phrenic nerve which sujjply the surface of 
 the diaphragm and the convexity of the liver. It is said only 
 to occur when the inflammatory process has extended to the 
 
S YMPTOMA TOL OGY. 95 
 
 surface of the gland, and is more frequently present when the 
 abscesses are multiple and pypemic in origin than in the single 
 tropical variety. Some observers have stated that it is present 
 only in those cases in which the convexity of the liver is 
 involved, but this does not appear to be correct, since Andral 
 has recorded a case of right-sided shoulder pain which was 
 found to be associated with an abscess situated upon the 
 inferior part of the right lobe. In a few cases paralysis and 
 wasting of the deltoid muscle, and of other of the arm muscles, 
 has followed an abscess of the liver, but the exact connection 
 between them is not clear. Irritation of the phrenic nerve, by 
 a reflex process, seems to be the cause of a short, dry, hacking 
 cough, which occurs in some cases, and has been named " hepatic 
 cough " or " tussis hepatica." This cough is distinct from that 
 which is caused by extension of the inflammation to the lung or 
 pleura, or that which occurs when an abscess has opened into 
 the lung, and its contents discharged into the bronchi and 
 coughed up. The sputum has been said by Councilman ^ 
 occasionally to contain the amoeba coli, the presence of which 
 indicates, in his opinion, that the abscess is in close relation to 
 the pneumonic tissue, and that it is the precursor of rupture of 
 the abscess and the discharge of its contents into the lung. 
 When the abscess is large and encroaches upon the thoracic 
 cavity, owing to its extension in an upward direction, a moderate 
 amount of dyspnoea may be induced. When the abscess is 
 situated on the inferior aspect of the gland, the portal vein and 
 the other structures in the portal fissure may be pressed upon, 
 and, as a result, ascites, enlargement of the spleen, and jaundice, 
 may be established. 
 
 The structures in the portal fissure or in the gastro-hepatic 
 omentum, however, are very uncommonly obstructed in abscess 
 of the liver. The skin in many cases has a dirty or muddy 
 coloration, which resembles slight jaundice, and the sclerotic has 
 a yellowish tinge. True jaundice only occurs when the bile 
 ducts in the portal fissure are pressed upon. The course of the 
 temperature in cases of abscess of the liver varies very consider- 
 ably. When the abscess follows an injury, the commencement 
 of the suppurative process will usually be marked by a definite 
 rise of temperature, or even by the occurrence of a rigor, and 
 during the course of the affection the temperature will remain 
 
 1 Councilman, Brit. Med. Journ., London, 1892, p. 67 (Epitome). 
 
96 ABSCESS OF THE LIVER. 
 
 elevated unless a free exit for the pus is established. In those 
 cases which are py.iemic in origin (such as those following 
 affections of the abdominal viscera, after head injuries, and in 
 ulcerative endocarditis), the commencement of the hepatic 
 affection will usually be accompanied by the occurrence of a 
 rigor, and the subsequent course will be similar to that of an 
 ordinary case of pyaemia. The temperature in cases of tropical 
 abscess is usually found to be raised, especially in the evening, 
 but not, as a rule, higher than 102° or 103° F, Eigors have 
 been noted occasionally, but these are not very frequent. 
 
 Sometimes the temperature has been said not to have 
 undergone any elevation at all, and this especially is the case in 
 those patients in whom the disease runs a chronic or latent 
 course. It is not possible to diagnose a case of abscess from the 
 temperature chart alone, but when this is considered along with 
 the other clinical symptoms and the history, it may afford 
 valuable help. Digestive disturbances are often met with. 
 When the abscess is situated on the inferior surface or in the 
 left lobe, it may press upon the anterior and upper portion of 
 the stomach and be the cause of attacks of vomiting. The 
 appetite is usually impaired, but in some cases it remains good. 
 The urine in those cases in which the temperature is raised is 
 of high specific gravity, loaded with urates, and of dark colour, 
 but the presence of bile pigments is uncommon. The state of 
 the bowels varies a good deal ; they may be constipated, or 
 diarrhoea may be a marked symptom, and in other cases these 
 conditions may alternate. When the abscess communicates with 
 some portion of the alimentary canal, large quantities of pus 
 may be found in the stools. In cases of dysentery the stools 
 peculiar to this affection are, of course, met with, and, according 
 to some recent observers, the amoeba coli is constantly seen. 
 In all cases of hepatic abscess, especially the non-tropical ones, 
 the symptoms which are due to the presence of an abscess in 
 the liver are liable to be partially masked and modified by the 
 symptoms of the disease of which the hepatic affection is only a 
 secondary manifestation. 
 
 ComiMcations. — Abscess of the liver is very commonly 
 associated with or liable to l)e followed by certain complica- 
 tions, the most frequent of which is rupture into one of the 
 adjacent viscera. 
 
 {a) Iliqdarc into the stomach or some part of the alimentary 
 
COMPLICA TIONS. 9 7 
 
 canal. — When the abscess bursts into the stomach, it is 
 generally followed by an attack of vomiting, during which 
 the pus is evacuated through the mouth. In most cases 
 the pus is foul-smelling, and contains a quantity of blood 
 mixed with it, or it may contain either a foreign body or a 
 gall stone, or an ascaris, if any of these have been the cause 
 of the formation of the abscess. In a few cases of rupture into 
 the stomach, the pus has passed along the alimentary canal and 
 been evacuated through the anus, after having been partially 
 disintegrated by the processes of digestion. Symptoms of 
 anorexia, and a continual feeling that the stomach is full, are 
 said to precede a rupture into the stomach in many of the 
 cases. Kupture into the duodenum is occasionally met with, 
 and may be followed by vomiting of pus, blood, and bile ; or 
 the purulent matters may pass along the intestine, to be 
 evacuated per anum in the form of diarrhoeic, pus-containing 
 motions. The opening of a hepatic abscess into the stomach is 
 not very frequent ; much more common is bursting into the large 
 intestine, especially into the hepatic flexure and the transverse 
 colon. When this occurs it is usually associated with the 
 occurrence of symptoms of shock, followed by the passage of 
 a considerable amount of pus and blood per anum. An abscess 
 may also open into the small intestine, but this is of very in- 
 frequent occurrence. According to Thierfelder,^ out of 120 
 cases, thirteen opened into the stomach and thirty-two into the 
 intestine. 
 
 (&) Into the -peritoneal cavity. — This is not uncommon in 
 cases of hepatic abscess, and among Thierfelder's cases, twenty- 
 three opened in this way. In Cyr's ^ statistics, thirty-nine 
 cases out of 543 ruptured into the peritoneum. Eupture 
 usually occurs during some muscular exertion such as straining 
 at stool, and in these cases is immediately followed by symptoms 
 of severe shock and the development of acute peritonitis. In 
 some cases, if the abscess is small and chronic, the pus may 
 become encysted and shut off from the remainder of the 
 peritoneal cavity, and so result in the formation of a localised 
 peritonitis. Up to the present time most of these cases have 
 been followed by fatal results, but in the case recorded by 
 Hulke,^ recovery ensued after a surgical operation. 
 
 1 Thierfelder, "Ziemssen's Handbuch," 1878, vol. vii. - Cyr, loc. cit. 
 
 3 milke, Med.-Chir. Trans., London, 1894, p. 81. 
 
98 ABSCESS OF THE LIVER. 
 
 (c) Opening of the abscess into the pelvis of the right hidney. — 
 This condition is very rare, and only about ten cases have been 
 recorded (Waring, Huet, Hashimoto, Colin). When it occurs 
 it is accompanied by signs of diminution in size of the hepatic 
 swelling, and immediately afterwards by the presence of pus, 
 blood, and liver cell debris in the urine. Cases of this kind 
 have terminated favourably in a few instances. 
 
 (d) Rupture into the inferior vena cava. — This is a very rare 
 complication, and when it occurs it is fatal either at once from 
 embolism of the lungs, or later from secondary abscesses. This 
 accident occurred three times in Waring's three hundred cases. 
 A similar result has followed rupture of the abscess into the portal 
 vein, a condition of affairs which has been seen in a few cases. 
 
 (e) Rupture into the Uliary passages. — Opening of the 
 abscess into the gall bladder, or more rarely into one of the 
 larger bile ducts, has been met with in only a small number 
 of cases. In a case which has been described by Jubiot,^ the 
 patient passed a large amount of pus and blood per anum, a 
 short time before death, and when examined afterwards the 
 abscess was found to have opened into the gall bladder. As a 
 result of this form of rupture, an inflammatory condition of the 
 mucous membrane lining the biliary passages may be established, 
 which is associated with symptoms of liver colic and the 
 development of jaundice. These cases are not necessarily fatal ; 
 occasionally recovery follows, which was the case in a patient 
 mentioned by Galloupe.^ 
 
 (/) Bursting into the pleura or lung. — Before either of these 
 complications can occur, it is necessary that the inflammatory 
 process should extend to the convexity of the liver, and thence 
 to the diaphragm, and through this to the pleura or lung, 
 or both. Eupture into the lung is more frequent than rupture 
 into the pleura. In many cases the inflammatory process 
 causes adhesions to be formed between the visceral and parietal 
 layers of the pleura, and in this manner the pleural cavity 
 is shut off, and the abscess makes its way into the lung 
 tissue. According to the tables of Thierfelder,^ out of 170 
 cases, twenty-six burst into the right pleural cavity, whilst 
 Rendu ^ thinks that about 5^ per cent, of cases open in this 
 
 1 Jiihiot, quoted hy Langenbuch. 
 
 - Giilloupe, Boston Med. and S. .Tourn., 1883, p. 271. 
 
 3 Tliierfulder, Inc. cit, •• Rendu, loc. cit. 
 
COMPLICATIONS 99 
 
 way. In the table of collected cases given by Scheube,^ 
 out of 563 cases, thirty-one opened into the pleura, and fifty- 
 nine into the lung. The symptoms of this complication are 
 those of a rapidly developing empyema of the right side. It 
 is only very rarely that the left pleura is the seat of rupture of 
 a hepatic abscess, but this may occur when the abscess is 
 seated in the left lobe of the liver, although a case has been 
 recorded by Peacock,^ in which an abscess of the left lobe 
 perforated into the right pleura. Eupture into the lung is 
 the most common complication, and, according to Eendu, it 
 occurs in a little over 10 per cent, of cases. Among the 170 
 cases collected by Thierfelder, rupture into the lung occurred in 
 seventy-four. The right lung is the seat of rupture in nearly 
 every case, and the base is the part into which the rupture 
 takes place. It is preceded by a localised pleurisy, which 
 terminates in the formation of adhesions between the base of 
 the lung and the upper surface of the diaphragm. In most 
 cases the rupture opens into one of the larger bronchi in the 
 lower lobe of the right lung, through which the purulent con- 
 tents of the abscess pass into the trachea, whence they are 
 coughed up and evacuated through the mouth. Eupture into 
 the lung is said to be preceded by premonitory symptoms of 
 cough, and if the base of the right lung is examined with the 
 stethoscope, crepitations or rales can be detected, whilst the 
 sputum may, in the tropical cases, contain the amoeba coli. 
 When rupture has occurred, quantities of purulent material 
 mixed with blood corpuscles and liver-cell debris is coughed up. 
 The pus is generally of a very foul odour, and in some cases 
 foul-smelling breath has been noticed to precede bursting of 
 the abscess into the lung. When the abscess cavity has been 
 evacuated, the walls may bleed freely, the blood passing into 
 the bronchus, and thence through the mouth, so as to give rise 
 to the impression that the patient is suffering from haemoptysis. 
 This condition must be remembered when dealing with cases of 
 apparent hsemoptysis in patients who have been the subjects 
 of an attack of dysentery. After an abscess has been evacuated 
 in this manner, the sputum of the patient may be so dark in 
 colour as to resemble that from a case of pneumonia, and in 
 treating patients affected thus, care must be taken not to 
 
 1 Scheube, " Kraukheiten des Warmeu Lander," 1896, s. 380. 
 - Peacock, Med. Times and Gaz., Loudon, 1867, vol. ii. p. 611. 
 
loo ABSCESS OF THE LIVER. 
 
 make a mistake in diagnosis. For analogous reasons, hepatic 
 abscess must not be confused with pulmonary phthisis. Occa- 
 sionally the sputum has been noticed to be coloured slightly 
 yellow, owing to the presence of bile, and Wolfes has dis- 
 covered the presence of sugar in the pus which was coughed up 
 from an abscess of the liver. The course of the disease in 
 patients suffering from abscess of the liver which has burst 
 into the lungs, has often been very favourable ; although dis- 
 charge of purulent material may go on for a very long time. 
 According to Castro ^ a good result follows in 7 6 per cent, of 
 patients in whom the abscess bursts into the lung. In Castro's 
 statistics the abscesses were of the tropical variety, and in 
 these undoubtedly a good result often follows ; but when the 
 abscess is due to a pysemic affection, the termination is nearly 
 always fatal. Fig. 11 is a drawing made from the liver and 
 lung of a patient who died from a pyemic abscess of the liver 
 which perforated the diaphragm and opened into the right lung. 
 {g) Bursting into the pericardium. — This is fortunately 
 a rare complication, but when it does occur it is invariably 
 fatal. Cases of this kind have been recorded by Christiansen,^ 
 Mayet,^ Hambursin,^ Pimser,^ etc. It is said by some authors 
 that the condition may be preceded by signs of pericarditis, 
 when the inflammatory process has extended through the 
 diaphragm .to the superjacent pericardium. The complication 
 appears to have come on without any recognisable premoni- 
 tory symptoms, and to have been characterised by symptoms 
 of severe shock, weak and irregular pulse, and signs of fluid 
 in the pericardium, in the majority of those cases which have 
 been placed on record. Death usually follows this condition 
 within twenty-four hours of the occurrence of the rupture. In 
 a certain number of cases, rupture into the pericardium appears 
 to be the termination of an abscess situated in the left lobe. 
 Abscesses in this position, however, are much less frequent than 
 in the right lobe. It seems, therefore, that an abscess of the 
 left lobe is much more liable to be followed by rupture into 
 the pericardium than one which is situated in the right lobe. 
 The aperture of communication between the abscess cavity and 
 
 1 Castro, loc. cit. ^ Fijrh. Xorske med. Selsk. i. Kristiania, 1890, p. 211. 
 
 3 Mayet, daz. liehd. de med., Paris, 1873, Nos. 39-42. 
 ■* Hamhursin, I'resse med. beige, Bruxelles, 1869. 
 ' Piinser, Wieii. med. Wchnschr., 1883, s. 1244. 
 
COMPLICATIONS. loi 
 
 the pericardium may be very small, and the purulent matter 
 may consequently only pass slowly into the cavity of the 
 pericardium, in which case the symptoms are not so acute as 
 when the aperture is larger. 
 
 (7i) Bursting of the abscess on the surface of the hocly. — An 
 abscess of the liver may occasionally point on the surface of 
 the body, and discharge its contents externally. The point 
 of exit of the pus may be in the epigastrium, in the right 
 hypochondrium, or between the ribs through one of the lower 
 intercostal spaces ; or in rare cases the pus may track underneath 
 the superficial tissues and open at some distant point, such as the 
 lower part of the abdomen, over the sacrum, in the axilla, or even 
 in the scrotum or thigh. After a liver abscess has opened upon 
 the surface of the body, it may terminate in the development 
 of a fistula, from which bile is discharged and which is liable to 
 persist for a long time. When the abscess tends to come to 
 the surface, it in many cases causes a necrosis of the super- 
 jacent portions of the lower ribs. 
 
 Symptoms in connection with the general nervous system 
 may develop in the later stages of a case of hepatic abscess. 
 These tend to be of the nature of melancholia and hypochon- 
 driasis, or there may be well-marked delirium and coma. They 
 are more common in the later stages of cases which are of pysemic 
 origin, and are dependent upon pathological conditions of the 
 brain or its membranes. In some cases oedema and thickening 
 of the arachnoid and pia mater have been noticed, in others 
 purulent meningitis has been present, and in others, again, 
 secondary abscesses have been • found in some part of the brain. 
 Hammond^ advises, in cases of hypochondriasis and melancholia 
 occurring in regions where hepatic abscess is common, that 
 the condition of the liver should be carefully examined, and if 
 any doubt exists, that an exploratory puncture with an aspirator 
 should be made. The patient is irritable, and often has fits of 
 depression, without exhibiting definite signs of hypochondriasis 
 or melancholia, in most cases of abscess of the liver. 
 
 Diagnosis. — In those cases in which the abscess is latent, the 
 diagnosis is impossible until it bursts into one or other of the neigh- 
 bouring organs, or comes to the surface of the liver and gives rise 
 to definite symptoms. Pain localised in the right hypochondriac 
 region, and associated with pain in the right shoulder or in the 
 
 1 Hammond, St. Louis Clin. Rec, 1878. 
 
I02 ABSCESS OF THE LIVER. 
 
 right scapular region, together with muddiness of the complexion 
 or slight jaundice, and an enlargement of the liver which can be 
 felt on palpation or recognised by percussion, and the presence 
 of a raised temperature, will suggest the existence of hepatic 
 suppuration. The presence of dysentery, or some septic 
 inflammatory process in connection with one of the abdominal 
 viscera, will help in forming a correct diagnosis. A feeling of 
 weight and fulness in the right hypochondrium, which is 
 associated with an elevated temperature, malaise, and general 
 wasting, together with signs of a localised enlargement of the 
 liver in some direction, will point to the possible occurrence of 
 an abscess of the liver. Jaundice is most common in infective 
 or pyaemic cases, and is said to be due to a general infection of 
 the blood ; when it is deep and intense, it may be due to 
 pressure upon the hepatic ducts. If hepatic suppuration has 
 existed for some time, it may cause perihepatitis, which condition 
 will be rendered evident by the presence of signs of friction 
 over the inflamed area. Localised perihepatitis may simulate 
 the symptoms of a hepatic abscess. In these cases the pain is 
 very localised, develops suddenly, and on auscultation a distinct 
 friction sound is heard. There are usually no signs of enlarge- 
 ment of the liver, and the general symptoms are not so severe. 
 The previous history of the patient may afford important 
 evidence of abscess ; thus the history of a blow or perforating 
 wound in the hepatic region, or an attack of dysentery, or of 
 some focus of suppuration, especially in the pelvis or caecal 
 region, would favour the diagnosis of abscess, if there are any 
 symptoms which point to an affection of the liver. The 
 possibility of the occurrence of an abscess of the liver must 
 always be borne in mind when suppurating head injuries are 
 under consideration. In many cases it is impossible to make a 
 diagnosis as to the nature of a swelling in connection with the liver, 
 before aspiration. This procedure is justifiable, but arrangements 
 should always be made so that if an abscess is found it can be 
 evacuated by a surgical operation. The nature of the abscess, if 
 present, can often be determined by an examination of the pus 
 which is withdrawn by the aspirator. Thus, if it is due to 
 dysentery, the amoeba coli may be demonstrated ; if it is due to 
 suppuration in connection with a hydatid cyst, booklets may be 
 seen ; and if it is due to coccidia, these micro-organisms will be 
 found. The pus from a tropical abscess has very often the colour 
 
TREATMENT. 103 
 
 and consistence of anchovy sauce, and that in pyiemic cases is 
 generally thick and mucoid in nature, and contains pyogenic 
 bacteria. In cases of actinomycosis the fungus of this affection 
 can be seen under the microscope, or the yellow granules may 
 be apparent to the naked eye. 
 
 Treatment. — Whenever the presence of a collection of pus 
 within the interior of the liver has been definitely diagnosed, 
 direct surgical treatment is indicated, and the object of the 
 operative procedure is the evacuation of the purulent matter 
 through an opening upon the surface of the body. A 
 variety of operations have been made use of for this purpose 
 by different surgeons. In former times it was recommended 
 that the pus should be evacuated through the needle of an 
 aspirator, or through a cannula which had been pushed into the 
 interior of the abscess, along with a trocar which was removed. 
 It was found in cases which were treated by this method, that 
 suppuration along the track of the needle or cannula was very 
 liable to occur, and in many cases a leakage of pus into the 
 peritoneum or the pleura followed and set up an attack of acute 
 septic peritonitis or pleurisy, which in most cases proved fatal. 
 On this account it is advisable to regard puncture of an abscess 
 of the liver with the needle of an aspirator or exploring syringe, 
 as a diagnostic measure, or at most an accessory procedure in the 
 evacuation of a collection of pus from within the liver. 
 
 In all cases a free opening should be made into the cavity of 
 the abscess, so that the purulent contents can be thoroughly 
 evacuated, and a complete examination made of its interior, and 
 if any secondary abscesses are present they can be made to com- 
 municate with the cavity of the one first opened. 
 
 Before deciding upon the area which is to be incised, so as 
 to allow of the evacuation of the abscess, the patient should be 
 anaesthetised, and the hepatic area rendered quite aseptic by 
 washing, first with soap and water, then with ether, and finally 
 with a solution of perchloride of mercury. When this has been 
 done, the exact extent of the liver, and the location of any 
 enlargement is made out. If the position of an abscess can be 
 made out in this manner, a point is taken which is nearer the 
 upper margin of the enlargement than the lower, and the needle 
 of an aspirator is pushed inwards until the interior of the abscess 
 cavity is reached. When the needle is felt to enter a cavity, 
 its point is moved about so as to ascertain, as far as possible 
 
3 04 ABSCESS OF THE LIVER. 
 
 the size, shape, and extent of the abscess. In every case in 
 which the point of the exploring needle enters a space within 
 the liver, it is advisable to withdraw a small quantity of the 
 contents, so as to ascertain their nature and character, and by 
 this means obtain information which may be of great value 
 during the further treatment. When the exact locality of the 
 abscess within the liver has been made out, a point is selected, 
 which is situated over its most prominent part, and somewhat 
 nearer the upper limit than the lower (and, if possible, im- 
 mediately below the costal margin), and an incision made 
 through the overlying tissues until the surface of the liver is 
 reached. This incision is best made with a knife, though Zan- 
 carol^ advises that it should be made with a thermocautery. 
 The further stages of the operation depend upon the condition of 
 the surface of the liver and the surrounding structures. In all 
 cases where the visceral and parietal layers of peritoneum in the 
 region of the incision have become adherent, and so cut off the 
 area of the operation from the peritoneal cavity, the incision is 
 deepened through the hepatic substance until the abscess cavity 
 is opened. This incision through the hepatic tissue may be made 
 either with an ordinary scalpel or with the knife of a thermo- 
 cautery, preferably the latter, since it tends to arrest hciemorrhage 
 from the injured liver. 
 
 When no adhesions have formed between the visceral 
 and parietal layers of peritoneum within the area of the 
 incision, the further methods of procedure vary according as 
 to whether it is thought better to shut off the peritoneal cavity 
 or not. It appears to me that the following is the safest course 
 to adopt, and the least likely to be followed by septic complica- 
 tions. The adjacent portion of the peritoneal cavity is packed 
 with flat aseptic sponges, so as to protect the other abdominal 
 viscera, and prevent any of the contents of the abscess from 
 infecting the exposed area of peritoneum. Then the cavity of 
 the abscess is opened by making an incision through the liver 
 substance with the knife of a thermocautery, or an ordinary 
 scalpel ; when the cavity of the abscess has been opened, the 
 finger of an assistant is introduced, and the liver hooked forwards 
 and held in contact with the parietes. The contents of the 
 abscess are evacuated, the interior of the cavity thoroughly 
 irrigated with an antiseptic solution (hyd. perchlor. 1-1000), 
 
 1 Zanc.arol, loc. clt. 
 
TREATMENT. 105 
 
 and then the internal surface swabbed by means of sponges on 
 holders. When this has been done, a long strip of iodoform 
 gauze is packed in the interior of the abscess so as to fill the entire 
 cavity. The exposed surface of the liver and the adjacent portion 
 of the peritoneum should then Ije thoroughly irrigated and 
 cleansed from blood, purulent matter, or debris ; and, finally, the 
 margins of the hepatic wound are united to those of the parietal 
 incision by a ring of silk sutures, inserted according to the method 
 described in the operation of " hepatotomy." A dry antiseptic 
 dressing is applied and fixed in position with a bandage. The 
 antiseptic gauze tampon should be allowed to remain unchanged 
 for about two or three days, in order to permit the formation of 
 adhesions between the approximated layers of peritoneum. After 
 this time it is advisable to change the dressing daily, and on 
 each occasion to irrigate the interior of the abscess cavity. Some 
 surgeons have advised that this operation should be performed 
 in two stages, so that adhesions may form between the surface of 
 the liver and the abdominal wall before the abscess is evacuated ; 
 but in order to effect this it is necessary to delay the evacuation 
 of the purulent matter from the abscess for four or five days, a 
 proceeding which appears to me to be somewhat unsurgical. 
 
 In many cases of abscess of the right lobe of the liver, it is neces- 
 sary to perform the operation through an incision in the thoracic 
 wall, on account of the high level at which the purulent collection 
 is located, and the difficulty which is experienced in dealing with 
 it from an incision in the abdominal wall. The details of the 
 operation through the chest wall are discussed in the chapter 
 on Operations.. It is advisable in all cases in which an incision 
 is required in the substance of the liver, when this organ is 
 situated at some distance from the surface, to incise the liver 
 tissue with the knife of a thermocautery, since this procedure 
 tends to avoid or prevent the occurrence of haemorrhage and the 
 passage of purulent matter into any of the small hepatic veins. 
 On this account it is recommended that the incision in the liver, 
 in cases of hepatic abscess which are being treated through a 
 thoracic incision, should always be made with the knife of a 
 thermocautery. An abscess of the liver may be situated either 
 in the right or left lobe, or it may involve both. When situated 
 in the right it may be necessary to carry out the evacuation, 
 either by an abdominal or a thoracic incision, but when it is 
 located in the left lobe the operation can always be performed 
 
io6 ABSCESS OF THE LIVER 
 
 through an incision in the abdominal wall. When an abscess of 
 the liver communicates with the right pleural cavity, it is advis- 
 able to make a very free opening into the chest by resecting 
 portions of two or even more ribs, and through this opening to 
 evacuate the collection of pus within the liver, and to drain both 
 the pleural space and also the pus-containing space in the liver. 
 If it is found that the abscess does not communicate with the 
 pleural cavity, and there is at the same time an empyema of the 
 right pleural cavity, it is recommended that the two pus- 
 containing spaces should be opened, evacuated, and drained 
 through separate incisions. In all cases the empyema is treated 
 by incising and resecting one or more ribs, whilst the hepatic 
 abscess is treated through an incision which may or may not 
 require resection of a portion of rib, according to the locality of 
 the pus within the liver. When the abscess has burst into the 
 lung, and the contents are evacuated by the mouth, it is not 
 necessary to perform an operation, unless there are signs of 
 considerable lung infiltration, and the patient suffers from the 
 cough which is induced, in which case it is advisable to drain the 
 abscess through an incision in the chest wall. The abscess is 
 situated in the upper and posterior portion of the liver in most 
 cases of this kind, and it can be reached most easily through an 
 incision in the lower and posterior part of the thoracic wall. If 
 the abscess communicates with the pericardium no operation 
 appears to be of any value, since in all instances of this compli- 
 cation a fatal termination has resulted. When the abscess has 
 burst into the peritoneum, two distinct pathological conditions 
 may be brought about. In the first, adhesions are formed which 
 shut off the pus from the general cavity of the peritoneum, and 
 a localised encysted abscess develops ; whilst, in the second, no 
 such favourable condition follows, but, instead, the purulent 
 matter infects the entire peritoneal cavity, and a general acute 
 septic peritonitis results. In the first of these conditions the 
 course of treatment which should be adopted is similar to that 
 of an uncomplicated abscess situated in the inferior portion of the 
 liver ; that is to say, the overlying abdominal wall should be in- 
 cised, and the abscess evacuated and drained in the usual manner. 
 In the second class of case, surgical treatment does not offer 
 much relief, since nearly all cases of this nature terminate 
 fatally. The only course, however, to adopt which offers any 
 chance of cure, is to open the peritoneal cavity by an abdominal 
 
FJiO GNOSIS. 107 
 
 incision in the region of the hepatic abscess, and through this 
 opening to evacuate the abscess, and also wash out the general 
 peritoneal cavity with an antiseptic solution, so as to remove the 
 products of the septic peritonitis as completely as possible, and 
 then to establish free drainage. It occasionally happens that an 
 abscess of the liver bursts into some part of the alimentary 
 canal, usually the duodenum or the stomach, and the purulent 
 contents are discharged into the lumen of the perforated organ. 
 In these cases septic matter usually passes from the alimentary 
 canal into the abscess and keeps up the inflammation. The 
 safest course to adopt in such cases appears to be to establish 
 drainage of the abscess through an incision in the overlying 
 portion of the abdominal wall. 
 
 In all cases of hepatic abscess which have been submitted to 
 an operation, it is necessary, in addition to the local measures, to 
 maintain the patient's general condition by the administration of 
 plenty of easily digested and nourishing food, with stimulants, if 
 it is thought that they are requisite. Opium in small and 
 repeated doses may be required to alleviate pain and induce 
 sleep. Bleeding or depleting measures of any kind are to be 
 strongly deprecated. 
 
 Prognosis. — The prognosis in cases of abscess of the liver 
 differs very considerably in the individual cases. When the 
 abscess is single (or there are not more than two or three), the 
 result is much more likely to be favourable than in those pysemic 
 cases where there are a number of small abscesses. According 
 to the statistics which have been collected by Zancarol, the 
 mortality of cases which have been treated, by puncture with a 
 trocar or an aspirating needle has been 80 per cent. ; in those 
 which have been treated by incision with the knife, 71 per 
 cent. ; whilst in those which have been treated by him with the 
 thermocautery it has fallen to 50 per cent. In Zancarol's 
 cases the proportion of multiple non-curable abscesses was about 
 40 per cent., and that of single abscesses which ought to have 
 been cured was about 60 per cent. Zancarol's list comprises 
 157 cases, of which seventy-seven were cured, seventy-seven 
 were fatal, and three left the Hospital before the result was 
 known. 
 
CHAPTER VII. 
 
 TUBERCULAR ABSCESS OF THE LIVER. 
 
 Tubercular disease of the liver and the biliary system is a rare 
 affection. It occurs as a localised manifestation of a general 
 miliary tuberculosis, but in this case it is of little surgical 
 interest, as it is not possible to adopt any measures for its treat- 
 ment beyond those medical means which are made use of in the 
 treatment of the general disease. It also occurs as a local disease 
 of the organ, and is due to the presence of deposits of the 
 Bacillus tuberculosis in the hepatic tissue. This form of the 
 disease occurs much more commonly in children and young 
 people than in adults, and when it exists it usually gives rise to 
 the development of a localised abscess which is tubercular in 
 character. Two varieties of this form have been met with, and 
 have been described by various observers. The first of these is 
 characterised by the fact that the tubercular process is confined 
 to the interior of the organ and terminates in the formation of 
 an intra-hepatic abscess ; whilst in the second the pathological 
 condition involves the hepatic substance in the neighbourhood of 
 the surface of the gland, and at the same time extends to the 
 capsule and the adjacent tissues, so as to cause the development 
 of a perihepatic abscess. The perihepatic abscess is a much 
 more common result of a localised tubercular process in connec- 
 tion with the liver than the intra-hepatic variety. These tuber- 
 cular affections of the liver in occasional cases may be the sole 
 localised manifestations of the disease, but it is found that in 
 the greater number of instances they only constitute a small 
 part of the pathological condition. The intra-hepatic abscesses 
 when present are usually of small size, but in exceptional cases 
 they have been known to attain a diameter of several inches. 
 Fig. 15 is an illustration of a specimen of a large circum- 
 scribed tubercular abscess of the liver which is in the Museum 
 of St. Bartholomew's Hospital. The abscess is quite localised, 
 
ETIOLOGY. 
 
 109 
 
 and the internal surface is covered with shreds of partially 
 organised lymph, and in this tissue the tubercle bacillus 
 was found. The specimen was obtained from a patient who 
 died from phthisis. In the same museum there is a second 
 specimen, in which the left lobe contains a number of tuber- 
 cular masses, the largest being about 2 in. in its longest 
 
 Fig. 15. — Section of a portion of liver containing a circumscribed tubercular 
 abscess. The abscess wall is covered with shreds of partially organised 
 lymph. From a patient who died of pulmonary phthisis. — St. Barth. 
 Hosp. Museum, Spec. 2196 a. 
 
 diameter, and showing signs of breaking down in several places. 
 The patient from which this specimen was obtained was a boy 
 who suffered from amyloid disease of the abdominal viscera, as 
 well as presenting other signs of tubercle. In most cases of this 
 kind the abscess in the interior of the liver is not associated 
 with special symptoms dependent upon its presence, and its 
 existence is only discovered on making a post-mortem examina- 
 
no TUBERCULAR ABSCESS OF THE LIVER. 
 
 tion, after death has occurred from disease of some other organ. 
 The perihepatic variety of tubercular abscess, which is the more 
 common, usually commences as a localised tubercular affection of 
 some part of the superficial portion of the liver, and extends 
 thence towards the surface, where it causes the development of 
 a perihepatitis and the formation of inflammatory adhesions 
 between the peritoneal covering of the liver and that of the 
 adjacent organs. These adhesions, when formed, help to localise 
 the abscess to the region of the diseased portion of the liver, and 
 so prevent the occurrence of a general tubercular peritonitis. 
 Any part of the surface of the liver may be affected in this 
 manner, but it has been found that the convex portion of the 
 right lobe is the area which is most commonly involved. When 
 this part is affected, and the abscess attains a considerable size, 
 one variety of subphrenic abscess is established. In those cases 
 in which the inferior aspect of the organ is the seat of the 
 disease, it often happens that a localised chronic abscess is 
 formed, which exists for a long time without giving rise to the 
 appearance of any train of symptoms which render a diagnosis of 
 the nature and situation of the affection possible. Sooner or 
 later an abscess of this kind spreads towards the an tero- inferior 
 border of the gland and the neighbouring portion of the posterior 
 aspect of the anterior abdominal wall, and gives rise to the 
 formation of an abdominal swelling, which has the characteristics 
 of a localised abscess. In some cases the inflammatory process 
 may spread to the peritoneum and set up a more or less general 
 tubercular peritonitis, which is accompanied by the manifestation 
 of symptoms which are characteristic of this disease. 
 
 Diagnosis. — In those cases of tubercular disease of the liver 
 in which an intra-hepatic abscess is formed, it is practically im- 
 possible to form a correct diagnosis of the pathological condition 
 of the patient, since an abscess of this kind is not usually 
 associated with any considerable enlargement of the organ, and 
 it does not give rise to a special train of symptoms. The sub- 
 phrenic variety causes the development of a series of physical 
 signs and symptoms which are similar to those met with in the 
 case of an ordinary subphrenic abscess, which is dependent upon 
 the extension of a tubercular process from the overlying lung or 
 pleura. AVhen the inferior aspect of the organ is the seat of 
 the disease, it is not possible in most cases to diagnose its 
 presence before the inflammatory process has extended to the 
 
TREA TMENT— PR O GNOSIS. 1 1 1 
 
 adjacent portion of the anterior abdominal wall, and a localised 
 abscess has been formed. The tubercular nature of an abscess 
 which is in connection with the liver, can sometimes be discovered 
 by a microscopical examination of the material which is with- 
 drawn from the swelling when it has been explored with the 
 needle of an aspirator or a syringe. If the swelling is due to a 
 tubercular process, the tubercle bacillus may be found in the 
 matter evacuated, but it must not be assumed that if bacilli 
 cannot be demonstrated the disease is not tubercular in origin, 
 since in many cases of old tubercular disease it is not possible to 
 see the bacilli under the microscope on the first examination. 
 The material which is withdrawn by the needle in cases of 
 tuberculosis is usually very thick, and it is necessary to wash 
 out the needle before the contents can be seen and examined. 
 
 Treatment. — The treatment of a tubercular abscess of the 
 liver does not differ from that which has been recommended in 
 the case of other forms of abscess of the same viscus. In order 
 to promote the easy evacuation of the contents, it will generally 
 be found advisable to scrape the interior of the abscess with a 
 Volkmann's spoon or other similar instrument. After the 
 abscess cavity has been evacuated, its interior should be packed 
 with strips of aseptic gauze which have been impregnated with 
 iodoform emulsion or with iodoform paste, and this method of 
 dressing should be repeated daily. If there are signs of the 
 development of tubercle in other organs, the treatment which is 
 necessary for these affections must also be carried out. The 
 treatment of the subphrenic variety of tubercular abscess will 
 be dealt with in further detail when subphrenic abscess is under 
 consideration. When the affection involves the inferior aspect of 
 the liver and the adjacent portion of the peritoneum, an incision 
 is made over the most prominent part of the swelling, the con- 
 tents evacuated, and the cavity irrigated and drained. 
 
 Prognosis. — The prognosis in most cases of tubercular abscess 
 of the liver is not hopeful, since the disease is generally associated 
 with the presence of the tubercular process in other organs, 
 especially in the lungs. When, however, it is localised to the 
 hepatic region, and its presence is diagnosed at an early stage, 
 and appropriate treatment at once adopted, there is a possibility 
 that the disease may be eradicated at least for a time. 
 
CHAPTER VIIL 
 
 ACTINOMYCOSIS OF THE LIVER. 
 
 Actinomycosis of the liver is a chronic infectious disease of a 
 specific nature, which is caused by the presence of a distinct 
 fungus called the " ray fungus " or actinomyces. This micro- 
 organism in animals usually causes the development of chronic 
 intiammatory affections in the lower jaw, or in the anatomical 
 structures which lie adjacent to the buccal cavity ; but in man 
 some part of the intestinal or respiratory tract is the situation 
 where the disease most often commences. In a very small 
 number of cases the liver has been the place where the affection 
 has first become apparent. Usually, however, the liver is not 
 the only situation where the disease manifests itself, but this 
 organ only becomes affected in the later stages of the patho- 
 logical condition, the primary disease being located elsewhere. 
 During the past few years I have seen at least five cases of this 
 nature. In three of these cases the disease was primary in the 
 base of the right lung or the neighbouring portion of the pleura, 
 and spread from this situation through the underlying diaphragm 
 to the adjacent part of the superior aspect of the liver ; in the 
 fourth case, the primary seat of the disease appeared to be either 
 in the spleen or possibly in the wall of the alimentary canal, 
 and particles of the growth had been carried from this organ to 
 the liver by the splenic and portal veins ; whilst in the fifth case 
 it could not be ascertained in which organ or anatomical structure 
 the affection had originally commenced, on account of the exten- 
 sive nature of the disease when an examination was made after 
 the death of the patient. From a consideration of these cases, 
 and also those of similar nature which have been published by 
 various observers, it appears to be established that the liver is 
 very liable in man to become aifected secondarily in the course 
 of actinomycosis, and this is especially the case when the ali- 
 mentary canal or the respiratory organs are the primary seats 
 
SYMPTOMS. 113 
 
 of the affection. The liver is not usually involved in cases of 
 actinomycosis of the skin or of the jaws and the region of the 
 buccal cavity, unless the affection proves to be not amenable 
 to surgical treatment, and the patient dies from a general 
 dissemination of the disease. When the pus from a case of 
 actinomycosis is examined, it is found to contain a number of 
 small, rounded, or somewhat oval-shaped granules, each about 
 the size of a pin's head, and either of a yellowish tinge 
 or even dirty-white in colour. Under the microscope each 
 yellow granule is seen to consist of a closely-woven network of 
 mycelium threads, to the extremities of which small club-shaped 
 bodies may be attached. These bodies are arranged in a radiating 
 manner, and on this account the parasite has been named the 
 " ray fungus." The parasite appears in many of the recorded 
 cases to have obtained an entrance into the human organism 
 with some article of food. If there happens to be an abrasion 
 of the mucous membrane which lines the mouth and buccal 
 cavity, infection may occur through local absorption, and in a 
 similar manner infection may take place from the mucous 
 membrane of the alimentary canal. When the respiratory 
 organs are the seat of the primary affection, it is probable that 
 the infecting agent has been introduced with the inspired 
 air in the form of spores. In those cases in which the liver 
 appears to be the situation of the primary disease, it seems 
 possible that the parasite has been introduced into the ali- 
 mentary canal along with an article of food, and that it has 
 passed through the walls, either of the stomach or intestine, 
 into one of the radicles of the portal vein, by which it has been 
 carried to the liver, where its progress has been arrested in the 
 portal capillaries of that organ, and it has commenced to grow. 
 When the liver becomes involved secondarily, it is due either to 
 a direct extension of the chronic infectious inflammatory process, 
 or to the conveyance to the liver of emboli which contain the 
 fungus from a focus of disease in one of the adjacent organs, 
 by the blood vessels or the lymphatics, more commonly by the 
 portal vein. 
 
 SymiJtoms. — When the liver is afiected primarily, it exhibits 
 the signs and symptoms of a slow and gradual enlargement, 
 characterised by the development of localised swellings which 
 project upon the superficial surface of the organ, and give to it 
 an irregular and bossed outline, which becomes apparent on pal- 
 8 
 
114 
 
 ACTINOMYCOSIS OF THE IIVER. 
 
 pation. These localised enlargements are at first solid, but as 
 the disease progresses they break down and undergo disin- 
 tegration, and collections of pus are formed which contain the 
 
 yellow granules men- 
 tioned above, each 
 granule having the 
 microscopic structure 
 of actinomyces. The 
 inflammatory process 
 tends to spread to and 
 implicate the surround- 
 ing structures at an 
 early stage, and to 
 extend to the surface 
 of the body in the form 
 of a superficial abscess. 
 In one case of this 
 kind which I have seen, 
 the affection became 
 manifest by the forma- 
 tion of a small abscess 
 in the anterior and 
 lower portion of the 
 right side of the chest. 
 The affection in the 
 early stages is slow 
 and insidious, and gives 
 rise to few definite 
 symptoms beyond those 
 of localised swellings. 
 When the affection of 
 the liver is secondary 
 to the development of 
 the primary disease else- 
 where, the symptoms 
 which are dependent 
 upon the original 
 disease will assist in determining the nature of the hepatic affec- 
 tion. In one patient upon whom I operated the liver was found to 
 be involved only after the lower part of the chest had been opened 
 in order to drain an empyema whicli had formed in that region. 
 
 Fig. 16. — Actinomycosis of the Liver. Section of a 
 human liver from a case of actinomycosis. The 
 diseased parts are situated in the upper portion of 
 the specimen, and consist of a coarse meshwork of 
 white fibrous tissue, witli a spongy or honeycombed 
 appearance, enclosing spaces of various sizes. The 
 section through the right edge shows the spaces to 
 have coalesced, so as to form an irregular cavity. 
 The diseased tissue has for the most part replaced 
 the normal liver substance. — Ht. Jiarth. Ilos^}. 
 Museum. 
 
DIA GNOSIS— TREA TMENT. 1 1 5 
 
 Recently I have had a second case of this nature, in which the 
 right pleura and the pericardium, together with the right lung, 
 were the seat of an extensive inflammatory affection dependent 
 upon actinomycosis ; and on draining the empyema and examining 
 the upper surface of the diaphragm, the disease was felt to extend 
 through this structure into the upper portion of the right lobe 
 of the liver. In most cases of actinomycosis of the liver, the 
 infective process spreads to the adjacent portion of the peri- 
 toneum and causes a localised chronic peritonitis, a condition 
 which was met with in the first of the two cases which have 
 been referred to above. When suppuration occurs the tem- 
 perature of the patient is elevated, but it does not present any 
 definite characteristics in this respect. 
 
 Diagnosis. — In the early stages of the disease the signs and 
 symptoms resemble those which are due to the development of 
 a slowly-growing malignant tumour, and when these have existed 
 for some time the clinical appearances are those of a chronic 
 abscess. In order to be able to make an absolutely certain 
 diagnosis, it is essential that the characteristic yellow or white 
 granules should be obtained from the swelling, and that these 
 should have the microscopic appearances of the actinomycotic 
 fungus. Naked -eye appearances must not be relied upon, 
 since it is not uncommon for the purulent matter from a tuber- 
 cular focus to resemble actinomycosis in its superficial and 
 general characters. The pus which is obtained from an 
 actinomycotic abscess is usually very thick and mucoid in 
 nature, and has a peculiar odour. 
 
 Treatment. — When actinomycosis of the liver has become 
 established, it is difficult to decide which is the best method of 
 treatment to adopt. Some authors have advised the internal 
 administration of large doses of potassium iodide ; but in two 
 cases in which I made use of this drug in the treatment of this 
 affection of the liver, I found that it was of no permanent 
 value. The only method of treatment which appears to be 
 likely to be of any great assistance in the destruction of the 
 disease, is the complete removal of the whole of the affected 
 tissues. In those cases in which a diagnosis of the nature of 
 the disease has been made before the granulation tumour has 
 undergone disintegration and gone on to the formation of an 
 abscess, an attempt may be made to remove the diseased tissues 
 in a manner similar to that which is suggested for the treatment 
 
ii6 ACTINOMYCOSIS OF THE LIVER. 
 
 of localised malignant tumours. In the majority of cases it 
 will only be possible to make a diagnosis after an abscess has 
 developed, and this has been treated by incision, and the pus 
 evacuated. If an actinomycotic abscess is diagnosed, a free 
 incision is made, the contents of the swelling removed, and if 
 necessary any partitions which may be present between two or 
 more abscesses broken down, so to allow of complete evacuation. 
 The internal wall of the abscess cavity should then be carefully 
 curetted, so as to remove any infected tissue which may be in 
 the liver substance adjacent to the area of the abscess. When 
 this has been done, the cavity which remains is irrigated, and 
 then packed with tampons of iodoform gauze, upon which has 
 been spread a quantity of iodoform paste. This method of 
 dressing should be carried out at first daily and later every 
 other day. In many cases it is found to be impossible to 
 remove the whole of the infected tissues, on account of the 
 extensive nature of the disease. It is advisable, in addition to the 
 local treatment of the disease, to give potassium iodide internally, 
 commencing with small doses, and increasing them to about 
 30 grs. three times a day. 
 
 Prognosis. — The outlook in every case of actinomycosis of 
 the liver is extremely serious. All the cases of this kind which 
 I have seen have terminated fatally. In some cases it may be 
 possible to remove the primary focus of the disease, and drain 
 the abscesses in the liver, but in most cases the connections of the 
 diseased tissues are so extensive that surgery is unable to effect 
 its total extirpation, and it does not seem possible to depend 
 upon any medical measures alone for its relief. The prognosis 
 of actinomycosis of the skin or of the jaws and mouth is in most 
 cases very favourable, but when the internal viscera, especially 
 the liver are involved, it is the reverse. 
 
CHAPTER IX. 
 
 SYPHILIS OF THE LIVER. 
 
 Affections of the liver are met with in both the secondary and 
 tertiary stages of acquired syphilis, and also as manifestations of 
 the congenital form. When the extreme frequency of acquired 
 syphilis is taken into consideration, the liver appears to be only 
 rarely attacked, but if we make a comparison between the occur- 
 rence of syphilitic affections of the liver and of the remaining 
 abdominal viscera (the rectum being excepted), we shall find that 
 this is the organ which is most commonly the seat of the disease. 
 In congenital cases, it is found that the liver is one of the organs 
 which is most frequently affected. 
 
 Secondary affections. — During the secondary stages of syphilis, 
 at the period when the cutaneous eruptions are manifest, the 
 individual affected is liable to become jaundiced. The jaundice 
 comes on somewhat gradually, lasts for a short time, usually not 
 more than from one to three weeks, and then disappears. This 
 condition is supposed by some authorities to be caused by the 
 development of an interstitial infiltration of the hepatic tissue, 
 which presses upon the commencement of the small bile ducts 
 so as to obstruct the flow of bile along them, and thus induce 
 the occurrence of an attack of jaundice. Other observers think 
 that there is a catarrhal condition, followed by swelling of 
 the mucous membrane lining the bile ducts, diminution in 
 size of their lumen, and consequently biliary obstruction and 
 jaundice. In all probability the latter hypothesis is correct. In 
 one case which I have had under my own observation, an attack 
 of jaundice developed during the eruptive stage of secondary 
 syphilis, and was accompanied by a distinct fluid enlargement of 
 the gall bladder, this viscus projecting as a smooth oval tumour 
 below the costal margin half-way towards the umbilicus. Mer- 
 curial treatment was adopted, and after about ten days the 
 jaundice and enlargement of the gall bladder simultaneously 
 
ii8 SYPHILIS OF THE LIVER. 
 
 disappeared. The jaundice had developed in this patient about 
 two weeks after the appearance of the cutaneous eruption. 
 
 Treatment. — The usual anti-syphilitic remedies should be 
 administered, most reliance being placed upon the preparations 
 of mercury, and the bowels kept freely moved. In the majority 
 of cases the jaundice will disappear and the liver resume its 
 normal condition. 
 
 Tertiary affections. — Under this heading are included those 
 pathological affections of the liver which are met with in patients 
 suffering from congenital syphilis, and also in those who are the 
 subjects of tertiary syphilis. In all cases the condition is one 
 of chronic inflammation, and this may be either diffuse, affecting 
 the whole gland, or it may be localised to one or more definite 
 spots. Thus there may be distinguished two classes, the first of 
 which we shall call " diffuse syphilitic hepatitis," and the second 
 " localised syphilitic hepatitis." The two classes will be dis- 
 cussed separately. 
 
 Diffuse syioliilitic hepatitis. — This affection is met with much 
 more frequently in children who are the subjects of hereditary 
 syphilis, than in older people who are suffering from acquired 
 syphilis. In fact adults are very rarely the subjects of this 
 affection. The disease is characterised by a general infiltration 
 of the liver with small cells, which at first occupy the space in 
 the neighbourhood of the intra-hepatic blood vessels and bile ducts, 
 and later extend into the glandular acini. These small cells are 
 apparently derived from a proliferation of the connective tissue 
 cells which are found in the prolongations of Glisson's capsule 
 within the liver. When the growth of small cells has extended 
 into the acmi, the groups of hepatic cells become flattened and 
 pressed upon, and they may exhibit signs of fatty or granular de- 
 generation. The liver itself in these cases is considerably enlarged, 
 especially in the earlier stages, and on section it usually presents 
 a greyish or greyish-red appearance. In the later stages, the 
 small-celled growth tends to form fibrous tissue, which undergoes 
 contraction, and then the bulk of the gland will be diminished, and 
 its surface become nodular or irregular. Some cases of cirrhosis of 
 the liver in young children have been said to be the later stages 
 of a diffuse syphilitic hepatitis, in which the fibrous tissue has 
 gone on to the stage of contraction. There is, however, very 
 great difficulty in making an exact and correct diagnosis in these 
 cases. Several cases have been recorded in which the liver has 
 
LOCALISED SYPHILITIC HEPATITIS. 119 
 
 been the seat of a chronic induration, involving the whole gland, 
 and accompanied by a small amount of nodosity on the surface. 
 As we have already seen, the majority of cases of this variety of 
 disease are to be found in children who are the subjects of con- 
 genital syphilis. Occasionally, however, patients of mature age 
 have been found to be affected, and in these cases acquired 
 syphilis has been present. Still-born children, the offspring of 
 syphilitic parents, are often found to have their livers in a state 
 of induration and enlargement, owing to this form of hepatitis 
 having been established. 
 
 Between the form of diffuse syphilitic hepatitis and the local- 
 ised variety there are a considerable number of gradations, one 
 form of the disease running insensibly into the other. In these 
 cases, in addition to the interstitial inflammation, there are 
 present numerous small tubercles, which have the structure of a 
 minute gumma or granulomata. 
 
 Localised syphilitic Iiejxititis.— This is the commonest variety of 
 disease of the liver in connection with syphilis. It is usually 
 met with in the tertiary stage of acquired syphilis, but less fre- 
 quently it is found in children or young adults as a manifestation 
 of the hereditary form. The inflammatory process may involve 
 one or more localised portions of the hepatic substance, and give 
 rise to the development of definite tumours, which are usually 
 situated near the surface of the gland, although less commonly 
 they are embedded in its substance, and are not apparent upon 
 the surface. The anterior and superior surfaces of the liver are 
 more frequently the seat of these tumours than the inferior. The 
 tumour may be single or multiple ; when single it consists of a 
 large, somewhat irregularly-shaped mass of fibrous tissue or small- 
 celled growth, which is circumscribed, but may have processes 
 passing into the neighbouring hepatic tissue ; or it may have the 
 form of a roundish mass, consisting, as regards its central portion, 
 of caseating material, and enclosed externally by a definite fibrous 
 capsule. When multiple, the individual tumours or gummata 
 may be entirely separate and distinct, or may at certain points 
 run into one another. Occasionally a gummatous tumour, situ- 
 ated at the margin of the liver, becomes pedunculated. When 
 these tumours involve the surface of the liver, they usually give 
 rise to the development of localised perihepatitis, which causes 
 the gland to become adherent to the adjacent anatomical struc- 
 tures, especially the lower surface of the diaphragm, less commonly 
 
I20 SYPHILIS OF THE LIVER. 
 
 the stomach and transverse colon, and, in rare cases, other of the 
 abdominal viscera. When this variety of tumour has existed for 
 some time, in the majority of cases the fibrous tissue or small- 
 celled growth of which the swelling is composed, undergoes con- 
 traction and causes the formation of depressed scars or cicatrices. 
 
 Fig. 17. — The liver of a girl who was the subject of coBgenital syphilis. The 
 right lobe is divided into two superimposed halves, the lower being the 
 larger, by a ring of dense cicatricial tissue, which is the remains of old 
 gummata. The left lobe is only represented by a small fibrous mass, 
 a, upper half of right lobe ; i, left lobe ; c, ring of cicatricial tissue ; (/, lower 
 half of right lobe. 
 
 By this means the surface of the organ may become very irregular, 
 and present a nodulated appearance, whilst the volume of the 
 gland is diminished. The remaining uninvolved hepatic cells are, 
 however, said to undergo a compensatory hypertrophy. The 
 deformities which are produced in this manner are very various. 
 
SYMPTOMS. 121 
 
 The left lobe has often been found to be represented by a 
 shrivel led-up nodule of hard, dense, fibrous tissue. In one case 
 which I saw in St. Bartholomew's Hospital, the right lobe was 
 completely divided into two superimposed halves, and the left 
 lobe had almost disappeared. Fig. 17 represents the liver of 
 this case in vertical section. The patient was a girl, at. 20, who 
 was the subject of congenital syphilis. The tumour may occa- 
 sionally press upon and obstruct the hepatic or portal vein, the 
 hepatic artery, or one of the large bile ducts, or the cicatrix 
 which results may involve these same structures. In both cases, 
 ascites or jaundice may be produced. Dr. Fagge mentions a case 
 occurring in Guy's Hospital in which the hepatic vein, close to 
 its junction with the vena cava inferior, was pressed upon in this 
 way, and ascites produced. In one patient whom I have had 
 under observation, a perihepatitis of syphilitic origin caused 
 pressure upon the portal vein in the portal fissure, and consequent 
 ascites. The exciting cause of the development of gummatous 
 tumours in the liver is unknown. It has been suggested that 
 injuries in the hepatic region in patients who have suffered from 
 syphilis may be the exciting cause in a certain number of cases. 
 In nearly all cases of gummata of the liver, caseation and for- 
 mation of fibrous tissue take place ; in very rare instances, how- 
 ever, the tumour, instead of undergoing this change, may break 
 down and liquefy, and there is produced a fluid swelling, generally 
 filled with a yellow liquid in which are numerous flakes. 
 
 Symptoms. — Tertiary syphilitic disease of the liver in many 
 patients gives rise to the production of few symptoms. Often its 
 existence only becomes apparent when a post-mortem examination 
 is made after the death of the patient from some other affection. 
 When definite symptoms are present they are due to changes in 
 the size and shape of the viscus, to obstruction of the portal vein 
 or the bile ducts, or to perihepatitis. If there are numerous 
 gummatous tumours in the liver, they alter the shape and size of 
 the gland, so that irregular nodular swellings can be felt upon its 
 surface, which are usually painless to pressure from without. The 
 liver may attain a considerable size as a result of the develop- 
 ment of these tumours, and then it resembles in many respects 
 a liver which has been enlarged owing to the formation of 
 numerous primary or secondary malignant growths. The rate 
 of increase in size of the organ is, however, much slower in 
 syphilitic affections than is the case in malignant disease, whilst 
 
122 SYPHILIS OF THE LIVER. 
 
 there is not the same marked wastmg and cachexia. Ascites or 
 jaundice may be well-marked symptoms, resulting from pressure 
 upon or involvement of the structures surrounding the portal 
 vein or the bile ducts in the portal fissure. In the later stages 
 of the affection contraction takes place, and a condition may 
 arise which may be called syphilitic cirrhosis. This is much 
 more common in children, although it has been observed in 
 adults, and usually follows the interstitial form. The localised 
 variety is succeeded by scarring or the formation of irregular 
 deformities, which have been already mentioned. If the deform- 
 ities so produced are considerable, they may become apparent as 
 definite tumours which occupy the upper portion of the abdominal 
 cavity ; in all cases they move with the respiratory movements and 
 are fixed above to the liver. In some cases of this kind diagnosis 
 is very difficult or almost impossible. In the case which was 
 mentioned above, where the liver had been divided into two 
 superimposed halves, the left lobe being represented by only a 
 small amount of hard fibrous tissue, the lower portion projected 
 as a large tumour downwards below the umbilicus, and was 
 apparently attached to the inferior part of the right lobe. When 
 the liver is generally enlarged, there may, in some cases, be a 
 feeling of fulness or heaviness in the right hypochondriac region ; 
 in others, pain is the predominant symptom, and this may be 
 slight or severe. It may be localised to definite spots or it may 
 involve the entire hepatic region. The pain may be constant 
 and last for several weeks or even months, or it may only come 
 on at intervals. Symptoms of perihepatitis with localised pains 
 may occur in any case of localised syphilitic hepatitis. Pain 
 in the region of the right shoulder or the lower end of the 
 scapula does not appear to be very often present in cases of 
 syphilitic perihepatitis. In some cases a friction rub can be felt 
 and heard over the upper portion of the hepatic area. This is 
 said to be due to friction between the upper surface of the liver 
 and the lower surface of the diaphragm during the movements of 
 respiration. It is only met with in perihepatitis. 
 
 Lancereaux says that the tumours on the surface of the liver 
 in tertiary syphilis are more circumscribed and harder in con- 
 sistency than the swellings which are formed in malignant disease. 
 This distinction appears to be too slight to be of any value, since 
 it is often impossible to make out such differences, especially 
 when the patient is not emaciated. Slight bronzing of the skin 
 
DIAGNOSIS — TREATMENT. 123 
 
 has been said by Lancereaux to be often present in cases of 
 syphilitic disease of the liver. This, however, does not appear 
 to be constant, but when it is present it will help in making a 
 correct diagnosis. 
 
 Enlargement of the spleen, owing to the presence of gum- 
 matous growths or to amyloid disease, accompanies a similar 
 condition of the liver, whilst in malignant affections it is very 
 infrequent. 
 
 In congenital cases the liver often projects a variable distance 
 below the costal margin, as far as the umbilicus, or even lower, 
 and it then forms a smooth hard swelling with a definite inferior 
 margin. 
 
 Diagnosis. — The history of heredity as regards syphilis, or 
 symptoms of previous syphilitic affections, such as scars on the 
 legs, external genital organs, or about the mouth and pharynx, 
 help very considerably in forming a correct diagnosis. The 
 absence of well-defined symptoms, the slow rate of growth of 
 the tumour, and the non-existence of marked cachexia and 
 wasting, are of great importance and value in establishing a 
 diagnosis and in distinguishing the affection from a case of malig- 
 nant disease. The advanced stages of syphilitic cirrhosis of the 
 liver are difficult to distinguish from malignant disease, especially 
 when old people are affected and when there is much nodulation 
 and general marasmus. It is said by some authorities that 
 malignant disease is more commonly localised to either the right 
 or left lobe of the liver, at least in the early stages, whilst in 
 syphilis both lobes are usually involved. This fact is not of 
 much value in establishing the diagnosis, since it is very difficult 
 and often impossible to make out whether one or both lobes of 
 the liver are affected with the disease. In some cases the age 
 of the patient is of importance, as quite one-half of the cases of 
 syphilitic disease of the liver occur in people who are under forty, 
 and cancer of the liver usually occurs in patients who are con- 
 siderably over this age. The presence of an enlarged spleen 
 is in favour of syphilis, since it is common in this affection and 
 rare in cancer. 
 
 Treatment. — The usual anti-syphilitic remedies are the most 
 useful in combating the affection. Potassium iodide is the most 
 valuable, and should be administered in gradually increasing 
 doses. If there is much aneemia, iodide of iron will be found 
 more serviceable. It should be given in doses of half a drachm 
 
124 SYPHILIS OF THE LIVER. 
 
 twice or thrice daily. Good climatic and hygienic conditions 
 should be insisted upon as adjuvants to the drugs. A sea- 
 voyage or residence at a seaside resort will often prove beneficial. 
 There are a few cases on record in which gummatous tumours of 
 the liver have been diagnosed as malignant disease, and have 
 been excised and the patients have recovered. In doubtful cases 
 a course of potassium iodide should be tried before any operative 
 measures are adopted. Preparations of mercury have, in some 
 cases, been followed by improvement. Usually, however, potas- 
 sium iodide will be of more value. 
 
 Prognosis. — The prognosis is moderately good in many cases, 
 but when syphilitic cirrhosis is well established, and is accom- 
 panied by general marasmus, a fatal issue usually occurs at an 
 early date. Some cases which are apparently hopeless, improve, 
 however, under the influence of drugs and good nursing. Many 
 cases improve for a time, or even apparently recover, and at a 
 later date are followed by a relapse which is ultimately fatal. 
 A certain number of patients recover and die from other diseases. 
 In children the prognosis is much worse than in patients who 
 suffer from acquired syphilis. They usually die during the first 
 few months of life. In adults the disease may go on for several 
 years before it ends fatally. 
 
 Amyloid disease of the liver. — Amyloid disease of the liver 
 may occur during the course of tertiary syphilis. The whole 
 gland is involved and becomes generally enlarged. It is very 
 hard and smooth, often projecting for some distance below the 
 margin of the ribs. It is accompanied by symptoms of amyloid 
 disease in other organs, such as the kidneys and the intestines. 
 The treatment is the same as for tertiary syphilis. 
 
CHAPTER X. 
 
 HYDATID CYSTS OF THE LIVER. 
 
 Hydatid or echinococcus cysts are the larval forms of a tape- 
 worm, which is called Tmnia echinococcus. The adult worm has 
 its habitat in the alimentary canal, usually the small intestine, 
 of various animals, and it has been most commonly found 
 infesting the domestic dog, the wolf, and the jackal. Each 
 worm is small, and does not measure more than 5 mm. in 
 length. It is divided by transverse constrictions into three 
 or four segments, the anterior, which is the smallest, being the 
 head. The head is armed with four suckers, two rows of 
 booklets, each row having from twenty to forty, and a rostellum. 
 The two middle segments are small and immature. The fourth 
 or terminal segment of the parasite is sexually mature, and 
 in this segment the ova are formed, and then shed into the 
 lumen of the alimentary canal of the host, whence they are 
 voided per anum along with the excreta. The ova generally 
 reach the alimentary canal of man by becoming mixed with, 
 or adherent to, some substance which is used as an article of 
 food. They are often taken along with drinking water, or with 
 some vegetable which is eaten as a salad, such as watercress. 
 Human beings who are of uncleanly habits, and who, by their 
 occupation, come into intimate contact with dogs, are liable 
 to contaminate their food with ova, and become infected in 
 this manner. When an ovum has gained an entrance into the 
 alimentary canal of man, the external coat of the parasitic egg is 
 dissolved by the chemical action of the gastric juice, the outer 
 surface of the egg gives way, and a small embryo with six 
 booklets is set free. This embryo makes its way through 
 the tissues which form the walls of the alimentary canal, and 
 may then pass in different directions. In the majority of 
 instances it bores its way into one of the radicles of the portal 
 vein, by the blood stream of which it is conveyed to the liver. 
 
126 HYDATID CYSTS OF THE LIVER. 
 
 where its onward course is arrested in one of the portal capil- 
 laries. The early stages of development are gone through 
 after the ovum has been arrested in the liver. According to 
 Leuckart,^ in the earlier stages the embryos have the appearance 
 of small, white, rounded spots, the outer portion of wnich 
 consists of a layer of thick transparent material, and forms the 
 external wall of a small capsule or cyst. This wall shows signs 
 of concentric lamellation, and the interior of the cyst is oc- 
 cupied by material which has a coarsely granular appearance. 
 The cyst gradually increases in size, and at the end of four 
 or five months it has attained a diameter of 5 mm., and minute 
 echinococcus heads begin to develop upon the mternal aspect of 
 the cyst wall as small buds. Each bud represents the head and 
 neck of a mature taenia echinococcus, and has four suckers and 
 a small rostellum, which is provided with booklets. Each head 
 is contained within a brood capsule, and the rostellum, with 
 its suckers and booklets, can be protruded and withdrawn. The 
 brood capsules are continuous with one another by means of the 
 parenchyma which forms the wall of the cyst. If the heads 
 or scolices become detached from the wall of the cyst, they very 
 soon lose their vitality and die (Leuckart). The brood capsules 
 occur in groups or bunches, and each capsule, with its contained 
 heads or scolices, measures about I'o mm. in diameter. The 
 brood capsules may, however, increase in calibre, and have a 
 diameter of 1 or 2 cm., and then they form daughter cysts 
 upon their internal surface, which daughter cysts may in their 
 turn form on their internal surface so-called grand-daughter 
 cysts. 
 
 Structure of an adult hydatid cyst. — The external wall is 
 
 made up of two separate and distinct layers — an external one, 
 
 which consists partially of chitin, is elastic, and has a marked 
 
 tendency to curl up when it has been divided ; and an inner 
 
 or parenchymatous layer, which consists of a granular basis 
 
 n.'aterial, in which are calcareous particles especially between 
 
 lihe attachment of the scolices, a certain number of cells, and 
 
 ou. few unstriped muscular fibres. The brood capsules, which 
 
 hap 'tain the scolices, are derived from the parenchymatous layer. 
 
 howt structure of the wall of a brood capsule differs somewhat 
 
 the c that of a parent cyst. The wall consists of two layers, 
 
 ManA of which has a definite structure, the external layer being 
 
 they •* Leuckart " The Parasites of Man," 1886 (Eug. trans.). 
 
STRUCTURE OF AN ADULT CYST 127 
 
 of the nature of parenchyma, and the inner cuticular, a condition 
 which is the reverse of that which obtains in the wall of the 
 parent cyst. When crops of brood capsules are produced the 
 parent cyst increases in size, but it is possible for a cyst which 
 forms no brood capsules, to attain a considerable size. Leuckart 
 says that scolices are produced from the external wall of the 
 capsule, and that when fully developed they become invaginated, 
 ^o that the original internal cuticular surface of the scolex 
 becomes external. The presence of a hydatid cyst in the liver 
 acts, to a certain extent, as an irritant to the adjacent portion of 
 the hepatic tissue, causes increased vascularity, and gives rise to 
 the formation of a considerable amount of fibrous tissue, which 
 appears as a secondary capsule or covering to the parasite. In 
 the majority of cases in which hydatid cysts form in the liver of 
 man, it is found that the cyst is single, although occasionally 
 several may be present, but in cattle it is not at all uncommon 
 for hydatid cysts of the liver to be multiple. 
 
 It is not necessary that a hydatid cyst should pass through 
 all the stages in development which have been described. In 
 some cases it happens that no scolices or daughter cysts are pro- 
 duced, and then the cysts are known as sterile hydatids or 
 acephalocysts. Acephalocyst hydatids may, however, attain a 
 considerable size owing to the extensive growth of a single cyst. 
 It has been observed in rare cases that a hydatid cyst, instead of 
 producing daughter cysts on its internal aspect, has formed buds 
 upon its external surface, which penetrate between the tissues of 
 the organ in which the hydatid is situated, and also extend into 
 other anatomical structures in the neighbourhood. Fagge ^ 
 relates a case of this kind which occurred in Guy's Hospital 
 under Dr. Eees. 
 
 Frequency. — Hydatid disease is much more frequent in some 
 countries than in others. In London it is not uncommonly met 
 with, but in the provinces and in Scotland it is said to be much 
 less common. This fact is said to be associated with the circum- 
 stance that London dogs are far more frequently infested wi^"^ 
 the tsenia echinococcus than those living in other parts of 
 United Kingdom. The affection is very common in Austrf ^ 
 and in Iceland it is one of the chief etiological factors in ® 
 mortality rate. In France and Germany the affection is ^°' 
 with, but is not common, and in Eussia it is very rare. 
 
 1 Fagge, "Text-Book of Medicine," 3rd edition, vol. ii. "^ 
 
 e or 
 
128 HYDATID CYSTS OF THE LIVER. 
 
 Situation. — Hydatid cysts, when affecting the liver and 
 bih'ary system, may be met with in connection with the liver, 
 gall bladder, biliary ducts, or in the hepatic region ; and when 
 they are located in the hepatic region they may occupy 
 the subphrenic space, or they may lie between the liver and one 
 of the adjacent abdominal organs. When they are situated in 
 the liver they may be entirely hepatic ; that is to say, they 
 do not appear on the surface, but remain within the substance ot> 
 the organ, or they may protrude upon any of the surfaces of 
 the gland, the superior, anterior, and inferior portions being 
 most commonly involved in this manner. 
 
 Si/mjjtoms. — Hydatid disease of the liver may exist for a 
 long time without giving rise to any definite train of symptoms 
 from which its presence may be suspected, and in many cases 
 cysts have been discovered post-mortem, the existence of which 
 had not been thought of during life. Usually the first symptoms 
 to be noticed are either the presence of a localised tumour or 
 swelling within the hepatic area, or some form or variety of 
 pressure symptom. This is due to one or other of the neighbour- 
 ing viscera being pressed upon by the cyst. The tumour, when 
 it is first discovered, may be only the size of an orange, but 
 as the growth of the parasite proceeds it may occupy the greater 
 portion of the abdominal cavity, and even extend as far down- 
 wards as the pelvis. The direction of extension of the parasitic 
 cyst varies according to its primary position. If it is situated at 
 first upon the superior surface of the liver, it will extend upwards 
 and encroach upon the pleural cavity, especially the right, at the 
 same time pushing upwards the diaphragm ; whilst in most of 
 these cases the liver will be pushed downwards, so that its 
 inferior border can be felt a variable distance below the costal 
 margin. When the cyst is situated upon the anterior surface, 
 it tends to grow forwards and downwards, producing a smooth 
 elastic tumour, which is more or less globular in shape, and can be 
 easily felt by palpation through the anterior abdominal wall, 
 li" the cyst is multiple the surface will have a lobulated or bossed 
 ou.tline. Since a hydatid cyst is filled with fiuid, it often 
 hap^pens that on palpation fluctuation can be detected. This, 
 howfcwer, is not invariably the case, as, owing to the tenseness of 
 the c yst, it can often only be distinguished as an clastic tumour. 
 Many authors have described a peculiar thrill of vibration which 
 they call " hydatid fremitus," as being obtainable in tense 
 
SYMPTOMS— RUPTURE OF A CYST 129 
 
 hydatid cysts. It is obtained by placing three fingers of the left 
 hand upon the most prominent portion of the tumour, and then 
 tapping the middle of these three fingers with the index finger of 
 the right hand, when a distinct thrill is communicated to the 
 other two fingers. This sign is not always obtainable in hydatid 
 cysts, and when it is present it is not an infallible test of 
 the presence of a hydatid cyst, since it can be obtained occasion- 
 ally in tense cysts which are not hydatid in character. As the 
 tumour increases in size, pressure symptoms appear, and these are 
 of different kinds, owing to the fact that various structures 
 may become compressed and have their normal physiological 
 functions disturbed. Difficulty in breathing is caused by ex- 
 tension of the tumour upwards, and compression of the lungs 
 or bronchi. When hydatid tumours attain a very large size, 
 these disturbances in the respiratory function may be very 
 distressing. Pressure upon the stomach or intestinal canal 
 causes abdominal pain, vomiting, dyspepsia, constipation, and 
 occasionally attacks of diarrhoea, which may alternate with periods 
 of constipation. The inferior vena cava or the portal vein may 
 be pressed against the posterior abdominal wall, so that the blood 
 stream is impeded through the blood vessel involved. When this 
 occurs, oedema of the lower extremities, ascites, and haemorrhoids 
 become marked symptoms. These symptoms, however, are not 
 very common as the result of hydatid cysts of the liver. In 
 some cases it happens that the peritoneum which overhes the 
 tumour becomes inflamed, either as the result of pressure or 
 a local injury, and localised pain and tenderness are then 
 noticed. Jaundice is rarely seen in this class of disease, and 
 when present is due to direct pressure by the cyst upon some 
 portion of the biliary ducts, resulting in obstruction to the free 
 flow of bile ; or in the establishment of a catarrhal condition 
 of the mucous membrane lining the affected ducts which causes 
 secondary obstruction ; or the cyst may rupture into one of 
 the large bile ducts, and the daughter cysts pass into the lumen 
 of the biliary canal, where they become impacted, and produce a 
 mechanical obstruction, which is followed by the development of 
 jaundice. When a hydatid cyst ruptures, and its contents are 
 discharged into the bile ducts, attacks of colic may either co- 
 exist with or may precede the attack of jaundice. 
 
 Rupture of a hydatid cyst. — A hydatid cyst of the liver may 
 undergo spontaneous rupture, and its contents pass into one or 
 
 9 
 
T30 HYDATID CYSTS OF THE LIVER. 
 
 other of the surrounding viscera or serous spaces. The rupture 
 may be induced by the accidental application of a slight local 
 \T.olence, or it may occur quite independently of any such event. 
 When the cyst bursts into the stomach or some other part of 
 the alimentary canal, its external surface usually becomes 
 adherent to the hollow viscus by a process of adhesive inflam- 
 mation, which is followed by a giving way of the tissues which 
 compose the septum between the cavity of the alimentary canal 
 and that of the cyst. When the rupture takes place into the 
 stomach, the daughter cysts may be either vomited or passed 
 per anum ; but if the contents pass into the intestine beyond the 
 stomach, they are in all cases evacuated per anum. Eupture of 
 a hydatid cyst into some portion of the alimentary canal is a 
 favourable method of termination, since in the majority of 
 instances it is followed by a spontaneous cure. Eupture may 
 take place into the peritoneal cavity, and when this occurs it is 
 usually accompanied by the development of severe symptoms of 
 shock and collapse, which may prove rapidly fatal unless radical 
 surgical measures are promptly adopted. As a result of rupture 
 into the peritoneal cavity, the patient may develop an urticarial 
 rash, due to the absorption into the circulatory system from the 
 peritoneum of some of the chemical constituents of the contents 
 of the cyst. The substance which is the cause of the urticarial 
 rash is probably of the nature of a ptomaine or toxine, but its 
 presence in the fluid of hydatid cysts has not been established 
 in every case. Brieger has separated such a substance, which 
 may possibly be the body in question. Eupture into the right, or 
 rarely the left, pleural cavity occurs ; or, if the pleural cavity has 
 been obliterated by adhesions, the contents of the cyst may pass 
 into the substance of the lung. When rupture into these 
 viscera occurs, pleurisy or pneumonia or both may result, and 
 occasionally the daughter cysts or their membranes may be 
 coughed up after having previously passed into one of the 
 bronchi. The pericardium may also be the seat of the rupture, 
 and then a fatal termination quickly follows in nearly every 
 case. Occasionally the external surface of the cyst becomes 
 adherent to the posterior aspect of the anterior abdominal wall, 
 and then as a result of inflammatory processes or local injury 
 the cyst ruptures externally and its contents are discharged. 
 Eupture may also take place into the gall bladder or the lumen 
 of one of the larger biliary ducts. This is accompanied by signs 
 
RUPTURE OF A CYST. 
 
 131 
 
 of biliary colic, which is due to the passage of small cysts or 
 portions of cyst membrane along the bile duct to the duodenum. 
 In the Museum of St. Bartholomew's Hospital there is a 
 specimen which was obtained from the body of a boy, set. 
 14, who three months previous to his death had signs of acute 
 inflammation of the liver, and six days before death had acute 
 
 Fig. 18. — Portion of a duodenum with a large hydatid, rolled xip and 
 impacted in the common bile duct, which it dilates, and from which 
 a portion of it protrudes into the lumen of the intestine, a, biliary 
 papilla ; h, rolled up hydatid cyst. — St. Earth. Hosp. Mitseum. 
 
 pain in the right hypochondrium, followed by jaundice (Fig. 18). 
 He was relieved for a time, but the symptoms recurred with 
 greater severity, and he died delirious. On examination after 
 death, the common bile duct was found to be the seat of a large 
 rolled-up hydatid cyst, part of which protruded into the 
 duodenum through the opening of the common bile duct. In 
 
132 HYDATID CYSTS OF THE LIVER. 
 
 the right lobe of the liver there was a large cyst filled with 
 hydatids. As a result of rupture into the biliary passages, 
 cholecystitis, or an inflammatory condition of the bile ducts, may 
 be induced and give rise to jaundice, or, as mentioned above, the 
 jaundice may be due to the impaction of a cyst in the common 
 duct. If the daughter cyst, or a portion of membrane, remain 
 within the cavity of the gall bladder, it may act as the exciting 
 cause of the development of a gall stone, owing to the deposit 
 upon its surface of some of the solid constituents of the bile. 
 Cases have been recorded in which hydatid cysts have burst 
 into some part of the urinary system, usually into the bladder 
 or the pelvis of the kidney. Jonassen ^ mentions a case of this 
 kind where the cyst became impacted in the urethra, and it was 
 necessary to open this canal in the perineum in order to extract 
 the cyst membranes. In a few cases a hydatid cyst has become 
 adherent to the inferior vena cava, and this has been followed 
 by a rupture of the cyst wall and the wall of the blood vessel, 
 and then the contents of the parasitic cyst have passed into the 
 blood stream. The smaller daughter cysts and portions of the 
 membranes of the larger ones have in these cases been carried 
 to the pulmonary artery, where they have become arrested and 
 caused embolism which rapidly proved fatal. Eupture of the 
 cyst may also occur into the portal vein as it lies in the 
 neighbourhood of the transverse fissure of the liver. In many 
 cases which have been recorded in surgical literature, it has been 
 found that a hydatid cyst has ruptured and formed communica- 
 tions simultaneously with more than one serous sac or hollow 
 viscus. Thus Cay la mentions a case where a cyst communicated 
 with the bile duct and the right pleura, and Bulau records a 
 similar case. Guterboch also records a case in which the cyst 
 lay between the liver and diaphragm, and communicated with 
 the pleura and the intestine. Communications between a 
 hydatid cyst and the gall bladder and the duodenum, and with 
 the intestine and the pelvis of the kidney, have been met 
 with. 
 
 Suppuration. — In certain cases of hydatid cyst of the liver, 
 after the tumour has existed for some time suppuration is 
 established, and is associated with the signs and symptoms of a 
 hepatic abscess. This suppurative process may be due to the 
 application of a localised mechanical force to the region of the 
 
 1 Jonassen, quoted by Langeubuch, 
 
SUPPURATION. 
 
 133 
 
 cyst in the liver, or it may be dependent upon the conveyance 
 of a septic embolus, from a focus of suppuration in some other 
 part of the body, to the parasitic cyst. Small boils of the skin, 
 and similar small local suppurations, have been met with in 
 
 Fig. 19.— Hydatid cyst of the liver.— Part of a liver, with half of a large hydatid 
 cyst which occupied the superior surface of the right lobe. Its wall is 
 tough, and iu places has degenerated into a calcareous mass. The interior 
 of the cyst is occupied by the remains of many hydatids, whose walls, 
 contracted and shrivelled, are recognised by the tortuous lines and fissures 
 seen on the surface of the section. The remaining contents of the original 
 cyst, as well as those of the contained daughter cysts, are converted into 
 a pultaceous substance, filling the interstices between the remains of the 
 cyst wall. — St. Earth. Hosp. Museum. 
 
 association with the occurrence of suppuration in old hydatid 
 cysts, and have been supposed to be the focus from which the 
 suppurative micro-organisms have been derived. In other cases 
 the suppuration appears to be dependent upon a pysemic process, 
 
134 
 
 HYDATID CYSTS OF THE LIVER. 
 
 the cause of which is not apparent. Whenever suppuration in 
 
 a hydatid cyst of the liver 
 occurs, the symptoms and 
 physical signs resemble those 
 of an abscess of the liver, 
 usually preceded by symptoms 
 of hepatitis. A hydatid cyst 
 of the liver may exist for 
 many years before it under- 
 goes suppuration. 
 
 Sponfmieous mire. — Some 
 hydatid cysts of the liver, 
 especially those which have 
 a tendency to remain small, 
 may cease to grow, and finally 
 die and undergo a spon- 
 taneous cure. After the 
 death of the parasite the 
 fluid portion of the tumour 
 is absorbed, until the only 
 remnant of the original swell- 
 ing is a focus of caseous white 
 material, which has been com- 
 pared to a mass of wet mortar 
 (Fig. 19). The cyst wall in 
 these cases becomes thickened 
 or cartilaginous, or even cal- 
 careous (Fig. 20), whilst the 
 vesicles shrivel up and burst. 
 The colour of the mortar-like 
 contents of the dead cysts 
 varies ; usually it is white, but 
 it may be of a yellowish tinge. 
 When the mortary contents 
 of the dead cyst are examined 
 under the microscope, they are 
 found to consist of fat cells, 
 cholesterin crystals, remains 
 of booklets, and debris con- 
 taining numerous calcareous 
 
 particles. After a cyst has undergone the so-called spontaneous 
 
 Fig 
 
 20. —Calcareous degeneration of a cyst 
 wall. Section through a portion of a liver 
 with a large cyst, probably hydatid in 
 nature, the walls of which are calcified. 
 The liver was normal in size and texture, 
 and from the antero-inferior margin of 
 the right lobe, just to the right of the 
 gall bladder, a tumour projected, in size 
 equal to a cricket ball, of stony consist- 
 ence, and calcified. It was intimately 
 adherent to the duodenum and colon, and 
 slightly to tlie right kidney. On sawing 
 througli the tumour, it was found to con- 
 tain bile-stained fluid and a few pultaceous 
 masses, from which all trace of structure 
 had disappeared. The tumour gave rise 
 to no symptoms during life, and the 
 patient died from an intercurrent disease. 
 — St. Jiarth. Ihisp. Museum, 
 
COMPOSITION OF THE FLUID OF A CYST. 135 
 
 cure, suppuration may occur, and an abscess of the liver result. 
 There is a specimen of this kind in the Museum of St. 
 Bartholomew's Hospital. 
 
 Entrance, of tile into the c^/s^.— Occasionally, as the result of 
 pressure, or on account of an extension of an inflammatory process, 
 a hydatid cyst of the liver may communicate with the lumen 
 of one of the bile ducts, or with the cavity of the gall bladder, 
 and bile may pass mto the interior of the tumour. When this 
 occurs the parasite is killed by the action of the bile, and then 
 the cyst either shrivels up and undergoes a spontaneous cure, or 
 a process of suppuration is induced, which is followed by the 
 development of a hepatic abscess. This is the more usual result 
 of the entrance of bile into a hydatid cyst, but in rare cases 
 the parasite may survive. 
 
 Hmmorrhage from the sac. — Eupture of a cyst may be fol- 
 lowed by a hsemorrhage from the blood vessels which lie in the 
 adjacent tissues, and this may be so severe as to lead to a fatal 
 termination. A case has been recorded in which haemorrhage 
 from the surrounding tissues took place into the bed of the 
 tumour. This was the result of an injury, and the patient died 
 from the shock. 
 
 Composition of the fluid of a hydatid cyst. — The fluid which 
 collects within the interior of a hydatid cyst is neutral in 
 reaction, colourless or very slightly opalescent in appearance, and 
 it has a specific gravity which varies between 1006 and 1016. 
 From the analyses which have been made by Hayem, Munk, and 
 Heintz, the proportion of the water varies between 9 7 "8 per cent, 
 and 98'7 per cent., and the amount of solids between 1'3 per cent, 
 to 2*2 per cent. The solids consist partly of inorganic salts, chiefly 
 sodium chloride and phosphates, sulphates, and carbonates, whilst 
 the organic substances consist of traces of proteid material and 
 a small quantity of extractives. Brieger and Moursou and 
 Schlagdenhauffen have separated a poisonous ptomaine from the 
 fluid, and this body may be the cause of the urticarial eruptions 
 which are observed in many cases of rupture of the cyst 
 associated with the entrance of the fluid into a serous cavity, 
 from which it is absorbed into the general circulation. Small 
 quantities of sugar, urea, and kreatin have also been obtained. 
 When the fluid is examined with the microscope, it is often seen 
 to contain a number of booklets, and occasionally shreds of cyst 
 membrane. 
 
136 HYDATID CYSTS OF THE LIVER. 
 
 Diagnosis and differential diagnosis. — The diagnosis of the 
 presence of a hydatid cyst in the liver is often somewhat difficult, 
 owing to the indefinite character of the symptoms. The exist- 
 ence of a slowly -growing swelling, situated in the hepatic region 
 and connected with the liver, which on palpation is found to be 
 elastic, or to present the signs of fluid, and which gives rise to 
 few symptoms, will suggest the possibility of the presence of a 
 hydatid cyst. A tumour which is due to the presence of a 
 hydatid cyst in the liver is usually single, but in very rare cases it is 
 multiple, and in the other case the surface of the liver is found to be 
 bossed and irregular in outline. It is attached to some portion 
 of the liver, or is embedded in its substance and participates in 
 the hepatic movements due to respiration. In doubtful cases 
 it may be justifiable to puncture the swelling with the needle 
 of an aspirator, and withdraw a small quantity of the fluid con- 
 tents of the swelling. In case the fluid which is evacuated in 
 this manner should happen to be purulent, it is advisable to be 
 prepared to proceed further and evacuate the contents of the 
 swelling by one of the methods which are described in the treat- 
 ment of hepatic abscess. If the fluid which is withdrawn is 
 found to contain booklets and fragments of cyst wall, the 
 diagnosis of hydatid cyst will be confirmed. 
 
 Hydatid cysts of the liver, hepatic region, or biliary system, 
 may be confounded with or mistaken for a considerable number 
 of distinct pathological conditions, the most important of which 
 are the following, namely : — 
 
 {a) Localised solid enlargements of the liver. — These enlarge- 
 ments are usually due to the presence of secondary foci of 
 malignant disease, the primary growth being found elsewhere, or 
 to localised gummata which are the manifestations of tertiary 
 syphilis. On palpation, tumours of this nature are found to be 
 solid, but if there is any difficulty in making a thorough 
 examination of the liver and the adjacent portion of the 
 abdomen, chloroform should be administered, and the examination 
 made when the patient is ansesthetised. If a sarcomatous or 
 carcinomatous growth is met with in any other part of the body, 
 especially in connection with the alimentary canal, it will point 
 to the fact that the enlargement of the liver is in all probability 
 due to deposit of the disease there. The past history of the 
 patient as regards a previous attack of syphilis may serve as an 
 indication in making a diagnosis, but the history alone must not 
 
DIAGNOSIS AND DIFFERENTIAI DIAGNOSIS. 137 
 
 be implicitly relied upon. If necessary, the swelling may be 
 explored with the needle of an aspirator. 
 
 (&) Simple cysts of the liver. — These cysts are very rare, and 
 when present are usually serous in nature. It is extremely 
 difficult to make a correct diagnosis in these cases, but their 
 existence may be suspected if the fluid which is withdrawn 
 through the needle of the aspirator is quite free from booklets 
 and contains a definite amount of albuminous material. The 
 treatment of both varieties of cyst is, however, similar, and a 
 mistake in the diagnosis is not of much importance. 
 
 (c) HeiDotic abscess. — This condition may be due to the 
 presence of a hydatid cyst which has become the seat of a 
 suppurative process, owing to the conveyance of micro-organisms 
 to the cyst by the blood stream. When suppuration occurs in 
 connection with a hydatid cyst of the liver, there is usually a 
 history of the formation of a slowly-growing swelling in the 
 hepatic region, which in the early stages of its development 
 caused few distinct symptoms, and at a later period somewhat 
 suddenly became tender on pressure and the seat of a throbbing 
 pain. A hydatid cyst of the liver may be distinguished from a 
 hepatic abscess by the fact that the cyst is of slow and insidious 
 growth, whilst the abscess develops more quickly, is tender to 
 pressure, is the seat of throbbing pain, and is accompanied in the 
 majority of cases by the occurrence of rigors and an elevated 
 temperature. In the early stages of hepatic suppuration, sugar 
 can usually be found in the urine, and this is not the case with 
 uncomplicated hydatid disease. 
 
 {d) Enlarged and dilated gall Uadder. — When a hydatid cyst 
 of the liver is pedunculated, and attached to the inferior surface 
 of the right lobe, it may be very difficult to distinguish it from a 
 dilated gall bladder, since both swellings are movable in a lateral 
 direction and have an attachment above. Usually the onset of 
 a distended gall bladder is preceded by an attack of jaundice, or 
 biliary colic, or both ; and when these symptoms occur they help 
 in making a correct diagnosis. In some cases, however, the gall 
 bladder becomes distended without the occurrence of colic or 
 jaundice, in which case the diagnosis becomes more difficult, 
 and it is necessary to make use of the needle of the aspirator. 
 Pedunculated hydatid cysts of the liver are not common, and 
 distension of the gall bladder, owing to an obstruction in connec- 
 tion with the cystic duct, is much more frequently met with. If 
 
138 HYDATID CYSTS OF THE LIVER. 
 
 a cystic swelling with the characters of a hydatid is present in 
 some other part of the body, it will suggest the possibility of the 
 hepatic tumour being of a similar nature. 
 
 {c) Subphrenic hydatid cyst. — In these cases the entire liver 
 is pressed downwards below the costal margin, and the right 
 pleural cavity is encroached upon. The costal arches which 
 overlie the swelling may also be somewhat everted. It is very 
 difficult, however, to distinguish between a hydatid cyst which is 
 situated in the superior portion of the liver, and one which lies 
 in the subphrenic space. 
 
 (/ ) Suhphrenic abscess. — In this affection the liver is pushed 
 downwards below the ribs, whilst its inferior border maintains its 
 normal outline ; there are concomitant signs of an inflammatory 
 process, and on puncture with the needle of an aspirator, pus or 
 purulent matter and gas are withdrawn. 
 
 {g) Cysts and soft solid enlargements of the hidney. — These 
 conditions are liable to become sources of difficulty in diagnosis 
 when they involve the right kidney. In most cases of this kind 
 the enlargement in the loin does not move synchronously with 
 respiration, whilst, if Ziemssen's test is applied, the colon is found 
 to lie along the upper margin of the swelling and not at its 
 lower border, a condition which is constant when an abdominal 
 swelling is in connection with the liver. 
 
 (/i) Pleural effusion. — The presence of an effusion into the 
 right pleural cavity, which may either be serous or purulent in 
 nature, is likely to lead to difficulty in diagnosis, especially 
 when both a hydatid cyst of the liver and a pleural effusion are 
 present together. A pleural effusion, when it is extensive, causes 
 bulging of the lower ribs and intercostal spaces, and at the same 
 time fluctuation may be detected in the spaces. The liver is 
 said to be pushed downwards to a greater extent in cases of 
 pleural effusion than in cases of hydatid cyst of the liver or sub- 
 phrenic space, whilst a hydatid tumour pushes upwards the 
 diaphragm and encroaches upon the space which is normally 
 occupied by the lungs. On percussion of the affected area the 
 thoracic dulness is found to be more localised in cases of hydatid 
 tumour, whilst in pleural efl'usion it is frequently found to extend 
 over the whole of the basal portion of the pleural cavity. The 
 constitutional symptoms of pleural efl'usion are more marked and 
 severe than those which are met with in hydatid disease. 
 
 {i) Aneurism of the hepatic artery or abdominal aorta. — 
 
DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. 139 
 
 Aneurism of the hepatic artery or of the upper portion of the 
 abdominal aorta gives rise to the formation of a localised swell- 
 ing which is situated in the hepatic region. This swelling 
 pulsates and is expansile, and on auscultation a distinct blowing 
 bruit can be distinguished. When the hepatic artery is the seat 
 of the aneurism, the common bile duct is invariably pressed upon, 
 and obstructive jaundice results. In cases of aneurism pain is a 
 prominent symptom, owing to the pressure of the swelling upon 
 the nerves. 
 
 (/) Cystic ovarian tumour. — When a cystic tumour of the 
 ovary is very large, and extends upwards from the pelvis to the 
 abdomen proper, so as to reach the hepatic region, it may simulate 
 a hydatid tumour of the liver which involves the inferior aspect 
 of the gland. By careful palpation, however, it can generally 
 easily be made out that the tumour has no connection with the 
 liver, and that it has its point of attachment in the pelvis, whilst 
 an examination of the vagina and the pelvic viscera will help in 
 establishing a correct diagnosis. 
 
 (Ti) Hydatid cyst of the anterior ctbdo7ninal wall. — If a 
 hydatid cyst involves the anterior abdominal wall in the 
 hepatic region, it will be found to be situated between the 
 intermuscular planes ; it will also be of small size, rarely more 
 than 3 in. in diameter, and sterile. When such a cyst of the 
 abdominal wall is met with, it will be found to be quite distinct 
 from the liver, and will not move synchronously with it, whilst 
 if the tumour is fixed by grasping it with the hand, the liver can 
 be felt to rise and fall with the movements of respiration, move- 
 ments which are quite independent of any movements of the 
 tumour itself. 
 
 (I) Hydatid cyst of the base of the lung. — A hydatid cyst of 
 the base of the lung cannot readily be distinguished from a 
 similar condition of the upper aspect of the liver. When the 
 lung is the seat of the affection, cough is more common ; and if 
 there is any blood in the sputum, it is a fact in favour of lung 
 affection. If there is an area of resonance below the area of 
 dulness, it will point to the lung, although it must be re- 
 membered that in subphrenic abscess in which gas has been 
 produced there may be an area of dulness above this, which is 
 due to an empyema. In this latter case the physical signs 
 resemble those of a subphrenic abscess containing gas and 
 associated with an empyema ; the symptoms, however, are more 
 
I40 HYDATID CYSTS OF THE LIVER. 
 
 acute, they develop more quickly, and are accompanied by an 
 elevation of the temperature of the patient. 
 
 (m) Phantom tumour. — This affection will very rarely 
 require consideration, and if any doubt is entertained, an 
 anaesthetic shovild be administered, and then, if the swelling is 
 a phantom tumour, it will spontaneously disappear. 
 
 {n) Localised abscess of the 2^(^'}^'iioneum. — Localised abscesses 
 of the peritoneum may give rise to symptoms which simulate 
 those due to the presence of a hydatid tumour of the liver ; and 
 when the hydatid has become the seat of a suppurative process, 
 it is not always easy to distinguish between the two affections. 
 Puncture of the swelling with the needle of an aspirator, and 
 subsequent examination of the evacuated fluid, will, in most cases, 
 enable the surgeon to make a correct diagnosis. 
 
 (o) Ascites. — A very large hydatid cyst may distend the 
 whole of the abdominal cavity, and give rise to symptoms of 
 ascites, in which case puncture and examination of the evacuated 
 fluid, together with the absence of the ordinary causes of ascites, 
 will clear up the diagnosis. 
 
 Frequency of affection of the liver in hydatid disease. — Accord- 
 ing to the statistics which have been collected by Thomas,^ the 
 liver is invaded in 57 per cent, of all cases of hydatid disease. 
 When hydatid cysts are multiple, the liver is nearly always one 
 of the organs to be involved, a fact which has also been shown 
 by Thomas,^ in whose list of sixty-seven cases the liver was the 
 seat of the parasite in sixty-two. 
 
 Treatment. — The treatment of hydatid disease of the liver 
 and biliary system is essentially surgical in nature ; medicines 
 administered internally appear to have no effect in killing the 
 parasite. Prophylactic measures, however, must be adopted 
 whenever there is any liability of contamination with the ova of 
 hydatids. As we have already seen, dogs form one of the hosts 
 in the life history of the parasite, and sheep also are not 
 uncommonly affected. When such sheep are killed the 
 echinococcus is set free, and if dogs are allowed to eat the 
 offal they become infected ; the tape-worm develops within 
 them, and produces ova which are shed into the alimentary 
 canal and voided along with the excreta. On this account dogs 
 should not be allowed to frequent slaughter-houses, and if they 
 become infected they should either be destroyed, or their excreta 
 
 iTlionias, "Hydatid Disease," 1894. 
 
TREATMENT. 14: 
 
 should be cremated, and means adopted to kill the intestinal parasite. 
 The surgical treatment which has been adopted for the treatment 
 of hydatid disease of the liver has varied considerably at different 
 periods and in the practice of different surgeons. The following are 
 the methods which have been made use of for the cure of the disease. 
 (1) Piincture. — Simple puncture of a hydatid cyst of the 
 liver with the needle of an aspirator or syringe, or with a trocar, 
 and removal of a portion of the fluid contents, has been followed 
 in some cases by a complete cure. It is, however, liable to be 
 fatal in its effects. According to Thomas, statistics which have 
 been collected by various observers show that the mortality in 
 all cases which have been treated in this manner has been 19 
 per cent., whilst there has been 46 per cent, of failures, and 54 
 per cent, of reputed successes. The use of the aspirator is said 
 to be twice as safe as that of the trocar. Puncture is liable to 
 be followed by leakage into the peritoneal cavity, which may 
 give rise to the development of peritonitis, or, owing to absorp- 
 tion of certain of the constituents of the contents of the 
 punctured cyst, an urticarial rash and symptoms of ptomaine 
 poisoning may become apparent. On account of the high rate 
 of mortality which has up to the present time been experienced 
 as a result of the performance of this operation, and the un- 
 certainty of its results, it is advised that this procedure should 
 not be adopted as a routine method of treatment. Puncture will 
 be found of great value in the diagnosis of many difficult and 
 obscure cases, but it should not as a general rule be performed 
 unless the surgeon is prepared, if the circumstances of the 
 case demand it, to proceed to the performance of a safer, more 
 radical, and more efficient operation, such as is described later. 
 Some surgeons have injected iodine (a small quantity of the 
 tincture) into the cavity of the cyst, after the removal of 
 a portion of the fluid contents. Others have injected perchloride 
 of mercury, strong carbolic acid, alcohol, ox-gall, or copper 
 sulphate. None of these injection methods can, however, be 
 recommended, since they have a higher rate of mortality than 
 certain of the operative measures which will be described later, 
 and they are much more liable to be followed by a failure to kill 
 the parasite. If an injection method is made use of, perchloride 
 of mercury appears to be the best substance for the purpose. 
 
 (2) The application of caustics. — Caustics, such as potassium 
 hydrate, or Vienna paste, have been used in the treatment of 
 
142 HYDATID CYSTS OF THE LIVER. 
 
 hydatid cysts, but the mortality of cases so treated was over 33 
 per cent., and on this account their use has been discontinued, 
 
 (3) Canule a demeure. — In this operation a cannula was 
 introdued into a cyst through the abdominal walls, and left 
 in situ. As this method was found to be very untrustworthy, 
 and was liable to be followed by suppuration, it is now no 
 longer practised. According to Thomas, the mortality from 
 this method of treatment was over 26 per cent. 
 
 (4) Electrolysis. — Electrolysis has been made use of in the 
 treatment of a few cases of hydatid disease of the liver. No 
 definite curative powers, however, can be attributed to this agent, 
 since, in the majority of cases which have been so treated, the 
 effects have been those of simple puncture. 
 
 (5) Treatment hy incision. — This is the best and safest 
 method of treatment of hydatid cysts of the liver. It can be 
 carried out in either one or two stages. The operation which is 
 completed at one sitting is the best, and it is the one which it 
 is advised should be made use of in the treatment of all cases of 
 hydatid cysts of the liver. In most cases the operation can be 
 carried out through an abdominal incision, but in the following 
 classes of cases it is requisite to make use of an incision which 
 passes through the lower portion of the thoracic wall, namely, 
 (a) unruptured hydatid cysts which are situated upon the 
 superior and posterior convex surfaces of the liver ; (&) hydatid 
 cysts which have ruptured into the pleural cavity. The details 
 of these operations are given in the chapter which is devoted to 
 a description of Operative Procedures. 
 
 (6) Treatment hy excision. — Tansini has put on record one 
 case in which he dissected out a hydatid cyst from the substance 
 of the liver. The operation was successful. This is an ideal 
 method of treatment, since the whole of the parasite is removed, 
 and the patient recovers much more quickly from the operation 
 than when an incision method is adopted. I have seen one case 
 in which a hydatid cyst was dissected out from the liver, and in 
 which, in order to control haemorrhage, a ligature was so applied 
 to the liver substance, that it caused occlusion of the portal 
 vein, and the patient died within a few hours from haemorrhage 
 into the abdominal cavity. The operation has, however, not yet 
 established itself firmly in legitimate surgery ; but when the ease 
 with which the liver recovers from simple wounds is taken into 
 consideration, it is quite possible that this may become a 
 
PROGNOSIS. 143 
 
 recognised method of treatment. Terrillon of Paris has removed 
 a portion of the liver which was the seat of a number of small 
 hydatid cysts, by means of an elastic ligature, which was fixed 
 around the affected portion of the gland, after he had brought it 
 into the abdominal wound and sutured it to the parietes with 
 silk. This ligature, by exerting continuous pressure upon the 
 base of the protruded portion of the liver, caused it to become 
 gangrenous, and the diseased tissue separated as a slough. This 
 method of treatment, like that of Tansini, has not been carried 
 out successfully in a sufficient number of cases to justify its 
 inclusion in the category of ordinary surgical operations. It 
 appears to be the best method of treatment when the liver is 
 the seat of a number of small hydatid cysts. 
 
 Prognosis. — The prognosis in a case of hydatid cyst of the 
 liver depends upon a considerable number of circumstances. 
 Usually, however, it is moderately good in uncomplicated 
 cases. It is much better in those cases in which there is no 
 suppuration, than in those in which suppuration has occurred. 
 The situation of the cyst, as regards the liver itself, is of 
 importance ; thus, when the cyst is not deeply placed, and it 
 also comes to the surface of the liver where that organ is in 
 direct contact with the posterior aspect of the anterior abdominal 
 wall, the prognosis is favourable. When the cyst is situated in 
 the upper portion of the liver, and comes to the surface of the 
 organ so that it pushes upwards the diaphragm and encroaches 
 upon the thoracic cavity, then the prognosis is more serious, 
 since an operation which is carried out through an incision of 
 the thoracic wall, is more liable to be followed by fatal results 
 than when it is carried out through an incision in the abdominal 
 wall. According to statistics which have been collected by 
 Thomas, the mortality in cases which have been operated 
 upon through the abdomen by the one-stage method of 
 Lindemann has been 10 "2 9 per cent., whilst in a similar class 
 of cases which have been operated upon by the thoracic method, 
 the mortality was 2 9 '4 per cent. A spontaneous cure results in 
 a certain number of cases, owing to the death of the parasite and 
 subsequent shrivelling up of the cyst. Simple puncture has in 
 a few cases been followed by immediately fatal results. In one 
 case of this kind the needle passed through the portal vein, the 
 vein having been pushed forward by the cyst ; and in another, 
 death was apparently due to an injury of the solar plexus. 
 
CHAPTER XL 
 
 MULTILOCULAE ECHINOCOCCUS OF THE LIVER. 
 
 A FORM of hydatid disease has been described by many con- 
 tinental observers, to which they have given the name of 
 " multilocular echinococcus." The affection is characterised by 
 the formation of a tumour, consisting of a considerable number 
 of small vesicles which are embedded in a soft stroma of con- 
 nective tissue. When the affection was first met with, it was 
 supposed to be a form of " alveolar colloid carcinoma of the 
 liver." Virchow ^ however, in 1856, conclusively showed that 
 the vesicles of the tumour are in reality small echinococcus 
 cysts, and not vesicles containing colloid matter, the result of 
 degeneration in a malignant tumour. This form of hydatid most 
 commonly affects the liver of man. It has been discovered in 
 other viscera, such as the lung, intestine, and peritoneum, in only 
 a few exceptional instances. The lower animals do not 
 appear to be commonly affected. 
 
 From the investigations which have been made by Leuckart,^ 
 Virchow, and Vierordt,^ it appears probable that the echino- 
 coccus multilocularis arises from originally simple bladder-worms, 
 by the formation of localised outgrowths from the external wall 
 of the mother cyst. These buds are covered by a layer of 
 parenchyma, which they push in front of them as they grow 
 outwards. Sooner or later these lateral buds become separated 
 from the original mother cyst, and, being surrounded by the 
 stroma, they come to have the appearance of separate cysts, 
 Leuckart has described a process of growth, in which solid 
 processes originate from the wall of the mother cyst, and become 
 dilated at their distal extremities so as to form secondary 
 daughter cysts. Tlie walls of the cysts have not in every case a 
 
 1 Virt:]iow, Vcrhandl. d. plijjK.-mcil. (/escllsch. zu Wurzhurcj, 1856. 
 
 2 Leuukart, "The Parasites of Man," 1886. 
 s Vierordt, Berl. Klinik, 1890, No. 28. 
 
GEOGRAPHICAL DISTRIBUTION. 145 
 
 spherical form ; often they are indented, or folded, or constricted. 
 Multilocular echinococcus of the liver takes the form of a 
 tumour, usually rounded in outline, occupying the interior of the 
 liver, and often projecting upon the surface, and varying in 
 size from a swelling not more than one or two inches in 
 diameter to one which fills the upper half of the abdomen. The 
 tumour is firm and hard, and in many respects resembles more 
 a malignant new formation than a parasite. If a section be 
 made through a tumour of this nature, the surface of the section 
 is seen to be studded with a considerable number of small 
 cavities, somewhat irregular in outline, and separated from one 
 another by a stroma which consists of connective tissue in- 
 filtrated with gelatinous material. The wall of each cavity, 
 however, has the structure of an ordinary hydatid cyst. The 
 hepatic tissue in the involved portion of the gland is completely 
 replaced by the new formation, and hence the tumour can easily 
 be made out when it is exposed by an operation. It has been 
 thought that this form of hydatid tumour extends by sending 
 out protrusions along the course of the intra-hepatic lymphatic 
 vessels, but this statement has not been conclusively proved to 
 be correct ; and it appears from an examination of sections of the 
 tumour, that the protrusions pass into the intra-hepatic bile ducts 
 and blood vessels in addition to the lymph channels. 
 
 Geographical distribution of the disease. — According to Vierordt, 
 the affection is most common in Wiirtemburg, next in Switzer- 
 land, and thirdly in Bavaria, Very few cases of the disease 
 have been described, and Vierordt gives the following numbers 
 of the cases which have occurred, namely, Bavaria, thirty -nine ; 
 Switzerland, twenty-one ; Wiirtemburg, twenty ; Austria, seven ; 
 Eussia, four ; Prussia, two ; Baden, one ; and United States of 
 America, one. No cases have apparently been recognised in 
 England. 
 
 Symptoms. — During the early stages of the development 
 of the parasite, few clinical symptoms become manifest 
 from the presence of which the existence of the affection 
 can be surmised. The first symptoms which have been 
 noticed in the early stages are for the most part pains in 
 the gastric region, and often a feeling of fulness accompanied by 
 tenderness on pressure in the epigastric or right hypochondriac 
 regions. Jaundice has been met with in about four-fifths of the 
 recorded cases of patients suffering from multilocular hydatid 
 
146 MULTILOCULAR ECHINOCOCCUS OF THE LIVER. 
 
 disease of the liver. The frequent occurrence of jaundice has 
 been thought to be due to the extension of the parasite to the 
 intra-hepatic bile channels. Jaundice in this affection presents 
 no special characteristics. It becomes noticeable on account of 
 the pigmentation of the skin and urine ; the occurrence of light- 
 coloured stools, and in the later stages haemorrhages from mucous 
 membranes or into the tissues. When the disease has existed 
 for several months, an enlargement of the liver may be recognised 
 on examination of the hepatic region, and this enlargement may 
 vary in extent from a small localised swelling, not more than 
 one or two inches in diameter, to a large tumour filling the 
 upper half of the abdominal cavity. When the liver is enlarged 
 as the result of multilocular echinococcus, the diseased portion 
 of the gland is quite hard on palpation, and usually is smooth 
 on the surface. The individual cysts of the parasitic new- 
 formation cannot be felt on the surface of the organ by palpa- 
 tion through the overlying soft tissue of the anterior abdominal 
 wall. Enlargement of the spleen is said to occur in nine-tenths 
 of the patients who suffer from the disease. This enlargement 
 becomes apparent in most cases soon after the appearance of 
 jaundice. When the parasitic infiltration has involved the 
 portal vein, the circulation in this vessel becomes impeded, and 
 oedema of the lower extremities and ascites develop. Diarrhoea 
 may occur in the later stages, and th^ stools are often stained 
 with blood. Cachexia is said to occur when the disease has 
 existed for some time. According to Vierordt,'- if the disease is not 
 treated, the patients who are affected with multilocular echino- 
 coccus only live from one to two years from the time of the 
 commencement of growth of the tumour. Both males and 
 females seem to be equally affected with the parasite. Of the 
 seventy-two cases which have been collected by Vierordt,^ thirty- 
 nine were males, and thirty-three females. The greater number 
 of the patients belonged to the middle decades of life, sixty-nine 
 cases being between 27 and 50. The oldest patient was aged 
 69, and the youngest 19. 
 
 Diagnosis. — The diagnosis of multilocular echinococcus of 
 the liver appears to be very difficult. The most important 
 points which are of value in making a diagnosis are the occurrence 
 of jaundice, the development of a tumour in connection with the 
 liver, which is hard and presents no signs of its cystic nature, 
 
 1 Vierordt, loc. cit. 
 
TREATMENT. 147 
 
 the enlargement of the spleen, and the presence of osdema of 
 the lower extremities, and ascites. The duration of the affection 
 helps to distinguish it from cancer of the liver. The absence of 
 fluctuation in the hepatic tumour is a fact of importance in 
 separating this affection from the ordinary cystic form of 
 echinococcus. Aspiration with the needle of an aspirator usually 
 fails to withdraw any fluid, but in some cases a small quantity 
 is drawn off, which has the chemical characteristics of the con- 
 tents of an ordinary single hydatid cyst. Often, however, it 
 will be found impossible to recognise the exact nature of the 
 disease until the hepatic tumour has been examined through 
 an abdominal incision. The chief affections from which it has 
 to be distinguished are cancer of the liver, thrombosis of the 
 portal vein, cirrhosis of the liver, hepatic syphilis, and chronic 
 obstruction of the biliary passages, either by an impacted gall 
 stone or by the scar resulting from ulceration induced by a 
 calculus. 
 
 Treatment. — Medical measures do not appear to be of any 
 avail in the treatment of this affection. When the disease has 
 been recognised, either after an exploratory laparotomy has 
 been performed, or from external signs and symptoms, the only 
 method of treatment which offers a moderate chance of recovery 
 is local extirpation of the diseased portion of the liver by re- 
 section of the organ. Terrillon ^ of Paris has removed a portion 
 of the liver, equal in size to two fists, on account of multilocular 
 echinococcus. The affected portion of the gland was brought 
 into the abdominal wound, and fixed there by the insertion of a 
 ring of sutures. The base of the protruded part was encircled 
 with an elastic ligature. This constriction caused gangrene of 
 that portion of the liver distal to the ligature, and on the 
 seventh day it was removed. The patient recovered. Bruns ^ has 
 also successfully operated upon a similar case. 
 
 1 Terrillon, "Communication sur la chirurgie du foie," Bull, et mem. Soc. de chir. 
 de Paris, 1890, p. 835. 
 
 ■-Bruns, " Leber-resection bei multilocnlaren Echinococcus," Beitr. z. klin. Chir., 
 Tiibingen, 1896, Bd. xvii. s. 201. 
 
CHAPTER XII. 
 
 CYSTS OF THE LIVER. 
 
 Simple or serous cysts. — Simple (non-parasitic) cysts of the 
 liver are very rare in their occurrence. A number of cases have 
 
 Fig. 21. — Large simple cyst of the liver. — llo>/. Coll. Surg. Eng, Museum. 
 
 been described under this name by different observers, but many 
 of them appear to have been sterile hydatid cysts. In the 
 
SIMPLE OR SEROUS CYSTS. 
 
 J 49 
 
 Museum of the Eoyal College of Surgeons of England, there are 
 several specimens of simple cysts of the liver, which do not 
 seem to have been sterile hydatid cysts. Two of these specimens 
 are represented in Figs. 21 and 22. The specimen from which 
 Fig. 21^ was taken is a large single cyst, which is attached to 
 the antero-inferior border of the gland, and hangs downwards into 
 the adjacent portion of the abdominal cavity. The second specimen, 
 Fig. 22,^ is a small cyst about the size of a walnut, attached to 
 the anterior surface of the liver, immediately above and to the 
 right of the fundus of the gall bladder. Each of these cysts has 
 
 Fig. 22. — Simple cyst of liver, situated ou the anterior surface a short distance 
 above the fundus of the gall bladder. — B.oy. Coll. Surg. Eng. Mxiseum. 
 
 a very thin wall, which consists externally of a layer of fibrous 
 tissue, and internally of a lining membrane, covered upon its 
 internal aspect with epithelium. Both cysts in the recent state 
 were filled with an albuminous fluid, which underwent coagula- 
 tion on the application of heat. From the nature of their con- 
 tents, these cysts have been called serous or watery cysts. The 
 exact mode of origin of this variety of hepatic cysts is very 
 doubtful. Some observers have thought that they are dilated 
 lymphatic vessels which from some cause have become obstructed, 
 
 1 Roy. Coll. Surg. Eng. Musewn.. Spec. 2757a. 
 
 2 Ibid., Spec. 2757b. 
 
150 CYSTS OF THE LIVER. 
 
 and subsequently have undergone considerable dilatation on 
 account of an accumulation of lymph in them, whilst others 
 attribute their existence to the development of obstructions in 
 connection with the commencement of the bile ducts, with 
 resulting dilatation of the proximal parts of these ducts. Others, 
 again, maintain that they are nothing more than old sterile 
 hydatid cysts. 
 
 Symptoms. — Few if any symptoms are produced by the 
 presence of these cysts in the liver, especially when they do not 
 attain a large size. A few cases have been recorded, such as the 
 one from which the specimen represented in Fig. 21 was taken, 
 in which the cyst has grown and attained considerable dimen- 
 sions, so as to fill the upper part of the abdominal cavity with a 
 tense fluid swelling, and push aside and displace the neighbour- 
 ing viscera. The fluid contents of the cysts are albuminous in 
 nature and contain no booklets, characteristics which help to 
 distinguisli them from ordinary hydatid tumours, when an 
 exploratory aspiration has been made. If the cyst grows to a 
 large size it may rupture, and its contents may suddenly pass 
 into the peritoneal cavity, causing shock and collapse. The 
 cysts, however, in the majority of cases, remain small, and do not 
 give rise to symptoms from which their presence in the liver 
 can be surmised. 
 
 Diagnosis. — When the cysts are large, they may be felt on 
 palpation of the abdomen as tense, fluid, and elastic swellings, 
 situated in the immediate neighbourhood of the liver, to which 
 organ they are attached. They move upwards and downwards 
 synchronously with the respiration. The physical signs are 
 similar to those which are met with in cases of single hydatid 
 cysts. The cysts are characterised by a slow rate of growth, 
 and, when they are aspirated and fluid withdrawn, albumin is 
 found to be present, on the application of heat, whilst no booklets 
 can be discerned microscopically. 
 
 Treatment. — When the cyst is large, the treatment which 
 must be carried out for its cure is similar to that which has been 
 recommended in the case of large single hydatid cysts, namely, 
 incision of the abdominal wall over the most prominent portion 
 of the tumour, drawing of the cyst into the wound and evacua- 
 tion of its contents, and then suture of the aperture in the cyst 
 - to the margins of the abdominal wound, and subsequent drain- 
 age. When the cyst is a large one, and it is not attached to any 
 
TREATMENT. 151 
 
 of the abdominal viscera by strong adhesions, the greater part or 
 the whole of the cyst may be excised, and if a small portion is 
 left behind the margins are fixed to the abdominal wall, as above. 
 If the cyst is pedunculated, its base may be ligatured at the 
 point where it is attached to the liver, and then the entire cyst 
 can be completely removed from the abdomen, after any adhesions 
 which may be present have been ligatured and divided. In this 
 case no after drainage will be requisite, and the wound in the 
 abdominal wall can be closed at once. In those cases in which 
 the cyst is sutured to the margins of the abdominal wall, 
 recovery will probably be materially hastened by thoroughly 
 scraping the internal aspect of the cyst cavity with a sharp 
 spoon, so as to remove the whole of the epithelium, and promote 
 the formation of adhesions between the opposing walls of the 
 cyst. The prognosis in these cases ought to be very good, since 
 operations carried out on aseptic cases with strict precautions are 
 usually successful. If the epithelium is not removed from the 
 interior, it is possible that the cyst may refill at a later date. 
 
 North ^ has recorded a case in which he evacuated a cyst of 
 the left lobe of the liver by a trocar. Five pints of a coffee- 
 coloured fluid were withdrawn. The patient died two days later, 
 and, on making a post-mortem examination, the gall bladder was 
 found to be filled with a large calculus, whilst in the common 
 bile duct two other calculi were discovered. This cyst appears 
 to have been of the character of a retention cyst. Carl Bayer ^ 
 has operated upon a woman, set. 56, in the liver of whom was a 
 large cyst containing eight litres of fluid. This cyst appeared 
 to have arisen as the result of atrophy of the hepatic acini and 
 subsequent dilatation of the intra -hepatic bile capillaries. The 
 patient recovered. The operation was carried out by making an 
 incision in the right linea semilunaris, opening the cyst, evacuat- 
 ing its contents, and stitching the margins of the aperture in 
 the cyst to those of the parietal incision. 
 
 W. Mliller has recorded a case similar to that of Bayer, but 
 two-thirds of the cyst wall were excised before the cyst was 
 sutured to the abdominal wound. 
 
 Multilocular cystic disease of the liver. — This disease is a very 
 rare pathological condition, and when met with it is often 
 
 1 North, "A Case of Cystic Tumour of the Liver," Med. Bee, N.Y., 1882, p. 344. 
 
 2 Carl Bayer, "Ueber eine durch Operation geheilte, ungewohnlich grosse Leber- 
 kyste," Frag, med, Wchnschr., 1892, No. 52. 
 
152 
 
 CYSTS OF THE LIVER. 
 
 associated with a similar condition of the kidneys. It is 
 characterised by the development of a number of cysts of vary- 
 ing size, usually not larger than a walnut, in the parenchyma of 
 the liver. Lejars ^ has collected sixteen recorded cases of this 
 disease, and published them in his thesis in 1888. Individual 
 cases have also been published since this date by Nicolle,^ 
 Demantke,^ Pilliet,^ Sabourin,^ and Claude.^ Bristowe'^ and 
 Dmochowski and Janowski^ have also described cases of this 
 kind. 
 
 The pathology of the disease does not appear to be the same 
 in all cases, and it is probable that several distinct abnormal 
 conditions are at present included under the term " multilocular 
 
 Fig. 23. — Multilocular cystic disease of the liver. — Roi/. Coll. Surg. Eng. Museum. 
 
 cystic disease of the liver." Claude ^ considers that the affection 
 may arise in the following ways : — (a) As true biliary cysts, 
 developed by an enormous dilatation of pre-existing biliary 
 canals ; (b) as mucous cysts, derived from the mucous glands 
 which are found in the biliary passages, owing to a degeneration 
 of these structures ; (c) as cysts developed from vasa aberrantia ; 
 {d) as cysts which are derived from a degeneration of the 
 
 1 Lejars, Tliese de Paris, 1888. - Nicolle, Bull. ,Soc. anat. de Paris, 1887. 
 
 3 Demantke, ibid., 1893-94-95. * Pilliet, Tribune m&d., Paris, 1893. 
 
 '' Sabouriu, Rev. demed., Paris, May 1883. 
 
 " Claude, Jiull. Hoc. anat. de Paris, 1896, Fasc. 4. 
 
 " Bristowe, Trans. Path. Soc. London, vol. vii. p. 229, and vol. x. p. 174. 
 
 8 Dmochowski and Janowski, Beilr. z. 2iath. anat. n. z. (dig. Path., Jena, 1893, Bd. xii. 
 
 8 Claude, loc. cit. 
 
MULTILOCULAR CYSTIC DISEASE. 153 
 
 hepatic epithelium, and retention of the products of this 
 degeneration. It appears to be probable that most examples of 
 this disease commence as a mucoid degeneration of the epithel- 
 ial cells of the intra-hepatic bile capillaries, and this is especially 
 so when the kidneys are simultaneously affected. Fig. 23 is a 
 representation of a specimen of a liver which is preserved in the 
 Museum of the Eoyal College of Surgeons ^ of England, and was 
 taken from the body of a woman who suffered from the disease 
 which is under consideration. The liver has undergone extensive 
 cystic degeneration, and is very much enlarged. When it was 
 removed from the body after death it weighed 13 lbs. 7 oz. 
 The cysts appeared from a microscopical examination to be dilated 
 intra-hepatic bile ducts. The microscopical appearances sug- 
 gested that the disease commenced as a cellular infiltration, 
 which was followed by the formation of connective tissue around 
 the intra-hepatic bile ducts, and that these structures then 
 became compressed and subsequently dilated. The patient had 
 presented signs of an enlargement of the liver for four years 
 previous to her death, and this enlargement had slowly increased. 
 Both kidneys of this patient were affected in a similar manner. 
 
 Several observers (Demantke,^ Juhel-Eenoy,^ and Wagner) 
 have described a condition of arterio-sclerosis as occurring in 
 multilocular cystic disease of the liver. The middle coat of the 
 arteries and the connective tissue surrounding these vessels 
 within the liver appear to have shown the most thickening, but 
 in one case the branches of the portal vein were also thickened 
 in a like manner. 
 
 Multilocular cystic disease of the liver occurs most commonly 
 in old people, and is rarely or never seen in children or young 
 adults. It nearly always occurs in individuals over sixty. No 
 definite train of clinical symptoms is manifested during the 
 course of the affection, but usually a gradual enlargement of the 
 upper part of the abdomen may be noticed, and in the later 
 stages symptoms of uraemia not uncommonly develop when the 
 kidneys are simultaneously involved. The destruction of the 
 secreting part of the hepatic tissue does not progress sufficiently 
 to cause the appearance of symptoms dependent on this condition. 
 Jaundice does not appear to occur in uncomplicated cases of the 
 
 1 Roy. Coll. of Surgeons Museum, Spec. 2758c. 
 
 2 Demantke, loc. cit. 
 
 3 Juhel-Renoy, Rev. de vied., Paris, 1881, p. 929. 
 
154 CYSTS OF THE LIVER. 
 
 disease. Most of the cases which have been described have not 
 been defiuitely diagnosed before a post-mortem examination has 
 been made. Often the patients die of an intercurrent affection, 
 and the disease of the liver is only recognised after death. 
 
 This disease is only of slight surgical importance, since 
 operative procedures do not seem likely to be able to effect a 
 cure of the abnormal condition, on account of the fact that the 
 entire liver is usually diseased, and the renal organs are also 
 affected. 
 
 Cystic adenoma of the liver. — Under this name various Ger- 
 man observers have described a disease characterised by the 
 development of an adenomatous tumour which arises from the 
 epithelial cells of the liver, or of the intra-hepatic bile channels, 
 and is associated with the formation of a number of cysts. In 
 many respects this pathological condition appears to resemble 
 the affection which we have already described as multilocular 
 cystic disease, but tends in most cases to be more localised, 
 and does not involve the entire liver in so extensive a 
 manner. The lymphatic vessels in the interior of the diseased 
 portion of the organ are said to undergo dilatation during the 
 early stages of the development of the affection, Koenig ^ has 
 placed on record the case of a girl aet. 11 years, from whom 
 he removed a large cystic tumour of the liver. The tumour 
 contained a number of large and small cysts, each of which was 
 lined internally by a layer of cylindrical epithelium, and was 
 described as a cystic adenoma of the intra-hepatic bile canals. 
 Schmidt has also recorded a case of a somewhat similar nature. 
 The patient was a woman fet. 60, from whom he removed a small 
 tumour of the liver which contained a number of cysts. The 
 growth was thought to be a cystic adenoma. Six years after 
 the removal of this tumour, the patient had not suffered from a 
 recurrence of the growth. 
 
 Dermoid cysts of the liver. — Dermoid cysts, as a primary 
 affection, do not appear to have been met with in connection 
 with the liver. Hulke ^ has described one case of multiple der- 
 moid tumours of the liver. The patient was a woman who came 
 under his observation at the Middlesex Hospital, and who also 
 suffered from dermoid tumours in both ovaries. It appeared 
 probable in this case that the affection of the liver was secondary 
 
 1 Koenig, " Handbuch der Spec. Chir." Bd. ii. 
 
 " Hulke, Trans. I'cUh. Soc. London, vol. xxiv. p. 157. 
 
DERMOID CYSTS. 155 
 
 to the cysts in the pelvis. Some of the cysts appeared to be 
 implanted on the superficial surface of the liver, a condition 
 which suggested that they had reached the liver by means of the 
 peritoneum. 
 
 This variety of cyst, either as a primary or secondary affec- 
 tion, appears to be very rarely met with in connection with the 
 liver. When present it is very difficult to distinguish a dermoid 
 cyst of the liver from other forms of cystic swelling, unless the 
 tumour has been aspirated and its contents examined, or explored 
 through an incision in the anterior abdominal wall. If a cyst of 
 this nature is discovered after the performance of a laparotomy, 
 the best method of treatment will be to dissect out the entire 
 tumour from the surrounding hepatic tissue, and then to unite 
 the margins of the wound so produced by deeply inserted silk 
 sutures. In those cases in which it is found to be impossible to 
 dissect out the entire cyst, on account of its deep connections and 
 adhesion to adjacent structures, the superficial surface of the 
 tumour should be incised, the contents evacuated, and the mar- 
 gins of the incision stitched to those of* the wound in the ab- 
 dominal parietes. The whole of the internal aspect of the cyst 
 should also be scraped with a sharp spoon, so as to prevent the 
 possibility of the cyst refilling after the abdominal wound has 
 healed. 
 
CHAPTER XIIL 
 
 MOVABLE LIVEE. 
 
 By the term movable liver is implied a condition of the organ 
 in which there is an abnormal amount of mobility. It has only- 
 been met with in rare cases, and in these the correctness of the 
 diagnosis has only occasionally been proved at a post-mortem 
 examination, or when the abdomen has been opened and a visual 
 examination of the conditions made. In origin the affection 
 appears to be either congenital or acquired. In those cases 
 which are due to congenital causes, the abnormal amount of 
 mobility of the gland seems to be dependent upon the existence 
 of an elongation of the suspensory lateral and coronary ligaments, 
 or in some rare cases these latter structures, coronary and 
 lateral ligaments, may be found to be absent, the suspensory 
 ligament being the only structure which serves to hold the 
 organ in its usual position. In this latter condition the liver 
 is suspended in a manner similar to that of a pendulum, and 
 oscillates like a body which is in a state of unstable equilibrium. 
 Large projecting lobes or portions of the liver which have been 
 partially separated from the main gland, either as a result of 
 deficiencies in development, or by inflammatory processes or by 
 pressure from without, may simulate in many respects a movable 
 liver. The acquired cases have a variety of causes for their 
 origin. In some of them the gall bladder is the seat of a 
 considerable enlargement, and by exerting traction upon the 
 attached portion of the liver a certain amount of downward 
 displacement and abnormal mobility is produced. Narrowing 
 of the inferior aperture of the thorax, which may be of 
 congenital origin, but in most cases is due to the practice of 
 wearing tightly-fitting corsets, is said to be a frequent cause 
 of displacement of the liver downwards ; but in most cases of 
 tliis kind the pressure which is due to the presence of tightly- 
 fitting articles of clothing causes a constriction of the organ, so 
 
MOVABLE LIVER. 
 
 157 
 
 that the inferior portion is pushed downwards, the superior part 
 upwards, and only in rare cases are the ligaments lengthened so 
 as to give rise to a true movable liver. Traction from below by 
 tumours or cysts which are attached to the lower part of the 
 gland, may produce a slight amount of lengthening of the liga- 
 ments, and hence a moderate amount of abnormal mobility. In 
 women who have pendulous and lax abdominal walls, a condition 
 which is often due to the occurrence of a series of pregnancies 
 following one another in close succession, a variety of movable 
 liver is occasionally met with, which may be associated with a 
 floating kidney or wandering spleen. It occasionally happens, 
 as a result of inflammatory processes in the region of the inferior 
 aspect of the diaphragm and the adjacent part of the liver, that 
 fibrous adhesions are produced which at a later period become 
 elongated, and a condition of abnormal mobility of the liver 
 results. Winkler ^ and Cantani ^ have asserted that a form of 
 fatty degeneration occurs in the tissues composing the suspensory 
 ligaments of the liver, and they consider this condition to be 
 one of the causes of the development of a movable liver. 
 Cantani attributes this degeneration to a change in the tissues 
 of the ligaments, which is induced by a localised peritonitis in 
 the neighbourhood. Segond^ divides the cases of movable liver 
 into three groups : the first group comprises those cases in which 
 the liver is pushed down by a force acting from above, such as 
 a congenital or acquired narrowing of the outlet of the thorax, 
 wearing tight corsets, cysts or tumours situated on the convexity 
 of the liver, or effusions into the pleural cavity. The second 
 group includes those cases which are dependent upon a 
 diminution in the intra-abdominal pressure, such as a relaxed 
 condition of the interior abdominal wall following pregnancy. In 
 the third group are placed those cases which are due to a change 
 in the liver itself, such as congestive conditions of the organ, 
 new growths, either cystic or malignant, which increase the size 
 and weight of the viscus, and on this account cause an elongation 
 of the suspensory ligaments. Very few well-authenticated cases 
 of true movable liver have been recorded, and on this account it 
 is advisable to regard the pathology of the affection as somewhat 
 uncertain. 
 
 1 Winkler, Arch. f. Gynaek., Berlin, 1872, s. 145. 
 
 2 Cantani, Ann. univ. di mecl. e chir., Milano, 1866, p. 373. 
 
 2 Segond, Duplay et Reclus, " Traite de Chir." Paris, vol. vii. 
 
iS8 MOVABLE LIVER. 
 
 Symptoms. — A movable liver may give rise to no symptoms 
 which inconvenience the patient, or the condition may cause a 
 series of troubles which render the life of the affected individual 
 very unpleasant. Dragging pains in the hepatic and abdominal 
 regions are usually of frequent occurrence, and there may be 
 paroxysms of severe pain and occasionally an attack of jaundice. 
 On making a physical examination, a tumour can usually be felt 
 in the abdomen, extending downwards even beyond the umbilicus 
 or into the right iliac fossa and the hypogastric region. This 
 tumour has the size and shape of the liver, and on manipulation 
 it can generally be made to occupy the position in which the liver 
 is normally situated. On percussion, the right hypochondriac 
 region is found to be resonant and occupied by the intestines. 
 In cases of movable liver, digestive derangements appear to be 
 common, whilst difficulty in walking may be experienced which 
 may prevent the patient following her ordinary occupation. In 
 most cases in which a condition of movable liver is supposed to 
 exist, it will be found very advisable to examine the patient 
 under an anaesthetic before making a definite diagnosis. By 
 this proceeding it is often possible to avoid errors of diagnosis 
 which would otherwise be made. 
 
 Diagnosis. — The condition of movable liver is met with most 
 commonly in the female sex, males being very rarely the subject 
 of the affection. When a tumour which has the shape, size, and 
 consistency of the normal liver, is present in the lower portion 
 of the abdomen, and at the same time the hepatic region is 
 occupied by structures which are resonant on percussion, it is 
 probable that a case of movable or displaced liver is under 
 consideration, and a diagnosis of this nature may be made, 
 especially in those cases in which the tumour can be replaced 
 in the hepatic region (Thierfelder).^ Great care, however, must 
 be taken in the examination of a patient before such a diagnosis 
 is made. 
 
 Treatment. — If the displaced liver can be replaced in its 
 normal position in the upper part of the abdominal cavity, and 
 retained there by the application of a suitable belt or other 
 mechanical contrivance, this should be done, and under these 
 conditions no operation advised. If the abnormal position of 
 the liver is due to traction caused by a distended gall bladder, 
 a cholecystostomy should be performed, the distended viscus 
 
 1 Thierfelder, Deutuches Arch./. Id in. Med., Leipzig, Btl. xiv. s. 146. 
 
TREATMENT. 159 
 
 evacuated, and then stitched to the anterior abdominal wall. In 
 those cases in which the displacement is due to the pressure of 
 tightly-Htting corsets, their use must be discontinued at once. 
 When the affection is due to traction, caused by the presence of 
 a cyst or tumour, the cause should be treated by appropriate 
 surgical measures. If the ligaments of the liver are much 
 elongated, and the symptoms which are due to the condition of 
 abnormal mobility become a source of considerable annoyance to 
 the patient, and at the same time cannot be remedied by the 
 application of a belt, it is justifiable to advise the performance 
 of a surgical operation to fix the liver in its usual position. 
 This operation is called hepatopexy or hepatorraphy. It may 
 be partial or complete, according to whether the entire gland 
 or only a part of it is displaced and requires fixation. 
 Langenbuch ^ and Tschering ^ have successfully performed the 
 partial operation, and Gerard-Marchant ^ the complete one. 
 Eichelot * and Lannelongue ^ have recorded cases of hepatopexy 
 which have been followed by good results. Eichelot recommends 
 that the incision of the abdominal wall should be made in the 
 linea alba or in the right semilunaris. The method of per- 
 forming these operations is discussed in Chapter XXIII. 
 
 1 Langenbuch, Berl. klin. Wchnschr., 1891, No. 3, s. 68. 
 
 2 Tschering, Centralbl. f. Chir., Leipzig, 1888, No. 23. 
 
 2 Gerard-Marchant, " Hepatopexie," Bull. Acad, de med., Paris, AoM 11, 1891. 
 
 4 Richelot, " Fixation d'un foie deplace," Uiiion med., Paris, Aout 5, 1893. 
 
 5 Lannelongue in Conturier's These de Bordeaux, 1894. 
 
CHAPTER XIV. 
 
 TRAUMATIC AFFECTIONS OF THE LIVER. 
 
 Injueies of the liver, gall bladder, or biliary ducts, when met 
 with in surgical practice, are often found to be associated with 
 similar injuries of either one or other of the neighbouring 
 thoracic or abdominal viscera. The traumatic agencies which 
 cause the injury to the liver may be either penetrating or non- 
 penetrating in character. Those traumatic affections which are 
 due to non-penetrating injuries are either of the nature of 
 contusions or of ruptures, and are due to some variety of 
 violence or mechanical force, directly or indirectly applied, which 
 has been severe enough to effect a rupture of the liver 
 substance, but has not destroyed the continuity of the over- 
 lying tissues. These affections may be caused by severe crush- 
 ing of the abdomen, as in buffer accidents ; by wheels of heavy 
 waggons or vehicles passing over the abdomen ; by heavy bodies, 
 such as logs of timber, falling upon the hepatic region of the 
 abdomen ; by blows upon the abdomen with blunt instruments, 
 by kicks in the abdomen ; by falls from a considerable height, 
 even when the patient alights upon his feet ; and by blows 
 upon the head and shoulders, the effects of which are trans- 
 mitted to the region of the liver. In a few recorded cases, 
 injuries of this nature have been caused by the fracture of one 
 or more ribs, owing to the driving inwards of the fragments 
 so as to cause a laceration of the underlying portion of the 
 liver. The severity of the injury which follows the application 
 of traumatism to the liver depends to a certain extent upon 
 the condition of the liver tissue at the time of the infliction of 
 the injury. Thus, when the liver substance is hard and slightly 
 cirrhosed, or rather more fibrous than usual, it will be able to 
 withstand the application of a mechanical force easily, and 
 without suffering much damage ; but in those cases where the 
 gland has undergone fatty degeneration, or is engorged with 
 
SITUATION OF THE RUPTURE. i6i 
 
 blood and lymph, and hence is much softer and more friable 
 than is normally the case, severe ruptures or contusions are 
 readily produced. The fibrous tissue which forms the chief 
 constituent of Glisson's capsule assists the liver to withstand 
 slight injuries. If, after the application of mechanical violence, 
 the liver substance which lies immediately underneath the 
 capsule of Glisson undergoes a solution of continuity without 
 the occurrence of a simultaneous rupture of the capsule itself, 
 then a contusion of the liver is said to take place. In this 
 case, several of the smaller blood vessels of the liver are 
 ruptured, haemorrhage takes place from them, and causes the 
 damaged portion of the gland to become infiltrated with an 
 effusion of blood, and if the organ is examined it is found to 
 present the appearance of one or more ecchymoses upon its 
 surface. In the Museum ^ of Guy's Hospital there is the liver 
 of a woman in whom an extensive subcapsular haemorrhage 
 had developed, apparently as the result of severe vomiting. 
 The woman was advanced in pregnancy at the time. A con- 
 tusion of the liver of this kind is one of the causes of hepatic 
 abscess. If the injury is more severe, both the capsule of 
 Glisson and the underlying portion of the glandular tissue 
 undergo a solution of continuity, and a rupture is produced. 
 This rupture may be small and affect only a limited portion of 
 the substance of one lobe of the gland, or it may be extensive, 
 causing partial or complete separation of a large piece of one 
 lobe or even a lobe itself from the remainder of the organ. 
 Thus, in a few recorded cases, after the infliction of severe 
 injuries, a portion of the liver has been found lying free in the 
 peritoneal cavity. 
 
 SitvMion of the contusion or rupture. — Those affections of 
 the liver which are due to the application of direct violence, 
 are located, in the majority of instances, opposite the point where 
 the injury was received ; but this is not invariable, and the 
 different statistics which have been collected in order to eluci- 
 date this point do not agree as to which is the commonest 
 situation of the injury. Thus, in Mayer's^ list of eighty-five 
 collected cases, fifty-four were located in the right lobe, twenty- 
 one in the median portion, and ten in the left lobe ; and in 
 Ogston's list of twenty-six cases, eleven were in the right lobe, 
 
 1 Crity's Hosp. Museum, Spec. 1246. 
 
 " Mayer, " Die Wundeu der Leber und Gallenblase," 1872. 
 II 
 
1 62 TRAUMATIC AFFECTIONS OF THE LIVER. 
 
 six ill the left, and nine in the median portion. In some 
 cases the portion of the liver which is the seat of the rupture 
 is the most protected part. This condition is brought about by 
 a forced doubling of the gland upon itself. This is especially 
 the case where the upper and posterior portion of the right 
 lobe is ruptured as a result of external compression. 
 
 Form and shape of the rupture. — Out of twenty-two fatal 
 cases of hepatic injuries which have been collected by Dr. 
 Frederick Taylor, fourteen cases were extensively injured, and in 
 six the liver was divided partially or completely in an antero- 
 posterior direction, whilst in eight the injury extended in 
 various directions. The shape of the laceration may be either 
 sagittal, transverse, oblique, or stellate. In the majority of 
 instances it is either in an antero-posterior direction, or it is 
 stellate in form. When a rupture of the liver is caused by 
 the driving inwards of a fractured rib or ribs, the injury, in 
 most cases, is multiple, and presents the appearance of a 
 superficial lacerated wound, but occasionally it may extend for 
 some distance into the viscus, and is then of the nature of a. 
 punctured wound. 
 
 Symptoms. — In cases of rupture of the liver, a variable 
 amount of shock usually follows immediately upon the reception 
 of the injury, and tends to mask the symptoms which are more 
 directly due to the injury to the liver. In very severe cases, a state 
 of collapse may be induced from which the patient does not re- 
 cover. In those cases in which the liver suffers a considerable 
 amount of laceration, or in which a large portion of one lobe 
 is separated, symptoms of severe internal haemorrhage develop 
 at a very early stage, and render the diagnosis obscure. The 
 symptoms which follow an injury to the liver, and which help to 
 localise the affection to the hepatic region, are — 
 
 {a) The nature and the point of application of the mechanical 
 force vjhich causes the injury. — Thus, if a mechanical force is 
 applied directly over some part of the hepatic area, it will 
 suggest the probability of the liver being the seat of injury. 
 In many cases, however, it is not possible to ascertain how and 
 where the injury has been inflicted, owing to the loss of 
 consciousness which has immediately followed the injury. In 
 some cases there are signs of bruising of the hepatic area, or 
 even ecchymoses and subcutaneous haemorrhage, in which cases it 
 is probable that damage to the liver has taken place, provided 
 
SYMPTOMS. 163 
 
 that there are also symptoms of internal hasmorrhage and pain 
 in the hepatic region. 
 
 (&) Fain. — This is generally most marked in some part of 
 the hepatic region, and often radiates either towards the 
 umbilicus, the ensiform cartilage, or the inferior angle of the 
 scapula. Some observers have attempted to localise the part 
 of the liver in which the injury is situated from the direction 
 of the radiating pains, but apparently without sufficiently trust- 
 worthy grounds upon which to base their theories. Thus, 
 Boyer ^ says that pains which radiate towards the scapula point 
 to the existence of lesions upon the convex surface of the 
 organ, whilst those which radiate towards the umbilicus indicate 
 the concave surface as the seat of the injury. The character 
 of the pain varies in intensity, and it may be either constant 
 or intermittent, but rarely the latter. It is intensified during 
 movements, and when pressure is exerted over the area of the 
 injured portion. 
 
 (c) Vomiting. — This symptom is often present, and the ejected 
 material is usually coloured with bile. 
 
 (rf) Jaundice. — Jaundice is only occasionally met with in 
 ruptures of the liver, and when present it usually commences 
 to develop on the second or third day after the reception of 
 the injury. In 249 cases of injuries to the liver collected by 
 Ludwig Mayer, jaundice occurred twenty-four times. 
 
 (e) The character of the respiratory movements. — The move- 
 ments of the abdominal walls are considerably diminished, or 
 are even entirely absent, and the respiration becomes costal 
 in character. 
 
 (/) SymiJtoms of internal hcemorrhage. — Haemorrhage is the 
 most important and constant concomitant of rupture of the 
 liver. In contusions it is small in amount, and is limited to a 
 small area underneath the capsule of Glisson, but in those 
 ruptures which involve the surface of the organ, blood passes 
 into the peritoneal cavity, and may be so considerable in 
 quantity as to cause the development of an obvious swelling in 
 the abdomen. This swelling is fluid in character, and at first is 
 localised to the upper part of the abdomen, but it may gradually 
 increase in size and ultimately occupy a considerable portion of 
 the abdominal cavity. The development of a tumour of this 
 kind is accompanied by the manifestation of all the symptoms 
 
 1 Boyer, quoted by Morris, "Encycl. of Surg.," vol. v. 
 
1 64 TRAUMATIC AFFECTIONS OF THE IIVER. 
 
 of internal haemorrhage, and in fact it may be said that signs 
 and symptoms of haemorrhage are the most important in all 
 varieties of injury to the liver. If the haemorrhage is severe, 
 and is unchecked by surgical or other means, a fatal result 
 quickly follows. The haemorrhage is much more severe when 
 the inferior aspect of the gland is the seat of the injury than 
 when the upper surface is affected. 
 
 {(j) Signs of shock and collapse. — Signs and symptoms of 
 shock and collapse are manifest in nearly all cases of injury to 
 the liver. They vary in intensity according to the severity of 
 the injury, and, as we have already seen, they may mask the 
 symptoms which otherwise would help to localise the organ 
 which has been damaged. 
 
 (h) Condition of the urhie. — The examination of the urine 
 may reveal the existence of a small quantity of bile, or of sugar. 
 Sugar is said to be frequently found in the urine after a con- 
 tusion of the liver. Its presence, however, is only transient, 
 and it soon disappears if the liver returns to its normal 
 condition. 
 
 Diagnosis. — If the patient affected comes under observation 
 with the history of the infliction of an injury, especially when it 
 has been applied over the region of the liver, and this is followed 
 by the occurrence of shock, and at a later period by the forma- 
 tion of a fluctuating swelling in the abdomen, which swelling 
 gradually increases in size, and is associated with the symptoms 
 of internal haemorrhage, then it will be probable that he is 
 suffering from a rupture of the liver. Contusions and small 
 ruptures are suggested by the character of the injury, and the 
 occurrence of pain in the hepatic region, which radiates towards 
 the umbilicus, the ensiform cartilage, or the inferior angle 
 of the scapula. Marshall^ relates a case in which a portion of 
 the liver became detached as the result of the severity of the 
 injury, and passed into the circulation, becoming impacted in the 
 pulmonary artery immediately above the valves. The portion of 
 liver weighed 4 grms. The patient died forty minutes after 
 the reception of the injury. Zenker and Schmorl have related 
 similar cases, all of them being fatal. When the rupture is 
 slight, and only a small amount of localised haemorrhage takes 
 place, few localising symptoms may become apparent beyond 
 pain in the region of the liver and a variable amount of shock. 
 
 1 Marshall, Lance', Londcn, Feb. 7, 1874. 
 
TREATMENT. 165 
 
 In these slight cases, however, if the part which has been injured 
 is auscultated with a stethoscope a few days after the injury, it 
 will be possible to hear friction sounds during the movements of 
 respiration, which are due to the development of a localised 
 plastic peritonitis. In some cases it happens that suppuration 
 occurs, and signs of a hepatic abscess develop. Hamilton ^ has 
 recorded a case in which a patient fell from a considerable height 
 on to his right side, but after the accident was able to walk. 
 About an hour afterwards he suffered from severe angina, with 
 embarrassment of the respiration, and died in a short time in a 
 condition of coma. Post-mortem the liver was found to have 
 been ruptured in several places, and also to be fatty. In the 
 lung the small and medium-sized branches of the pulmonary 
 artery were found to be occluded with fat, which stained with 
 osmic acid. 
 
 Treatment. — The plan of treatment which is to be adopted in 
 the case of injuries of the liver depends upon the character and 
 severity of the injury, and especially upon the amount of 
 hsemorrhage which results. In many cases the first treatment 
 which is requisite is that which has for its object the abatement 
 of the symptoms of shock and collapse. The patient should at 
 once be placed in bed and kept absolutely quiet ; warm bottles 
 are applied, and if there is evidence of a feeble pulse hypodermic 
 injections of strychnine should be given. It is not advisable to 
 administer alcohol or ether in any form, since both substances 
 dilate the peripheral blood vessels, and tend to increase the 
 haemorrhage, if any is present. After the patient has recovered 
 from the symptoms of shock and collapse, complete rest in bed 
 for a period should be enjoined, especially in those cases in which 
 the injury has been of a severe character. If no signs of the 
 occurrence of internal haemorrhage develop, rest in bed, combined 
 with careful nursing, will in most cases be followed by a recovery. 
 During the time the patient is confined to bed opium should be 
 administered in small doses, and nourishing food in small quan- 
 tities. Those foods, such as beef tea, which contain a consider- 
 able amount of extractives should not be given during the early 
 stages, since they throw an increased amount of physiological 
 work upon the liver. Milk given in small quantities, and diluted 
 with soda water or plain water, will be found to be the most 
 useful article of diet at first. 
 
 ^ Hamilton, Brit. Med. Joiirn., Loudon, Oct. 6, 1877. 
 
1 66 TRAUMATIC AFFECTIONS OF THE LIVER. 
 
 When signs and symptoms of hcTemorrhage into the peritoneal 
 cavity develop, and gradually or quickly become more manifest, 
 it is necessary in most cases to have resort to the performance of 
 a surgical operation. The skin of the abdominal area must be 
 rendered aseptic by one of the ordinary methods, and then the 
 abdomen is opened. The incision through the abdominal walls is 
 usually made in the middle line, but this will be decided when a 
 careful examination of the region of the greatest localised 
 enlargement or swelling has been investigated. In many cases 
 it will be found quite impossible to locate exactly the position of 
 the rupture in the liver, and under such circumstances the 
 abdomen must be opened by an incision which commences at the 
 ensiform cartilage above, and extends downwards over the linea 
 alba towards the umbilicus for about three or four inches. All 
 bleeding which is the result of the incision in the abdominal 
 walls should be arrested before the peritoneal cavity is opened. 
 When this has been done, an attempt is made to localise the 
 situation of the injury. All blood clots or collections of blood 
 should be removed, and if haemorrhage is still taking place, it 
 must be traced to its source, and temporarily arrested by means 
 of sponge pressure and packing with aseptic plugs of gauze. If 
 any bleeding vessels are met with, and they can be ligatured with 
 fine silk, this must be done. Much help may be derived, in 
 establishing a correct diagnosis in cases of severe injury, by 
 making a chemical examination of the fluid effused into the 
 peritoneal cavity, so as to definitely ascertain whether bile is 
 present or not. When evidence of the presence of free bile 
 in the blood which has passed into the peritoneum can be 
 obtained, it points to the existence of an injury to the liver 
 or one of the biliary ducts. If the liver is found to be the 
 seat of the haemorrhage, the locality, extent, nature, and character 
 of the injury must be ascertained. In order to do this satisfac- 
 torily, it will usually be found necessary to enlarge the incision 
 in the abdominal wall, and this should be done in a downward 
 direction. If either the anterior or inferior surface of the liver 
 is seen to be the seat of the injury and the area from which 
 haemorrhage is taking place, it will usually be found possible to 
 deal at once with the injury through the median wound of the 
 anterior abdominal wall. The liver should be raised as far 
 forwards as possible by packing the lower aspect with sponges, 
 and by traction and slight rotation, if requisite, by the hands of 
 
TREATMENT. 167 
 
 the surgeon's assistants, until the injured area is brought imme- 
 diately opposite the aperture in the abdominal wall. If the 
 rupture is linear, and does not extend to a very great depth, it 
 should be dealt with in the following manner : — All adherent 
 clots are carefully removed from the injured parts by sponging, 
 and if any bleeding points can be seen, these are ligatured with 
 fine silk. The margins of the rupture are then brought as far as 
 possible into exact apposition, and then fixed together by the 
 introduction of a row of sutures. Either silk or medium-sized 
 catgut can be used for this purpose, but it will be found that silk 
 is much easier to introduce, and it is less liable to slip afterwards. 
 The sutures are introduced with a Hagedorn's needle, of such a 
 shape that the long edge of the point is parallel with the margin 
 of the wound. The point of the needle is entered about one- 
 third of an inch from the margin of the rupture, and is first 
 carried to the bottom of the wound through the liver tissue, and 
 then made to pass through the opposite margin of the wound but 
 the same distance from the wound. The sutures are placed 
 about a third or a quarter of an inch from one another, and all 
 are introduced before any of them are tied. After the entire 
 row has been introduced, each one is tied separately, and the 
 free ends are cut short. Great care must be taken in tying these 
 sutures, so as to prevent any tearing of the liver substance. 
 They must be tied only just tight enough to hold the margins of 
 the rupture in close apposition along the entire length of the 
 wound. After the haemorrhage has been arrested in this manner, 
 and when there is no further sign of bleeding, the surrounding 
 peritoneal cavity is thoroughly cleansed of all blood clots and 
 other extraneous matter, and then the wound in the abdominal 
 wall is closed in the usual manner. If there is any oozing of 
 blood from the margins of the rupture, or from the perforations 
 of the liver substance which have been made by the introduction 
 of the sutures, it may be necessary occasionally to introduce a 
 drainage-tube or strip of aseptic gauze into the bottom of the 
 wound, and leave it there for the first twenty-four hours, at the 
 expiration of which period it must be removed. In most cases, 
 however, this will not be required, as the htemorrhage usually 
 entirely stops after the sutures have been put in and tied. 
 Experimentally, I have performed this operation upon healthy 
 cats after the liver had been ruptured by violence. In all the 
 cases which were operated upon in this manner perfect healing 
 
1 68 TRAUMATIC AFFECTIONS OF THE IIVER. 
 
 and recovery took place. When the liver is found to be the 
 seat of several ruptures, it is not always possible or practicable 
 to deal with the various solutions of continuity in the gland in 
 the manner, above described. If any small ruptures are seen in 
 the exposed surface of the gland, it is sometimes possible to 
 arrest the haemorrhage by the insertion of a " purse-string " suture, 
 such as is shown in Fig. 23 a. This form of suture is only of 
 use in small lacerated wounds. If the haemorrhage has ceased 
 naturally, as happens occasionally, the clots of blood should be 
 removed, and the wounded area should be packed with tampons 
 of sterilised gauze, whilst the wound in the abdominal wall is 
 partially closed, a portion being left open through which the 
 
 Fig. 23a, — Method of inserting a " purse-string " suture for a smal rupture 
 of the surface of the liver. 
 
 plugs of gauze can be afterwards removed, and fresh ones 
 inserted if necessary. The tampons should in any case be 
 removed at the end of twenty-four to forty-eight hours, and 
 sooner still if there are any signs of fresh hemorrhage, or of the 
 occurrence of septic infection of the wound. All these pro- 
 cedures must be carried out under the strictest aseptic precau- 
 tions, so as to avoid as far as can be done the infection of the 
 wounded area with the micro-organisms of suppuration. If it is 
 found impossible to obtain a free exposure of the wound in the 
 liver by means of the median vertical incision through the 
 anterior abdominal wall, it may be requisite to make a further 
 incision, either along the inferior border of the right costal margin, 
 or even to resect portions of the lower ribs. When the left lobe 
 
TREATMENT, 169 
 
 of the gland is alone injured, it will in almost every case be 
 found possible to deal with the injury through a median incision 
 in the linea alba. Schlatter-^ has recently recorded a case in 
 which he had to make an incision along the right costal margin, 
 and was able to suture a rupture which was situated close to the 
 lobulus Spigelii, and to arrest the haemorrhage, which had been 
 very severe. The patient, however, died owing to loss of blood 
 and shock consequent upon the injury and this operation, 
 although it was attempted to combat this by means of trans- 
 fusion of salt solution. Professor Kronlein ^ has operated upon a 
 case in which the left lobe was separated owing to a total sagittal 
 rupture. The injury was followed by htemorrhage and escape of 
 bile into the peritoneal cavity. Fourteen days after the occur- 
 rence of the injury, the abdomen was opened, and an attempt was 
 made to suture the injured portion of the liver, all blood and bile 
 being first removed from the peritoneum. The patient died 
 shortly afterwards from shock and collapse. If haemorrhage is 
 found to be still going on, and to be dependent upon severe 
 injury of the liver, it is probable that surgical measures for its 
 arrest will be difficult of application. When the peritoneal 
 cavity has been opened, the injured area of the liver should be 
 freely exposed, so as to enable the surgeon to deal with it satis- 
 factorily. In order to do this, it will be requisite in many cases 
 to make a second incision along the right costal margin, or even 
 to resect portions of the lower ribs. When this has been done, 
 all blood is to be removed from the area of the operation, and, if 
 possible, the bleeding should be stopped by temporary pressure 
 with sponges. If any bleeding points or the open mouths of 
 blood vessels can be seen, they should be closed by the application 
 of fine silk ligatures. It is somewhat difficult to apply ligatures 
 in this manner, owing to the friability of the hepatic tissue. 
 Some surgeons have made use of the thermocautery for the 
 arrest of parenchymatous haemorrhage from the liver, but it is 
 doubtful whether it is advisable to adopt this method of treat- 
 ment, since it is followed by the death of a layer of tissue, which 
 must separate or become absorbed before healing can take place, 
 and it is liable to be followed by secondary hcemorrhage. 
 Parenchymatous haemorrhage of this nature can usually be as 
 effectually arrested by the application of tampons of sterilised 
 
 1 Schlatter, Btitr. z. klin. Chir., Tiibingen, Bd. xv. Heft 2, s. 531-562, 
 
 2 Kronlein, quoted by Schlatter as above. 
 
lyo TRAUMATIC AFFECTIONS OF THE LIVER. 
 
 gauze ; and there is not the same risk of the occurrence of a 
 localised gangrene or of secondary haemorrhage. In a course of 
 experimental investigations which I have carried out in the 
 laboratories of the Eoyal College of Surgeons, I have found that 
 it is possible to deal with severe ruptures of the liver which 
 involve the partial or almost complete separation of an entire 
 lobe in the following manner : — After opening the abdominal 
 cavity and exposing the injured portion of the liver, an elastic 
 rubber tube is passed around that part of the organ in which the 
 ruptures are situated. The tube is then tightened sufficiently to 
 control the circulation in the blood vessels and temporarily arrest 
 the haemorrhage. This rubber tube is given to an assistant to 
 look after, and then the operator takes a sharp scalpel and quickly 
 removes the injured portion of the liver by means of a wedge- 
 shaped incision. Sponges are applied to the incised surface, and 
 any bleeding points which can be seen are clamped with fine 
 artery forceps whilst the ligatures are being applied. The margins 
 and surfaces of the wound in the liver are then brought into exact 
 apposition, and fixed by the introduction of a row of sutures, each 
 suture being applied after the manner which was recommended 
 in the case of linear ruptures. When all the sutures have been 
 introduced, they are tied and their ends cut short. The elastic 
 ligature is then removed, and the liver is allowed to drop back 
 into its place in the abdomen. A small amount of haemorrhage 
 may occur from the points of insertion of the sutures, but this 
 soon stops. The peritoneum is then washed out, and the 
 abdominal wound closed. I have carried out this operation a 
 number of times on cats and dogs, and have found that in most 
 cases it has been followed by a successful result. In one case, in 
 which I made use of catgut sutures alone, I found that some of 
 them gave way, and this accident was followed by haemorrhage 
 and the death of the animal. Silk sutures appear to be the best 
 for the purpose. This procedure, however, has not yet, as far as 
 I am aware, been tried in the treatment of ruptures of the liver 
 in man ; but it seems possible, from experiments which have 
 been made on animals, that it may be made use of in selected 
 cases. 
 
 If a portion of the liver has been detached completely from 
 the rest of the organ by the force of the injury, it must be re- 
 moved from the abdomen, and the injured surfaces brought into 
 apposition if possible, and fixed with sutures. When this con- 
 
PENETRATING WOUNDS. 171 
 
 dition occurs, it will usually be accompanied by severe internal 
 hsemorrhage, which causes a serious state of the patient, owing 
 to the development of shock and collapse dependent upon the 
 loss of blood, so that it is not possible to perform a prolonged 
 and extensive operation for the relief of the injury. In a few 
 cases of this kind, however, especially when the apex of the left 
 lobe is the seat of the injury, it will be possible for the above- 
 mentioned procedure to be carried out, and a favourable result 
 may be expected to follow. It will be found much easier to 
 pass an elastic ligature around the left lobe for the control of 
 hccmorrhage than around the right lobe. 
 
 Penetrating wounds. — Penetrating wounds of the liver are 
 only occasionally met with, and are due most commonly to either 
 one or other of two causes : they are either the result of a stab 
 with some sharp instrument, such as a knife or a bayonet, or 
 they are caused by the penetration of projectiles discharged from 
 firearms. In very rare cases, blunt bodies, such as the shaft or 
 centre pole of a cart or waggon, have been the cause of penetrating 
 wounds of the liver. Ludwig Mayer ^ has collected cases of 
 penetrating wounds of the liver from various sources, and finds 
 records of twenty-one cases which have recovered from stabs. 
 Punctured and incised wounds vary in position, size, and extent, 
 according to the form, direction, and mode of application of the 
 instrument which produces the injury. Thus some wounds, such 
 as stabs with penknives, may be small and only penetrate the 
 superficial surface of the liver ; whilst others, such as those 
 which are due to bayonet wounds, or to wounds which have been 
 inflicted with a homicidal intent (as in the case of the late 
 President of the French Eepublic), may be wide or pass through 
 the greater part of one lobe, and divide large branches of the 
 portal or hepatic veins, or even the inferior vena cava itself. 
 This kind of wound is met with much more frequently in 
 military than civil practice. 
 
 Gtmshot wounds. — These injuries differ considerably in 
 severity, owing to the varying characters and size of the 
 projectiles which cause the injury. In some cases there is only 
 a slight superficial grazing or grooving of the peritoneal and 
 fibrous coverings of the viscus and the underlying hepatic sub- 
 stance, whilst in others there may be deep perforations and 
 extensive lacerations which pass through or involve the greater 
 
 1 Loc. cit. 
 
172 TRAUMATIC AFFECTIONS OF THE IIVER. 
 
 part of one or other lobe, or both lobes may even be simultane- 
 ously damaged, or in very severe cases a portion of the liver may 
 be reduced to a pulp. These differences are due in the main to 
 the size, shape, velocity, and direction of the missile which causes 
 the injury. According to Otis, when the projectile is discharged 
 from a firearm which is located in the immediate neighbourhood 
 of the individual who is injured, a considerable and widespread 
 laceration is the almost invariable result, even when the ball is 
 discharged from a pistol or a rifle. These injuries are often 
 complicated, owing to the presence of foreign bodies, such as 
 the projectile itself, or particles of clothing, or portions of the 
 bony ribs, which have been carried inwards by the force of the 
 injury. 
 
 Lacerated wounds. — These affections are usually due to the 
 perforation of a blunt body from without. The shaft of a 
 carriage, the centre pole of a cart or waggon, or the penetration 
 of iron or wooden palings upon which a patient has fallen, have 
 been known to be the cause of these injuries. They are very 
 rare, and when met with are commonly fatal, on account of the 
 severity and extensive nature of the injury. The patient usually 
 dies from shock and primary haemorrhage. 
 
 Frequency. — Punctured, incised, and gunshot wounds of the 
 liver are much less frequently met with than ruptures and con- 
 tusions. They are seen for the most part in military practice, 
 but occasional cases of homicidal or suicidal wounds of the liver, 
 which have been caused by sharp instruments or by the ball 
 of a revolver or other variety of firearm, are met with in both 
 Hospital and private practice. Lacerated wounds which are the 
 result of perforation of the upper abdominal region with a blunt 
 body, are also very rare. Incised wounds of the liver are oc- 
 casionally made intentionally by the surgeon in the treatment 
 of abscesses or parasitic cysts, and in the removal of hepatic 
 tumours. 
 
 Symptoms. — Haemorrhage, which is either internal or external, 
 and its consequences, are the usual symptoms which become 
 prominent after the infliction of penetrating wounds of the liver. 
 When the wound upon the external surface of the body is large, 
 and communicates directly with the wound in the liver, there 
 may be a considerable amount of external haemorrhage, but in 
 the majority of cases it is found that the track of the penetrating 
 body becomes somewhat closed, owing to the approximation of 
 
LACERATED WOUNDS. 
 
 173 
 
 the margins of the aperture ; and then the greater portion or all 
 of the effused blood passes into the peritoneal cavity, and gives 
 rise to the symptoms of internal haemorrhage. Lacerated wounds 
 of the liver, owing to the fact that they are of considerable ex- 
 tent, are usually accompanied by more severe ha:^morrhage than 
 clean incised wounds, unless it happens that in the latter case 
 one or more branches of the portal or hepatic veins have been 
 cut across, or the inferior vena cava itself has been injured. If 
 the haemorrhage which follows the reception of the injury is 
 very severe, the symptoms of collapse and shock may obscure 
 all other symptoms. In many cases, however, pain is found to 
 be present ; it is usually dull in character, and radiates either 
 upwards towards the shoulder or the neck, or downwards towards 
 the ensiform cartilage and the umbilicus. It is said to radiate 
 upwards in the case of injuries of the superior aspect of the gland, 
 and downwards when the inferior surface is involved. The 
 location of the jjain, however, does not in all cases indicate the 
 position of the injury. A discharge of bile or bile-coloured fluid 
 from the external wound occasionally accompanies penetrating 
 hepatic injuries, and when it is met with it indicates the ex- 
 istence of an injury to one of the larger hepatic ducts, or of a 
 simultaneous injury to the gall bladder. It is not necessary in 
 these cases that one of the extra-hepatic ducts should be involved, 
 as injury of the larger intra-hepatic ducts is followed by an 
 escape of bile. Vomiting is an occasional symptom in these 
 cases, and, when the stomach is also injured, blood and possibly 
 bile will be found in the ejecta. The respiration is usually 
 laboured, and tends to be costal in type on account of the 
 injury to the abdominal organs. Hiccup may be present, and 
 is very annoying to the patient. If a patient who has received 
 a perforating wound of the abdomen or thorax, which involves 
 the liver, does not die at an early stage after the reception of 
 the injury, and the injury has not been treated by active surgical 
 measures, the following symptoms may arise, namely, {a) disten- 
 sion of the abdomen and tympanites ; (&) rigors at irregular 
 intervals ; (c) delirium ; id) peritonitis ; (e) secondary haemor- 
 rhage ; and (/) abscess of the liver. Although early surgical 
 treatment in many cases will tend to prevent the occurrence 
 of the above unpleasant complications, in a certain number of 
 patients these cannot be avoided. 
 
 Diagnosis. — The position, and especially the direction of the 
 
174 TRAUMATIC AFFECTIONS OF THE LIVER. 
 
 penetrating wound which causes the injury of the liver, are most 
 important points upon which stress must be laid in establishing 
 a correct diagnosis, whilst the escape of bile or bile-stained fluid 
 from the external wound also affords important information. If 
 the external wound is situated upon the right side of the body, 
 below the level of the sixth intercostal space, and its direction is 
 horizontally inwards or obliquely downwards, the liver must be 
 implicated if the instrument has passed inwards to any consider- 
 able depth ; and if the wound is situated in the right hypo- 
 chondriac region and below the costal margin, and its direction is 
 obliquely upwards, the liver will usually be found to be damaged. 
 If there is an escape of bile or bile-coloured fluid from the 
 wound, this occurrence will point to the existence of an injury of 
 some portion of the liver or the biliary system. When the liver 
 can be distinguished at the bottom of an external wound, and its 
 surface can be seen to have suffered a solution of continuity, the 
 diagnosis will be apparent. If the external wound is situated 
 over some part of the liver, and its infliction is rapidly followed 
 by the development of symptoms of internal heemorrhage, it will 
 in all probability be found that the liver is the organ which has 
 been injured and has given rise to hsemorrhage. In some cases 
 it will be found almost impossible to arrive at a correct diagnosis, 
 owing to the external wound being situated far from the hepatic 
 region, and the uncertainty which exists concerning the direction 
 which the penetrating instrument or missile has taken. This is 
 especially the case when the injury is due to a gunshot wound. 
 
 Treatment. — If it is possible to make a correct diagnosis con- 
 cerning the nature of the injury, and it is decided that the liver 
 has been involved, it will be found in nearly all cases to be im- 
 perative that the seat of the injury should be thoroughly 
 examined, and any surgical treatment which is requisite should 
 be at once carried out. This is especially the case when signs of 
 internal haemorrhage become manifest. The patient should be 
 anaesthetised if his general condition will allow of this being 
 done, and then the external wound is examined. If it is 
 requisite to enlarge this, in order to make a complete examina- 
 tion of the injured tissues, it should be done at once. By this 
 means the damaged organ is exposed, and the exact nature of the 
 injury made out. If it is found that haemorrhage is still going 
 on, it must be arrested, either temporarily, by the application of 
 sponge pressure over the bleeding area, or by packing the part 
 
TREATMENT. 175 
 
 with strips or plugs of aseptic absorbent gauze ; or permanently, 
 by the application of silk ligatures to the bleeding points, if they 
 can be distinguished. All blood and clots are removed, so as to 
 render a complete and uninterrupted view of the injured area 
 possible. If any foreign body is met with, it must be at once 
 removed. When the wound of the liver is a clean, incised, or 
 punctured one, which does not extend to a very great depth, its 
 margins and surfaces should be sponged as clean as possible with 
 an aseptic solution, and the edges then brought into apposition 
 and fixed by the introduction of a row of sutures of Chinese 
 twist or of catgut. Each suture should enter the uninjured area 
 of the liver, about one-third of an inch from the margin of the 
 wound. It should then pass to the bottom of the wound through 
 the liver substance, being brought out in a similar manner on the 
 opposite side. A complete row of sutures about one-third or 
 one-fourth of an inch apart is introduced, and then all are care- 
 fully tied and the ends cut short. Great care is requisite in 
 tying the sutures, otherwise it will be found that they cut 
 through the liver substance into the wound. A small amount 
 of haemorrhage usually follows from each point of puncture with 
 the suture needle, but this soon ceases. "When the entire row of 
 sutures has been introduced and tied, the neighbouring parts of 
 the peritoneal cavity and the abdominal wall are well sponged 
 or irrigated, if requisite, so as to remove all traces of blood or 
 foreign matter which may be present. The external wound in 
 the abdominal wall is then closed with sutures. If there is 
 much oozing of blood from the injured surfaces of the liver, it 
 will be advisable to leave open a small part of the external 
 wound. A drainage-tube may then be passed down to the region 
 of the wound in the liver, or it may be packed with tampons of 
 aseptic gauze, to be removed on the following day if the local 
 conditions are favourable. A similar procedure should be carried 
 out when much dirt has been introduced into the wound, either 
 by the penetrating instrument or from any other cause. In most 
 cases it will be found to be better and more convenient to make 
 use of tampons of sterilised and aseptic gauze in place of drain- 
 age-tubes. This is especially the case when there is much oozing 
 of blood from the injured tissues. In cases where there are signs 
 of the commencement of septic peritonitis, it is advisable to irri- 
 gate the infected portion of the peritoneal cavity with an aseptic 
 solution, and then to put in a drainage-tube, which can be 
 
176 TRAUMATIC AFFECTIONS OF THE LIVER. 
 
 removed at the end of twenty-four hours, if it is found that no 
 further symptoms of septic infection develop. In gunshot 
 wounds it is often difficult to decide which is the best method of 
 treatment to adopt. The projectile which has been the cause of 
 the injury cannot in all cases be found, whilst the wound extends 
 to a considerable depth, and often involves or implicates adjacent 
 viscera, the margins of the wound are frequently lacerated, and 
 the surrounding parts of the hepatic substance are considerably 
 contused. In every case where it can possibly be done, the pro- 
 jectile and any pieces of clothing which may have been intro- 
 duced into the wound along with it, must be at once removed. 
 The wound is then irrigated with an antiseptic solution, and 
 packed with tampons of sterilised gauze. The strips of gauze 
 are daily removed, the wound irrigated, and afterwards packed 
 again with similar tampons. When all escape of fluid has 
 ceased, and there is no danger of the occurrence of suppuration, 
 the packing with gauze is discontinued, and, if it is considered 
 necessary, a small drainage-tube is inserted, which should be 
 gradually shortened, and finally removed altogether. Schlatter ^ 
 has recently recorded the case of a man, set. 25, who suffered 
 from a stab of the abdomen which penetrated the liver, and was 
 associated with prolapse of the transverse colon and the great 
 omentum. Three and a half hours after the occurrence of the 
 injury, the patient was anaesthetised, and the abdomen examined. 
 After the prolapsed intestine and omentum had been replaced, it 
 was found that heemorrhage was taking place into the peritoneal 
 cavity. The external wound was enlarged, when the liver was 
 seen to be the seat of a penetrating wound from which the 
 haemorrhage was proceeding. The blood and clots were removed 
 from the neighbourhood of the injured area, and then the wound 
 in the liver was closed by the introduction of two catgut sutures, 
 which passed to the bottom of the wound, and the superficial 
 margins were afterwards approximated by the application of two 
 silk sutures. The abdominal cavity was then thoroughly 
 cleansed from all blood and other exudations, and the wound in 
 the abdominal wall was closed by the application of a catgut 
 suture to the parietal peritoneum, and tiers of sutures to the 
 abdominal muscles and skin. Finally, an aseptic bandage was 
 applied. The patient was said to have lost at least a litre of 
 blood. The operation was followed by the complete recovery of 
 
 1 Schlatter, Bdtr. z. klin. Ghir., Tubingen, Bd. xv. s. 531 et seq. 
 
COMPLICA TIONS. 1 7 7 
 
 the patient. Euepp ^ operated upon a man who attempted to 
 commit suicide by shooting himself with a revolver in the head 
 and also in the epigastric region. The first bullet was found 
 embedded in the skull, and was removed, no fracture of the 
 cranial bones having occurred. The second bullet appeared to 
 have passed into or through the left lobe of the liver, but its 
 whereabouts could not be discovered. The left lobe of the liver 
 was the seat of a star-shaped wound with irregular margins, from 
 which a moderate amount of haemorrhage was taking place. 
 This wound was closed by the application of three deep catgut 
 sutures, which arrested all haemorrhage. After the peritoneal 
 cavity had been freed from all blood and debris, the wound in 
 the abdominal wall was closed in a similar manner to that men- 
 tioned above. A few days after the operation a small abscess 
 formed in the abdominal wall, which necessitated the introduction 
 of a small drain. The patient recovered, the ball remaining in 
 some part of the posterior portion of the abdomen. Kronlein ^ 
 also has had a similar case. The patient suffered from a gunshot 
 wound of the abdomen, which caused injuries to the stomach, 
 duodenum, pancreas, left kidney, and the liver. The wound in 
 the liver was closed by the introduction of sutures, but the 
 patient succumbed eight hours after the performance of the 
 operation. In the case of lacerated wounds of the liver which 
 are the result of perforation of the abdomen by some blunt body, 
 the consequent shock and haemorrhage usually prove rapidly fatal ; 
 but if the condition of the patient admit of an examination, the 
 method of treatment which should be adopted is similar to that 
 which has been recommended in the case of gunshot wounds. 
 
 Complications. — Injuries of the liver are frequently followed 
 by the development of serious complications. One of the most 
 common of these is the formation of an abscess. When this 
 condition occurs it must be treated after the manner described 
 when dealing with hepatic abscess. Peritonitis may also occur, 
 especially in those cases in which the wound has been caused by 
 a dirty instrument or by the projectile of a firearm. When met 
 with it must be treated by incision of the abdominal wall, 
 irrigation and subsequent drainage. Secondary haemorrhage may 
 come on some time after the reception of the injury, and is 
 usually followed by a fatal termination. The only treatment 
 
 1 Ruepp, quoted by Schlatter, q.v. 
 
 2 Kronlein, quoted by Schlatter, q.v. 
 
178 TRAUMATIC AFFECTIONS OF THE LIVER. 
 
 which can be adopted is packing with tampons of aseptic gauze, 
 since it is practically impossible in most cases to find the bleed- 
 ing point. General hepatitis occasionally results from gunshot 
 wounds, but this is uncommon, as in most cases of injury of this 
 kind the inflammatory process tends to be localised to the track 
 of the projectile. Jaundice is sometimes met with as a con- 
 comitant of general hepatitis, and rarely occurs when the 
 inflammation is localised. Wounds of the liver, as we have 
 already mentioned, are often associated with the occurrence of 
 similar injuries to the ribs, spine, diaphragm, or the adjacent 
 abdominal or thoracic viscera. 
 
 Prognosis. — When the injuries to the liver are very severe, 
 or they are associated with similar injuries to other abdominal 
 viscera, the prognosis is usually very grave. In the case of 
 severe incised wounds in which surgical treatment can be 
 carried out soon after the infliction of the injury, it is 
 probable that the future mortality will be much less than has 
 been the case when the expectant treatment has been employed. 
 Most cases of slight incised or punctured wounds which are 
 submitted to early surgical treatment, ought to be followed by 
 recovery, especially when no large blood vessel has been damaged. 
 In the case of gunshot wounds, however, the prognosis and prospect 
 of recovery is not so good. If the patient survive the dangers 
 of shock and primary hasmorrhage, he is more liable to be the 
 subject of the various complications which have been mentioned 
 above than in the case of incised wounds. This is especially 
 the case as regards the development of peritonitis and abscess. 
 According to Otis,^ twenty-five, out of a total of fifty-nine uncom- 
 plicated cases of gunshot wounds of the liver, recovered ; whilst 
 only thirty-seven, out of a total of one hundred and eleven 
 complicated cases, were followed by a favourable termination. 
 Lacerated wounds of the liver which are due to the penetration 
 of a blunt body are in the majority of cases fatal, from shock and 
 primary haemorrhage. Mayer ^ has collected 267 cases of injuries 
 of the liver, and has found that in ruptures the mortality was 
 86'6 per cent., in gunshot wounds 34-4 per cent., and in stabs 
 56"5 per cent. Edler^ collected the statistics of 543 cases, 
 and found the mortality to be, in ruptures 85-7 per cent., in 
 gunshot wounds 55 per cent., and in stabs 64-6 per cent. 
 
 1 Otis, "Med. and Surg. Hist. War of Rebellion," Surg. vol. - Mayer, loc. cit. 
 
 3 Edler, Arch./, kiiii. Chir., Berlin, 1887, Bd. xxxiv., s. 173 et seq. 
 
PROGNOSIS. 179 
 
 From these statistics it appears that gunshot wounds have been 
 less frequently followed by a fatal result than either ruptures or 
 stabs and incised wounds. 
 
 Terrier and Auvray ^ have recently collected the various 
 cases of ruptures, perforating wounds, and foreign bodies in the 
 liver, which have been published in surgical literature, and which 
 have been submitted to direct surgical interference. They find 
 that forty-six cases of this kind have been recorded. This 
 number comprises eleven cases of rupture of the liver, which 
 were due to direct or indirect violence, and were not associated 
 with a perforating lesion of the abdominal or thoracic walls ; one 
 case of a foreign body in the liver ; twenty cases of perforating 
 wounds ■ caused by sharp instruments ; and fourteen cases in 
 which a perforating wound was due to the projectiles of firearms. 
 
 Among the eleven cases of rupture, six of the patients 
 recovered, and five died. In four of these cases the abdominal 
 cavity was opened, and the injured viscus dealt with surgically, 
 within twenty-four hours from the time of the occurrence 
 of the injury ; and in the remaining seven, surgical measures 
 were not carried out until after the expiration of a longer 
 period. It appeared probable that if the operation had been 
 performed sooner, recovery might have followed in three of 
 the fatal cases. In five of the cases, after the abdomen had 
 been opened, the wound in the liver was packed with tampons 
 of gauze ; and in one of these, in addition, a pair of artery-forceps 
 were left on a bleeding vessel for twenty-four hours. The 
 wound was closed by the insertion of sutures in two cases, in 
 three cases it was found impossible to discover the part of the 
 liver which was the seat of the injury, whilst in one case the 
 fluid was evacuated by a cannula. Death appeared to be due in 
 the fatal cases either to the severity of the injury, or to the 
 lateness of the operation, or to the inability of the operator to 
 find the injured portion of the liver. 
 
 The percentage of recoveries was higher in the cases of 
 incised and perforating wounds than in ruptures. Out of the 
 twenty cases collected, fifteen recovered and five died. Concern- 
 ing the time of operation, it is stated that in nineteen cases the 
 operation was performed shortly after the occurrence of the 
 injury, and in one case it was not done until some days after- 
 
 1 Terrier et Auvray, '• Les Traumatisms du Foie," Rev. de chir., Paris, 1896, No. 10, 
 pp. 718-775. 
 
i8o TRAUMATIC AFFECTIONS OF THE IIVER. 
 
 wards, as an injury of the liver was not suspected in the first 
 place. The operation was carried out through an abdominal 
 incision in eighteen cases, and in two cases the thoracic wall was 
 incised and portions of the ribs resected. Sutures were used to 
 arrest the haemorrhage ten times, tampons of gauze eight times, 
 and the thermocautery in one case. The successful cases in 
 most instances recovered quickly, but in one patient a biliary 
 fistula became established which necessitated the performance of 
 a second operation before complete recovery ensued. Of the five 
 fatal cases, one died on the operation table; a second died from 
 failure to arrest the haemorrhage, on account of the portal vein 
 being divided, and not discovered at the time of operation (the 
 case of the President of the French Eepublic) ; the third 
 died from haemorrhage, owing to a portion of the rupture 
 not being sutured ; the fourth died from peritonitis and 
 hfemorrhage ; whilst the fifth case did not die until eight days 
 afterwards. 
 
 Fourteen cases of gunshot wounds of the liver have been 
 treated by surgical operation. Ten of the patients recovered, and 
 four died. Exploratory laparotomy was performed within twenty- 
 four hours of the infliction of the injury in twelve cases, and in 
 two cases the operation was not done until a longer period had 
 elapsed. The cause of death in the fatal cases was, in one case, a 
 wound of the pleura and right lung, the pleural cavity containing 
 more than a litre of blood ; in the second case, the stomach and 
 colon were wounded and ffecal matter escaped into the peritoneum, 
 and caused peritonitis ; in the third case, there was a wound of the 
 abdominal aorta ; and in the fourth, several injuries of the 
 stomach, intestine, pancreas, and kidney were also present. As 
 regards the nature of the surgical procedures adopted, the wound 
 in the liver was packed with tampons of gauze alone in three 
 cases ; and in two, in addition to the tampons of gauze, a glass 
 drainage-tube was placed in the track of the projectile ; in three 
 cases it was closed by means of sutures ; in one, the collection 
 of blood and bile was evacuated through a simple incision ; 
 whilst in three cases all hcemorrhage was found to have ceased, 
 and in these cases the region of the wound was disinfected 
 with antiseptics. The projectile which had caused the injury 
 was found in only two cases, in one lying free in the peritoneal 
 cavity, and in the other embedded in the substance of the 
 liver. 
 
PROGNOSIS. i8i 
 
 One case has been recorded of a foreign body in the liver. 
 The patient was a child, tet. 5 months, who suffered from a 
 biliary fistula situated in the right hypochondrium. This was 
 due to a needle which had become embedded in the liver. A 
 laparotomy was performed and the needle extracted. The 
 patient recovered. 
 
CHAPTER XV. 
 
 TUMOUKS OF THE LIVER. 
 
 The liver is very frequently the seat of tumours, but in most 
 instances it is found that these tumours are secondary forma- 
 tions which are dependent upon the presence of a primary growth 
 in some other part of the body, small particles of the tumour 
 having been carried to the liver by the portal vein or by the 
 branches of the hepatic artery. In a small number of cases, the 
 tumours of the liver are primary in character, and usually of 
 a malignant type. Innocent tumours of the liver are met 
 with, but they are not common. The variety which occurs 
 most frequently is some form of angioma ; but fibromata, 
 tibro-neuromata, and simple adenomata have been described, and 
 cases recorded in surgical literature. 
 
 Awjioma. — An angioma of the liver is a localised tumour of 
 a non-malignant type, which, as regards its origin, may be either 
 congenital, or it may develop in the later periods of life. Several 
 distinct varieties of this affection have been described. The most 
 common variety has the form of a localised tumour, somewhat 
 variable in size, and situated immediately underneath the capsule 
 of Glisson. It consists of a number of dilated blood vessels, 
 which have the appearance and structure of ordinary cavernous 
 tissue, and which, according to Virchow, are in direct connection 
 with the smaller branches of the hepatic artery, from which they 
 can be injected ; but Eokitansky and Frerichs deny this, and say 
 that they only have communications with the veins. It has also 
 been maintained that these tumours are developed in connection 
 with an accessory spleen and its accompanying artery, owing to 
 an adhesion being established between the surface of the liver and 
 this accessory organ. The evidence upon which this theory is 
 based appears, however, to be very inconclusive. In some cases 
 of angioma of the liver, the cavernous tissue which constitutes 
 the tumour may be destitute of a capsule, and lie in close relation 
 
ANGIOMA — SYMPTOMS. 183 
 
 with the adjacent hepatic tissue ; or it may have a distinct 
 capsule, consisting of rather dense fibrous tissue, in which case 
 the tumour is called an encapsuled or encysted angioma. After 
 a tumour of this kind has been formed, the cavernous tissue may 
 be replaced to a considerable extent by fibrous tissue, in which 
 case it is known as a fibrous angioma. It occasionally happens 
 that, in connection with an angiomatous tumour, a large quantity 
 of melanin is deposited in the cells which line the blood spaces, 
 and in the surrounding cellular tissue, and when this occurs the 
 growth assumes a dark pigmented appearance, and is then 
 described as a melanotic angioma. If the blood vessels which 
 supply the tumour with blood become obstructed, so as to pre- 
 vent a continuous stream of blood passing to the cavernous spaces 
 within the tumour, the blood which normally occupies these 
 spaces may become absorbed, and the spaces filled with a 
 serous fluid, in which case the tumour is called a cystic angioma, 
 or an angioma which has undergone cystic degeneration. The 
 direct pathological cause which gives rise to the development of 
 this variety of tumour does not appear to be very clear. In 
 those cases which first appear in the later periods of life it has 
 been suggested that localised inflammatory conditions of the 
 interstitial tissue of the liver around the intra -hepatic branches 
 of the portal vein may be concerned in their origin. It has also 
 been maintained that the condition is associated with an atrophy 
 of the liver cells in the interior of an acinus of the gland. 
 
 Syiwptoms. — Those angiomata which are of congenital origin 
 usually grow quickly and increase in size so as to cause the 
 development of a large tumour in connection with the liver, 
 which may give rise to the appearance of a large abdominal 
 swelling extending downwards as far as the umbilicus. Children 
 who are afflicted with this variety of tumour generally die at an 
 early age ; of two recorded cases of this kind, one patient 
 succumbed at the age of 8 months, and the other at the 
 age of 6 months. Those cases which commence in later life, 
 and may be spoken of as " acquired cases," occur more commonly 
 in the male sex, and are usually met with in people who are over 
 60 years of age. They are very rarely seen before the age of 
 40. In most cases these tumours remain small and do not 
 attain large dimensions. They may be single or multiple, often 
 the latter, as many as thirty or more having been met with in 
 the same patient. Each tumour is most commonly rounded in 
 
1 84 TUMOURS OF THE LIVER. 
 
 outline, and it is separated from the surrounding liver tissue by 
 a layer of fibrous tissue, which is derived from the interstitial 
 substance of the gland. Usually these tumours project upon the 
 superficial surface of the affected viscus, and they are found most 
 frequently in the region of the antero-inferior margin or near 
 the suspensory ligament, but occasionally they have been met 
 with in the interior of the organ. Tumours of this kind 
 are rarely larger than a walnut in size. They do not give rise 
 to any symptoms by which their presence can be suspected 
 during life ; so that in nearly all cases they have only been 
 discovered post-mortem. 
 
 Treatment. — Owing to the absence of symptoms, and to the 
 innocent nature of the tumour in those cases which are of 
 acquired origin, surgical treatment is not called for. When the 
 tumour grows and attains a large size, as in the cases which occur 
 in young children, and are of congenital origin, surgery does not 
 afford any efficient method of treatment which offers a possibility 
 of a cure. If a tumour of this kind is met with, it may be pos- 
 sible in those cases in which the swelling has not attained a very 
 large size, to open the abdominal cavity and attempt to deal with 
 it by applying a ligature to its base or to the pedicle, if one 
 exists. In the majority of cases it is not advisable to attempt 
 the local removal of the tumour, on account of the very severe 
 haemorrhage which would be certain to occur ; but if it is found 
 possible to encircle the affected portion of the liver with an 
 elastic ligature, and so control the passage of the blood along the 
 blood vessel supplying the tumour, it may be practicable in such 
 cases to effect a complete removal of the affected portion of the 
 gland. 
 
 Eiselberg^ has recently recorded a unique case of cavernous 
 angioma of the liver which he submitted to operation. The 
 tumour was attached to the right lobe of the gland, and when it 
 had been removed it weighed 470 grms. In the early part 
 of the operation for the removal of the tumour, after the 
 abdominal cavity had been opened, an incision was made in 
 its base, but such severe haemorrhage resulted that it was 
 necessary to press the tumour back into its original position, 
 and to carry the incision through healthy liver tissue beyond the 
 margins of the growth. The thermocautery was used to effect 
 the separation of the tumour from the liver. When a vessel 
 
 1 Eiselberg, Whn. klin. Wchnschr., 1893, No. 1. 
 
FIBROMATA — ADEXOMATA. 185 
 
 was divided and blood exuded from the cut end, it was ligatured 
 at once with silk ; by this means the hcemorrhage was well con- 
 trolled. When the tumour had been separated, the margins of 
 the wound in the liver were brought into apposition and fixed by 
 the insertion of a number of silk sutures. "When this had been 
 done, the parenchymatous hemorrhage from the incised surfaces 
 of the gland immediately ceased. The region of the wound in 
 the liver was packed with tampons of iodoform gauze, the ends of 
 which were allowed to protrude from an angle of the parietal 
 wound which was left open for the purpose. The remaining part 
 of the external wound was closed with sutures in the usual 
 manner. The patient recovered completely, and at the expiration 
 of seven weeks left the Hospital. 
 
 Eosenthal ^ operated upon a case of fibrous angioma of the 
 liver, the tumour bein^ of the size of a child's head, and situated in 
 the region of the lobulus Spigelii. The tumour was somewhat 
 pedunculated, so that it was possible to pass an elastic ligature 
 around the pedicle close to its attachment to the liver. This 
 elastic ligature was held in position by a steel needle, and the 
 tumour was excised, only slight haemorrhage being encountered 
 during the performance of the operation. Five days later, when 
 the ligature had commenced to ulcerate through the pedicle, that 
 portion of the pedicle which lay distal to the ligature was cut 
 through with the thermocautery. When this had been done, 
 the entire wound in the liver was packed with tampons of 
 iodoform gauze, and the parietal wound closed. At the end of 
 six weeks the patient had completely recovered. 
 
 In those cases in which the tumour has attained a large size, 
 the only possible method of treatment appears to be that by 
 electrolysis ; but this does not seem to ofler much chance of cure, 
 judging by the results which have been obtained by this method 
 of treatment in other regions of the body. 
 
 Fihromata. — Fibromata and neuro-fibromata of the Kver are 
 exceedingly uncommon, and have only been met with very rarely. 
 Pisenta has described a case of multiple fibromata of the Kver. 
 
 Adenomata. — Adenomata of the liver, occurring in glands 
 which are otherwise normal, and also in cirrhotic livers, have 
 occasionally been met with and described, but their occurrence is 
 very uncommon. When present they do not always give rise to 
 the development of symptoms by which their presence can be 
 
 1 Rosenthal, Gaz. lek., Warszawa, 1S9-3, Xo. 45 (quoted by Kousnetzoff and Pensky\ 
 
1 86 TUMOURS OF THE LIVER. 
 
 recognised. It is possible that epithelial growths of this kind 
 may be the precursors of the formation of primary malignant 
 tumours of the liver. 
 
 Gronbe ^ of Kharkov has operated upon a man who was said 
 to be suffering from an adenoma of the liver. The patient 
 was a man tet. 5 5. He gave a history of having had a 
 swelling in the epigastric region for twenty years. Fifteen 
 years after the first appearance of the abdominal swelling, 
 severe pains in the region of the tumour compelled the patient 
 to seek medical advice. He was sent to Carlsbad, and under- 
 went the " cure " there. The pains disappeared, but the volume 
 of the tumour remained unaltered. Six months before the 
 patient came under the care of Groube, he was injured in the 
 hepatic region by the pole of a carriage. After this accident, 
 pains in the region of the abdominal swelling were severe and 
 constant, whilst the patient became emaciated. When seen by 
 Groube, the patient had a large tumour in the epigastric region, 
 which was firmly fixed to the liver and apparently embedded in 
 it. An operation was resolved upon, and the surface of the 
 tumour exposed by making an incision through the overlying 
 portion of the abdominal parietes. Numerous peritoneal 
 adhesions were met with, and when the surface of the swelling 
 had been laid bare, the tumour was found to be embedded in 
 normal liver tissue, whilst it had a distinct capsule which had 
 become calcified. The tumour was removed, and the cavity in 
 the liver which was left was packed with tampons of iodoform 
 gauze, and the parietal wound closed, except for a small part 
 where the ends of the strips of gauze were brought out. On the 
 fifth day the packing of gauze was removed for the first 
 time. At each succeeding change of the dressing, 5 to 10 
 grms. of a solution of pyoctanin (1 in 500) was injected 
 into the wound in the liver. This injection was repeated six 
 times in all. One month after the operation the patient was 
 discharged from the Hospital. He was free from pain and had 
 gained in weight, but a small fistula in the epigastric region still 
 remained. Six months afterwards the patient was seen, and was 
 then apparently quite well ; but eleven months after the opera- 
 tion he returned to the Hospital, and was found to be suffering 
 from cancer of the liver. 
 
 1 Groube, quoteil by Kousnetzoli' ;iml Pensky, Rev. dc chir., Paris, 1896, No. 10, pp. 
 512-514. 
 
MALIGNANT NEOPLASMS. 187 
 
 The structure of the tumour was said to be a tubular 
 adenoma. Groube assumes that in this patient a non- 
 malignant adenoma of the liver had existed for twenty years, 
 and that at the end of this time the swelling acquired malignant 
 characters, and ultimately caused the death of the patient. 
 
 Bergmann ^ has recorded a similar case. The tumour was 
 fixed to the left lobe of the liver. In the removal of the 
 tumour severe haemorrhage was experienced, but this was 
 arrested by the application of ligatures to distinct bleeding 
 points, cauterisation of the incised surfaces with the thermo- 
 cautery, and packing of the entire wound with strips of iodoform 
 gauze. The patient recovered from the operation, and at the 
 end of six weeks was quite well. 
 
 Malignant neoplasms of the liver. — Primary tumours of the 
 liver, which commence in the hepatic epithelium and are malig- 
 nant in character, occur in three different forms, which depend 
 upon the mode of growth of the epithelial elements. In the 
 first variety, the carcinomatous process commences at one focus 
 within the organ, and gives rise to the formation of a large tumour, 
 which may ultimately involve a considerable portion of the 
 gland. In most cases of this kind, the right lobe is the situa- 
 tion of the early development of the growth. Instead of the 
 disease commencing at one point, there may be several foci. 
 In the later stages of this variety, the interior of the large mass 
 of cancer may disintegrate and break down, and hsemorrhage 
 take place into its interior. Numerous secondary growths are 
 also frequent in the later stages of the disease. In the second 
 variety, the pathological process is characterised by the develop- 
 ment of an excess of fibrous tissue in connection with the 
 epithelial elements. The liver in these cases resembles in many 
 respects the liver in alcoholic cirrhosis, and the affection has 
 been called cancer with cirrhosis, or cancerous cirrhosis. 
 This form of the disease may occur in the course of ordinary 
 cirrhosis of the liver, owing to the epithelial cells of the gland 
 taking on or assuming an atypical form of growth, which results in 
 the development of cancer ; or the cancerous condition may first 
 commence and be associated with the formation of a consider- 
 able amount of fibrous tissue, which gives rise to the appearance 
 of cirrhosis. The former mode of origin of this variety of cancer 
 of the liver seems to occur most commonly. In the third 
 
 1 Bergmann, Arch.f. klin. Chir., Berlin, 1893, Bd. xlvi. s. 383. 
 
t88 tumours of THE LIVER. 
 
 variety of cancer of the liver, the tissue which surrounds the 
 branches of the portal vein in the substance of the organ is the 
 seat where the disease first becomes apparent. This is due to 
 the fact that in these cases the pathological process commences 
 in an atypical growth of the epithelial cells which line the 
 interior of the intra-hepatic bile ducts accompanying the 
 branches of the portal vein. In the earlier stages of this form of 
 cancer, multiple foci of new growths are in most cases found 
 to develop along the course of the branches of the portal vein 
 within the liver, and as the disease progresses many of these 
 may approach one another so closely as apparently to fuse and 
 thus form large masses of new growth. Carcinomata of the 
 liver may be divided into two classes, according to their seat 
 of origin. The first class comprises those cases in which the 
 cancerous process commences in the cellular elements which 
 normally occupy the interior of the hepatic trabeculge, and the 
 second class those which have their origin in the epithelial cells 
 of the intra-hepatic bile ducts. In the first class, the affection 
 is an adeno-carcinoma, and the cancer cells have the structure 
 and appearance of cylinder cells ; whilst in the second class the 
 growth is a true carcinoma, which is either of the nature of an 
 ordinary cancer, with a moderate amount of fibrous tissue 
 elements, or the epithelial cells form the greater part of the 
 tumour, and cause it to have the appearances of a medullary 
 carcinoma, and the cancer cells have the form and shape of large 
 epithelial cells, occurring as solid cell nests. Primary carcino- 
 mata of the liver, which have their origin in the epithelium 
 of the intra-hepatic bile ducts, appear to be more commonly met 
 with than those growths which commence in the hepatic cells 
 within the liver trabeculae. 
 
 Sarcomata of the liver which are primary in character are 
 very rare, and have only been recorded by a few observers. 
 Podrouzek,^ writing in 1888, says that up to that time he had 
 only been able to find the records of thirteen cases of primary 
 sarcoma of the liver, and of these it was doubtful whether all 
 were cases of true primary sarcoma, and to this list he adds 
 a personal observation of a case of primary spindle-celled sarcoma. 
 Hans Kehr has recently recorded a case of sarcoma occuring in 
 a girl of 15. The primary sarcomata of the liver which have been 
 described comprise cases of angio-sarcoma, melanotic sarcoma, and 
 
 1 Podrouzek, Frafj. med. Wchnschr., 1888, Nos. 32 and 33. 
 
MALIGNANT NEOPLASMS. 
 
 189 
 
 ordinary round and spindle-celled growths. It is possible that 
 those growths which were melanotic in character, were secondary 
 to a primary focus of disease which was not discovered at the 
 time of the post-mortem 
 examination. 
 
 The liver is very 
 frequently the seat of 
 metastatic malignant 
 growths. The primary 
 growths may be either 
 carcinomata or sarco- 
 mata. They dev^elop 
 most commonly after 
 carcinoma of the abdo- 
 minal alimentary canal, 
 of the uterus, the pan- 
 creas, the mammary 
 gland, and the pelvic 
 viscera ; and after all 
 varieties of sarcoma, 
 especially the melanotic 
 forms and those which 
 affect the region of the 
 abdomen or one of the 
 long bones. Carcino- 
 mata of the gall bladder 
 and the biliary ducts 
 may by direct exten- 
 sion involve the ad- 
 jacent portions of the 
 liver, or less commonly 
 they may be the cause 
 of the development of 
 secondary growths. As 
 an explanation of the 
 great frequency of 
 secondary growths in 
 the liver, after malig- 
 nant disease of the abdominal viscera, it appears to have been 
 conclusively proved that it is due to the fact that small particles 
 of the primary growth pass into one of the radicles of the portal 
 
 Fig. 24. — Sarcoma of the liver (primary). A portion of 
 the right lobe of the liver of a child, set. 3. The 
 cut surface shows that scarcely any traces of liver 
 tissue remain, the entire organ being infiltrated 
 with a soft disintegTating sarcomatous growth, in 
 which cavities of various sizes have been formed. 
 The organ was irregularly lobulated in all directions 
 from the presence of numerous globular growths 
 from 1 to 2 inches in diameter. The liver weighed 
 a little over 4 lbs. The growth was a small round- 
 celled sarcoma. No secondary deposits were found 
 in other viscera. — St. Barth. Hosp. Museum. 
 
190 
 
 TUMOURS OF THE LIVER. 
 
 vein which is involved in the disease, and by this vessel are 
 carried to the liver, where they are arrested in the portal 
 capillaries and become a commencement of a secondary focus 
 of disease. 
 
 Primary carcinoma of the liver is, as we have already seen, 
 rare, and when it occurs it involves either a part or the whole of 
 the organ in a malignant infiltration, which manifests itself by 
 causing the development of a general or more often of a localised 
 
 Fig. 25.— Sarcoma of the liver (secondary). The liver of a boy £et. 10, 
 enormously enlarged and studded with large nodules, presenting all the 
 appearances characteristic of secondary deposits. The grow^th is a sarcoma 
 secondary to a growth of the kidney. — 81. Barth. IIosp. Museum. 
 
 solid enlargement of the liver. When the disease is secondary, 
 the enlargements are most commonly multiple, and they then 
 give rise to the formation of swellings, which can be felt as 
 tumours upon the external surface of the liver when the hepatic 
 region is palpated through the abdominal wall. In certain cases 
 these swellings have a soft and elastic feel, which suggests the 
 presence of fluid. This is due to the occurrence of a process 
 of disintegration and breaking down in the interior of the 
 
SYMPTOMS. 
 
 191 
 
 tumour, and the consequent formation of spaces which contain 
 blood and carcinomatous or sarcomatous debris. 
 
 Sym])toms. — The formation of a mahgnant growth in the 
 liver is usually pre- 
 ceded by the occurrence 
 of lancinating pains in 
 the hepatic region, 
 especially in the right 
 hypochondrium, and 
 associated with the 
 appearance of signs of 
 wasting and loss of 
 flesh. In a considerable 
 number of cases it is 
 possible to find evidence 
 of a primary focus of 
 disease in some part of 
 the body, especially in 
 one of the abdominal 
 viscera, or in one of the 
 long bones. Sarcomata 
 of the umbilicus, in 
 nearly every case, ex- 
 cept during the earliest 
 stages of the affection, 
 are accompanied by the 
 development of second- 
 ary growths in the 
 liver. In a case of this 
 kind which recently 
 came under my ob- 
 servation, I found that 
 although the primary 
 growth was small and 
 localised, and easily 
 capable of removal, it 
 
 Fig. 26. — Carcinoma of tlie liver (secondary). The 
 section of a liver containing secondary growths, 
 following a primary carcinoma of the rectum. 
 The substance of the liver is occupied by numerous 
 cancerous deposits of varying size. The largest in 
 the centre of the si^ecimen shows degeneration in 
 the deeper parts, the softened matter having fallen 
 out, leaving a ragged cavity. Other nodules 
 similarly, but to a less degree, show the central 
 softening and breaking down. The surface of the 
 liver is nodular. — St. Earth. Hosp. Museuon. 
 
 was associated with 
 numerous secondary growths on the inferior aspect of the liver, 
 which could not be felt through the anterior abdominal wall. 
 Enlargement of the liver occurs in all cases, but in those in which 
 the malignant process is associated with the condition of cirrhosis, 
 
192 TUMOURS OF THE LIVER. 
 
 it does not become manifest until a much later stage of the disease. 
 The enlargement may cause the organ to extend downwards into 
 the abdomen for a variable distance below the costal margin, or 
 upwards so as to encroach upon the space which is normally 
 occupied by the lungs, especially the right, and in many cases it 
 is found that an enlargement has taken place in both directions. 
 This enlargement may exist for some time and attain considerable 
 dimensions before it gives rise to the appearance of symptoms 
 from the occurrence of which the existence of the disease can be 
 diagnosed. As a result of enlargement of the liver, an abdominal 
 tumour becomes manifest, and in those cases in which the foci 
 of disease are multiple this tumour will have an irregular outline, 
 and its surface present several bossed projections which are 
 apparent on palpation. In most cases the tumour moves with 
 the respiratory movements, and it is dull on percussion. In the 
 later stages of the disease the tumour may occupy the greater 
 portion of the cavity of the abdomen, and in this condition it is 
 not always possible to detect that the tumour moves synchron- 
 ously with the respiratory movements. Disturbances of the 
 digestive processes are constantly present, and the appetite is very 
 poor. In the general diffuse form of primary cancer of the liver 
 the patient is anaemic and the skin pale, but in the later stages 
 there may be jaundice, although this is not of constant occur- 
 rence. In the nodular variety, jaundice is often present in the 
 early stages of the disease, and after its appearance it gradually 
 deepens in intensity and persists until death. Ascites may be 
 a prominent symptom, and may be due, either to pressure upon 
 the portal vein as it lies in the portal fissure or in the gastro- 
 hepatic omentum,, or to the irritation which is caused by the 
 extension of the cancerous growth to the peritoneum and the 
 development of cancerous peritonitis. Pressure of the growth 
 upon the common bile duct may cause an accumulation of bile 
 in the gall bladder, and the appearance of a tumour which is 
 dependent upon the distension of this viscus. In rare cases the 
 inferior vena cava may be pressed upon by a growth, and phlebitis 
 and thrombosis of this vessel induced. Eecently, I saw a case in 
 which a secondary growth in the lobulus Spigelii caused throm- 
 bosis of the adjacent portion of the inferior vena cava and 
 complete obliteration of its lumen. Progressive emaciation is an 
 invariable symptom of hepatic cancer, and it becomes especially 
 manifest in the later stages of the affection. Malignant disease 
 
DIAGNOSIS. 193 
 
 of the liver may be met with in persons of almost all ages, but, 
 in those cases in which the affection is primary, adults over 40 
 are chiefly the subjects of the disease. When, however, the 
 affection is sarcomatous in nature, young people and even children 
 may be affected. In those cases in which secondary centres 
 develop in the liver, it is found that sarcomata occur chiefly in 
 young persons, and that carcinomata are for the most part met 
 with in adults. 
 
 Diagnosis. — Primary neoplasms of the liver, as we have 
 already seen, are not very common, and when they are met with 
 their diagnosis is often somewhat difficult. When a patient is 
 found to be suffering from a tumour which is situated in the 
 upper portion of the abdomen, and connected with the liver itself, 
 and this tumour moves with respiration, and on palpation appears 
 to be solid in consistency, the possibility of the existence of a 
 malignant disease of the liver must be taken into consideration. 
 In all cases of this kind a careful search must be instituted for 
 the presence of a primary focus of disease elsewhere : thus, a 
 rectal examination should be made so as to determine the con- 
 dition of the rectum and the other pelvic viscera ; and at the 
 same time the abdomen should be examined, an anaesthetic being 
 administered if requisite. Echinococcus cysts, abscess of the 
 liver, amyloid disease, and tertiary syphilitic affections may 
 be mistaken for cancer of the liver. These pathological con- 
 ditions can usually be excluded by paying careful attention to 
 the signs and symptoms which are present. In cancer of the 
 liver the organ is enlarged, the surface is irregular, and presents 
 several localised elevations which are hard in consistency and do 
 not give any evidence of the existence of fluid ; icterus is fre- 
 quently met with, ascites is usual in the later stages, pain is a 
 constant symptom, and enlargement of the spleen is in all 
 uncomplicated cases absent. In all cases of malignant disease, 
 especially those which involve the pelvic or abdominal viscera, 
 or the bones of the extremities, an examination of the liver and 
 hepatic region should be made before an operation is performed 
 for the removal of the primary growth, in order to exclude the 
 possibility of the occurrence of secondary deposits in the liver. 
 It occasionally happens in cases of sarcomatous disease of the 
 bones, especially those of the lower extremities, that secondary 
 growths develop in the liver at a very early stage of the affec- 
 tion. In those cases in which an exact diagnosis is impossible, 
 13 
 
194 TUMOURS OF THE LIVER. 
 
 and in which a tumour of the abdomen exists and is perhaps in 
 connection with the liver, it is justifiable to perform an explora- 
 tory laparotomy, so as to make clear the nature of the affection, 
 and then to proceed according to the conditions which are 
 discovered after the abdomen has been opened. 
 
 Treatment. — Whenever multiple nodular cancerous growths 
 of the liver have been definitely diagnosed, it may be said that 
 there is no surgical procedure available which will arrest the 
 progress of the disease, and at the same time save the life of 
 the patient. If, however, the cancerous affection is primary in 
 the liver, is limited to a small portion of the gland, and there 
 are no secondary deposits elsewhere, it appears to be within the 
 .province of surgery to attempt its extirpation, and this method 
 of treatment has the support of a number of eminent surgeons. 
 The removal of the growth can be effected according to one of 
 the methods which are described in the chapter dealing with 
 resection of the liver, or partial hepatectomy. Keen of Phil- 
 adelphia has successfully removed a large malignant adenoma of 
 the liver, and many other surgeons (Langenbuch, von Bardeleben, 
 Israel, Lins, G-roube, von Bergmann, Tricomi, Liicke, Miiller, 
 Schmidt, and Mayo Eobson) have removed similar tumours, 
 and in most instances successfully. Hans Kehr, Slifossowsky, 
 Israel, and Bardeleben have also successfully removed sarco- 
 matous growths from the liver. Hochenegg has described a 
 case in which Albert removed a portion of the right lobe of 
 the liver, together with the gall bladder which was the seat 
 of a carcinomatous growth, and the patient recovered from the 
 operation. Haemorrhage from the liver tissue appears to be the 
 chief danger in the performance of these operations, but if careful 
 precautions are taken for its prevention it seems to be possible 
 to avoid trouble from this source. When large veins in the 
 interior of the liver are divided, air is liable to be drawn into 
 them and carried to the heart by the inferior vena cava, and 
 thence to the lungs, where it may cause embolism. This must 
 be avoided by continuous pressure upon cut surfaces of the liver, 
 and immediate ligature of all bleeding points. In those cases in 
 which it is found to be impossible to approximate the cut 
 surfaces of the organ, the margins of the wound in the liver 
 should be united to those of the wound in the abdominal wall 
 with silk sutures, and the wound itself packed with strips or 
 tampons of aseptic gauze, so as to prevent the occurrence of 
 
PROGNOSIS. 195 
 
 haemorrhage or embolism. An attempt to remove a malignant 
 growth of the liver should only be made when the affection is 
 strictly circumscribed and does not involve a large portion of the 
 organ, and when it is not associated with the development of 
 secondary growths elsewhere. Whenever the liver is the seat 
 of multiple malignant growths, no attempt should be made to 
 effect their removal. 
 
 Prognosis. — The prognosis in all cases of malignant affections 
 of the liver is distinctly bad. The dangers of the actual opera- 
 tions which have been carried out for their removal do not 
 appear to be so serious as has generally been imagined. The 
 haemorrhage can, in almost all cases, be controlled by passing an 
 elastic ligature around the base of the affected portion of the 
 gland, and by applying sponge pressure upon the incised tissues. 
 Hciemorrhage usually ceases when the incised surfaces have been 
 approximated and fixed in this position by the insertion of silk 
 sutures. In the removal of portions of livers from animals 
 experimentally, I have had no difficulty from hemorrhage, but it 
 is easier to control the circulation in animals than in man. 
 Some authors have recommended the use of Paqueliu's cautery 
 when the haemorrhage has been severe. It is better, however, to 
 avoid the use of this means for the arrest of heemorrhage, since 
 the cauterised surface must separate later, and healing is delayed 
 and the occurrence of suppuration is favoured. Most of the 
 cases which have been operated upon have succumbed later, from 
 a recurrence of the disease. In Liicke's case the patient was 
 well five years later, but generally recurrence has occurred 
 within a few months of the performance of the operation. In 
 Hans Kehr's case of sarcoma, the patient, a girl set. 15, died a 
 few weeks afterwards from a recurrence. In Hochenegg's case 
 the patient was quite well three years afterwards. 
 
CHAPTER XVI. 
 
 PENETRATING WOUNDS OF THE GALL BLADDER AND 
 BILIARY DUCTS. 
 
 Penetkating wounds of the gall bladder or of the biliary ducts 
 rarely come under the cognisance of the civil surgeon, since 
 their occurrence is very infrequent, owing to the small size of 
 the structures themselves, and to their protected position behind 
 the lower ribs and costal cartilages. These injuries are more 
 frequently met with by military surgeons in times of war, on 
 account of the large number of perforating wounds of the 
 abdomen and thorax which then require treatment. This class 
 of injury is met with as the result of the following varieties of 
 mechanical violence, namely, (a) stabs or penetrating wounds, 
 inflicted with sharp instruments, which involve the upper 
 portion of the abdomen or the lower part of the thoracic 
 region, especially when they are situated in the right hypochon- 
 driac region of the abdomen. When met with, these wounds 
 are generally found to have been made with a homicidal intent, 
 or to occur in military practice in the form of bayonet wounds. 
 (b) Gunshot wounds of the gall bladder or biliary ducts are in 
 nearly all cases associated with similar injuries of other of the 
 abdominal or thoracic viscera. The gall bladder is the organ 
 which is usually involved, but the hepatic ducts have in a 
 number of cases been found to have been divided as the result 
 of gunshot wounds. Courvoisier ^ has collected fourteen cases 
 of penetrating wounds of the biliary passages, six of which were 
 caused by the projectiles of firearms, and eight by sharp instru- 
 ments. Kehr ^ has also reported a case of revolver wound of 
 the gall bladder, and Dalton ^ one in which the gall bladder was 
 perforated by a stab. Bell, Paroissc, Poland, Sabatier, Stewart, 
 
 1 Courvoisier, op. cit. 
 
 - Kehr, Centralbl.f. Chir., Leipzig, 1892, s. 645. 
 
 3 Dalton, Am. Journ. Med. Sc, Phila., 1890, p. 708. 
 
SYMPTOMS. 
 
 197 
 
 and Watson have recorded cases of this kind, all except one 
 of which ultimately proved fatal. 
 
 Symptoms. — In all cases of injury of this kind a perforating 
 wound of the external surface of the trunk is seen, generally in 
 some part of the upper abdominal or lower thoracic area, 
 especially in the right hypochondriac region, which has been 
 
 Fig. 27. — Gall bladder, witli a punctured wound near the neck, which was 
 caused by a pitchfork. The patient died five days later from peritonitis. — 
 St. Earth. Hosp. Museum. 
 
 inflicted with a sharp instrument, or by a gunshot missile, which 
 has passed inwards towards the gall bladder or portal fissure of 
 the liver, and from this wound blood, bile, or blood and bile- 
 stained fluid often exude. Considerable abdominal pain and 
 tenderness, which is at first usually localised to the right 
 hypochondriac region, is present, and is associated with symptoms 
 
198 FENETRATING WOUNDS OF GALL BLADDER. 
 
 of shock and collapse ; the pulse is feeble, small, frequent, and 
 possibly intermittent ; the respiration is laboured ; whilst the face 
 is pale and pinched, and the patient has an anxious expression. 
 There may be in addition nausea and vomiting ; the limbs are 
 cold, owing to the weakening of the expulsive power of the heart, 
 and consequent slowing of the circulation of the blood ; and the 
 patient is very uneasy and restless ; in fact, there are all the 
 signs of a commencement of an attack of acute peritonitis, 
 combined with which are the symptoms of shock, which has 
 developed as the result of the mechanical injury to the abdominal 
 viscera, and those which are due to the passage of an irritating 
 fluid into the peritoneum. Jaundice may occur as a symptom 
 in these cases, but it is not common, and when it is met with it 
 is usually slight in amount, whilst bile is found in the urine 
 a short time after the contents of the gall bladder or the bile 
 ducts have been absorbed and passed into the blood stream, 
 either from the peritoneum, or by any other route. A short 
 time after the reception of the injury the abdomen becomes 
 swollen and tense in those cases in which the bile passes into 
 the peritoneal cavity, and on this account many of the localising 
 symptoms which would otherwise help to elucidate the patho- 
 logical condition are masked. The shock may be so severe as to 
 cause unconsciousness, and when the patient recovers from this 
 condition intense pain and tenderness in the hypochondriac region, 
 or in the abdomen generally, are complained of. 
 
 Diagnosis. — When a patient is suffering from a penetrating 
 wound of the abdominal parietes, from which bile or a mixture 
 of bile and blood issues, and the infliction of the wound is 
 immediately followed by the development of great pain and 
 tenderness in the right hypochondriac region, it is exceedingly 
 probable that the gall bladder or one of the larger bile ducts has 
 been injured. A careful examination of a penetrating wound of 
 the abdominal wall by means of a blunt-pointed probe, will help 
 in establishing a correct diagnosis. Much care, however, must 
 be taken in making this examination, since it is possible to cause 
 further injury to the peritoneum or abdominal viscera by a pro- 
 longed instrumental investigation of this kind. In those cases 
 in which signs of peritonitis as a result of an injury become 
 evident, without the development of any special localising 
 symptoms, it is necessary to perform an exploratory laparotomy 
 before any complete diagnosis can be made. 
 
TREATMENT. 199 
 
 Treatment. — All injuries of the gall bladder or of the biliary 
 ducts, which are due to perforating wounds of the abdominal wall, 
 require immediate surgical treatment in order to ensure to the 
 patient the greatest chance of recovery. If the symptoms 
 which follow the infliction of the injury are sufficient to enable 
 the surgeon to make a diagnosis that the gall bladder, or one of 
 the bile ducts, is the seat of injury, an examination of the 
 abdomen, either through an enlargement of the wound of the 
 abdominal wall, especially when this wound is located in the 
 right hypochondriac region, or through an incision in the right 
 linea semilunaris, or in the linea alba, should be made, and the 
 exact nature of the damage made out. In most cases it will be 
 found advisable to make the incision through the abdominal 
 wall in the right linea semilunaris, since it has been found in 
 nearly all cases of this injury that the gall bladder, or the cystic 
 duct, has been the portion of the biliary system which has been 
 damaged. If the gall bladder is found to have been injured, and 
 the perforation is seen to be small, and not to extend through 
 the posterior wall of the sac into the adjacent portion of the 
 liver, then the aperture should be closed by the insertion of 
 a row of fine silk sutures applied by Lembert's method. If the 
 wall of the gall bladder is thick enough, it is better first to close 
 the aperture of perforation by the application of a continuous 
 suture, which transfixes the mucous coat only, and then to 
 complete the operation as above. In most cases of this kind it 
 will be found that the wall of the gall bladder is too thin to 
 allow this to be done. Afterwards the abdomen is thoroughly 
 cleansed from any bile or other fluid which may have exuded, 
 the sutured gall bladder is dropped back into the abdominal 
 cavity, and the wound of the parietes closed with tiers of 
 interrupted sutures. When the wound in the gall bladder is 
 found to be a large one, and to be situated in the neighbourhood 
 of the fundus, the aperture should be closed in a manner similar 
 to the one described above, but after this has been done the 
 wounded part of the viscus must be fixed to the deep portion of 
 the parietal wound ; the external incision is then closed, except 
 for a small part where a drain is inserted, which will allow the 
 detection of any leakage of bile, if this should occur. If the 
 wound of the gall bladder be very large and involve that portion 
 of the sac which is adjacent to the cystic duct, removal of the 
 gall bladder by the performance of cholecystectomy must be 
 
200 PENETRATING WOUNDS OF GALL BLADDER. 
 
 effected without delay. If the cystic duct is found to have been 
 divided, the ends must be closed with silk sutures, and then the 
 gall bladder is to be removed. If the common bile duct, or one 
 of the hepatic ducts, is divided, the same method of treatment is 
 to be carried out as has been advised in cases of rupture of the 
 same structures. Thus, if the common bile duct is divided, the 
 two ends are ligatured and a cholecystenterostomy performed, 
 whilst, if the hepatic ducts are the seat of injury, the divided 
 ends are ligatured, in order that adhesions may be formed and 
 the biliary passage re-established. If the common bile duct is 
 only partially divided, an attempt may be made to close the 
 aperture by the application of a row of fine silk sutures. After 
 the local injury has been treated by one of the above methods, 
 the adjacent portion of the peritoneum and the abdominal cavity 
 is thoroughly cleansed by washing with sterilised water, so as to 
 remove all traces of blood, bile, and debris, and then the 
 abdominal wound is closed. If the gall bladder or the biliary 
 ducts are found to be the seat of an inflammatory affection, and 
 to contain purulent material, the wound of the gall bladder 
 should always be stitched to the abdominal wall, so as to create 
 a fistula, and into this a drainage-tube is inserted. 
 
 Prognosis. — If the affection can be diagnosed at an early 
 stage before extensive peritonitis has been established, and if 
 appropriate surgical treatment be at once carried out, the patient 
 will stand a fair chance of recovery, especially in those cases in 
 which the gall bladder or the cystic duct is the seat of the 
 injury. When the common bile duct or one of the hepatic 
 ducts is divided, the prognosis is much worse than when the gall 
 bladder or the cystic duct is damaged. If acute peritonitis has 
 been established, owing to the escape of septic matter into the 
 peritoneum, the prognosis is very serious, although, when the 
 results which have followed incision, washing out, and drainage 
 of the peritoneum in acute cases of septic peritonitis are taken 
 into consideration, it seems probable that the results in this class 
 of case will be much better in the future than they have been in 
 the past. 
 
 The cases of Kehr and Dalton were operated upon imme- 
 diately after the reception of the injury. In each instance a 
 wound of the gall bladder was found, which was closed by sutures, 
 after the damaged viscus had been exposed by laparotomy. 
 
CHAPTER XVII. 
 
 EUPTURE AND PERFORATION OF THE GALL BLADDER 
 OR BILE DUCTS. 
 
 Rupture of the gall bladder or bile ducts, which is not associated 
 with or due to the occurrence of a perforating wound of the 
 abdominal or thoracic parietes, may be caused by a blow or kick 
 over the hepatic region, or by severe crushing of the abdomen, such 
 as when the wheel of a heavy vehicle passes over the hepatic 
 region, or by a fall from a considerable height, the patient alighting 
 either upon his feet or some other part of his body. If the gall 
 bladder is distended with bile, owing to the presence of a 
 calculus in the neck of the viscus or in the cystic duct, at the 
 time of the reception of the injury, a rupture of the organ is 
 much more likely to occur. Rupture of the gall bladder or one 
 of the bile ducts is, however, an uncommon condition as a result 
 of abdominal injuries, and an examination of the clinical records 
 of St. Bartholomew's Hospital reveals only a few examples. In 
 one case of this kind a rupture of the sac, close to its attachment 
 to the liver, followed a kick in the hepatic region ; and in another 
 case a rupture of the fundus of the gall bladder resulted from a 
 fall against a log of timber. If the gall bladder or the bile ducts 
 are occupied by numerous or large calculi, traumatism applied to 
 the hepatic region may produce rupture of the gall bladder or 
 bile ducts, which is followed by the passage of bile and calculi 
 into the adjacent portion of the peritoneal cavity. Falls upon 
 the floor, under similar conditions, have also been productive of 
 a like result. The gall bladder and the cystic duct, especially 
 the former, appear to be the portions of the biliary system which 
 are most liable to be ruptured as the result of external violence ; 
 perhaps this frequency may be explained by the fact that these 
 parts of the biliary system are the places where gall stones are 
 most frequently located. In rare cases, the right or left hepatic 
 duct, the common hepatic duct, or the common bile duct, have 
 
202 RUPTURE OF THE GALL BLADDER. 
 
 been found to be raptured as the result of an external injury. 
 Accordiug to Eoutier/ it is probable that in cases of severe 
 injury, such as when the wheel of a waggon passes over the 
 abdomen, the abdominal wall is strongly pressed back under- 
 neath the liver so as to cause a sharp and sudden bending or 
 compression of the biliary canals between the liver firmly forced 
 into the concavity of the diaphragm and against the anterior 
 aspect of the posterior abdominal wall on the one part, and 
 the bending of the abdominal parietes on the other part, 
 the biliary channels being then pulled upon and torn. The 
 rupture appears always to occur in the front wall of the ducts, 
 apparently owing to the mechanical force obliterating the lumen 
 of the common bile duct and driving the contained bile towards 
 the gall bladder or the cystic and hepatic ducts, which, being 
 unable to find an exit, is forced through the walls of one of 
 the channels, and a rupture is thus produced. The external 
 violence may be so severe as to give rise to a complete 
 separation of the gall bladder from its connections with the 
 liver, and it has been found lying free in the peritoneal cavity, 
 with a small portion of liver substance and a part of its cystic 
 duct attached to it. In this class of case the patient usually dies 
 at an early stage after the reception of the injury, the cause of 
 death being severe shock, collapse, and internal haemorrhage. 
 Ulcerative processes affecting the walls of the biliary passages 
 are, in most cases, due to the irritation which is caused by the 
 presence of biliary calculi, and they may extend through the 
 walls of the affected portion and establish a communication be- 
 tween the lumen of the gall bladder or of one of the bile ducts 
 and the peritoneal cavity, and in this manner a rupture is produced 
 which allows the free passage of bile and pus into the peritoneum. 
 Ulceration of the mucous membrane of the gall bladder may 
 occur during the course of an attack of typhoid fever, owing to 
 the presence of the typhoid bacillus within the gall bladder, and 
 give rise to perforation, which is followed by the passage of the 
 contents of the gall bladder into the peritoneal cavity. Localised 
 tuberculosis of the walls of the gall bladder has also been men- 
 tioned as a cause of ulceration and perforation. An ascaris 
 which has passed from the duodenum into the common bile 
 duct, or into the gall bladder, may cause immediate rupture of 
 the walls of the duct or gall bladder, and pass thence into the 
 
 1 Rentier, Bull. Soc. de chir. de Paris, 1892, p. 773. 
 
CAUSES. 203 
 
 cavity of the peritoneum, or it may die and set up a local inflam- 
 mation and ulceration, which is followed at a later period by per- 
 foration and rupture. Epithelioma or carcinoma of the gall bladder, 
 or of one of the bile ducts, may cause perforation into the peritoneal 
 cavity, but this is a very uncommon sequence of these pathological 
 conditions, since in nearly every case adhesions are formed with 
 the surrounding structures before perforation takes place as the 
 result of an extension of the ulceration through the wall of the 
 canal. Extensive dilatation of the bile ducts or gall bladder, or 
 both, which has been produced by an obliteration of the lumen of 
 the common bile duct, owing either to compression from without 
 or to the presence of an impacted gall stone, or to the existence 
 of a fibrous or malignant stricture, may result in a thinning of 
 the walls of some portion of the biliary ducts, followed by a rup- 
 ture and passage of the fluid contents into the peritoneal cavity. 
 From the same causes the walls of the intra-hepatic bile 
 ducts may give way and allow an extravasation of bile into 
 the substance of the liver. Euptures, contusions, and lacera- 
 tions of the liver are in all cases accompanied by injury to 
 the intra-hepatic bile ducts, but the symptoms which are due 
 to the simultaneous haemorrhage and shock mask or disguise 
 those symptoms which are referable to the extravasation of 
 bile. After a rupture of some part of the gall bladder or bile 
 ducts has taken place, the bile, or the fluid contents of the injured 
 viscus, may either be poured out slowly, or at once and in large 
 quantities. If the bile is poured out slowly into the peritoneal 
 cavity, adhesions may be formed, and the effused fluid will collect 
 in a localised encysted portion of the peritoneum. This encysted 
 cavity may enlarge so as to form a fluid tumour in the hypochon- 
 driac and hepatic regions, which attains a considerable size, dis- 
 places the neighbouring viscera, pushing upwards the lung and 
 diaphragm, and appearing as a prominence of the abdominal walls 
 in the right hypochondriac regions and the adjacent part of the 
 abdomen. A cyst of this kind may contain several gallons of 
 fluid, consisting largely of bile. When a rupture or perforation 
 occurs as the result of an inflammatory ulceration, septic peri- 
 tonitis is much more liable to occur at an early stage than in 
 those cases where the rupture is due to a simple traumatism. 
 Experiments by Brodie, Gmelin, and Tiedemann, have shown that 
 when the common bile duct has been occluded by the application 
 of ligatures, ulceration of the walls of the occluded duct takes 
 
204 RUPTURE OF THE GALL BLADDER. 
 
 place after a few days, and bile is extravasated into the surround- 
 ing structures, and a large bile-containing cyst is established, into 
 which the proximal and distal ends of the occluded duct open. 
 After the expiration of two to four weeks, the biliary passage 
 became restored. I have made similar experiments in cats, which 
 have given like results. Several analogous cases have occurred 
 in man, and have been recorded by Fryer and Barlow. If the 
 bile passes at once, and in large quantities, into the peritoneal 
 cavity, in most cases an acute general peritonitis will be estab- 
 lished, which will usually prove fatal. 
 
 Symptoms. — The symptoms of rupture of the gall bladder or 
 bile ducts may be masked, or rendered obscure, by the symptoms 
 which are dependent upon injuries of other viscera, which have 
 been caused by the same traumatism. When the injury to the 
 gall bladder or bile ducts is uncomplicated, the symptoms vary, 
 according to whether the bile passes into the peritoneal cavity 
 and sets up a general peritonitis, or collects in a localised 
 portion of the peritoneum, which is shut off from the rest by 
 the development of adhesions, or a fibrous limiting membrane, 
 or no extravasation of bile takes place at all. If the bile 
 passes at once into the general peritoneal cavity, the abdomen 
 becomes swollen and the seat of much pain, and this is ac- 
 companied by much collapse, and all the signs of an acute general 
 peritonitis. In one case of this kind which occurred in St. 
 Bartholomew's Hospital, a man, eet. 50, received a kick in the 
 hepatic region, which caused a rupture of the gall bladder close 
 to its attachment to the liver. He died in fifteen hours, from 
 shock, collapse, and acute peritonitis. The gall bladder had 
 apparently been distended at the time of the injury, owing to 
 the presence of a calculus in the neck of the viscus. In another 
 case the patient fell over a log of timber and suffered from a 
 rupture of the gall bladder in the neighbourhood of the fundus, 
 and he died from peritonitis five weeks after the reception of the 
 injury. When the gall bladder is the seat of the rupture, the 
 bile usually passes immediately into the peritoneal cavity and 
 gives rise to symptoms of acute peritonitis, which may be either 
 general or localised. In the latter case the effused bile becomes 
 shut off from the rest of the peritoneum by the development of 
 adhesions; and the symptoms at first are those of an acute localised 
 peritonitis, which is followed by the formation of a fluctuating 
 swelling in the abdomen, usually in the right hypochondriac 
 
SYMPTOMS — DIAGNOSIS. 205 
 
 region, and the occurrence of jaundice. When the bile ducts are 
 the seat of the rupture or perforation, the escape of bile may be 
 delayed for several hours or days, or, as in the case of the gall 
 bladder, it may take place immediately after the occurrence of 
 the injury. When the whole of the bile which is secreted by 
 the liver passes into a localised portion of the peritoneum, the 
 patient is constipated, and the stools are white or clay-coloured. 
 According to Courvoisier,^ jaundice has been observed ten times 
 in twenty-four cases, and in only eight of these was absence 
 of colouring matter in the faeces noticed. When there is no 
 extravasation of bile, the symptoms may be slight or almost 
 non-existent. In these cases there is usually localised pain in 
 the right hypochondriac region, or even general abdominal pain, 
 accompained by vomiting and slight dyspnoea, together with slight 
 shock and collapse. These symptoms may soon disappear, or 
 they may be followed by those of extravasation, if this condition 
 takes place at a later period. When rupture or perforation has 
 taken place, and the contents of the gall bladder have passed 
 into the peritoneal cavity, bile can usually be detected in the 
 urine at a very early stage after the reception of the injury. 
 When the perforation or rupture of the gall bladder or bile ducts 
 is due to a septic process, or these channels are infected with 
 septic micro-organisms at the time of the rupture, acute general 
 septic peritonitis in practically every case at once develops. 
 
 Diagnosis. — It is often very difficult in this class of cases 
 to make an exact diagnosis. If after the occurrence of an 
 abdominal injury the patient soon becomes jaundiced, and bile 
 appears in the urine, and in addition signs of acute peritonitis 
 become manifest shortly after the injury has been inflicted, a 
 rupture of the gall bladder or some other part of the biliary 
 system may be suspected. If a localised abdominal swelling 
 develop, especially in the right hypochondriac region or in the 
 adjacent portion of the abdomen, after the reception of an 
 abdominal injury, and is associated with the occurrence of 
 jaundice, constipation, and white or clay-coloured stools, the 
 existence of rupture of the gall bladder, or of one of the bile 
 ducts, may be suspected ; and if this swelling is found to contain 
 biliary fluid when it is punctured with the needle of an aspirator, 
 the diagnosis of such a condition is made more certain. The 
 occurrence of attacks of severe biliary colic, followed by symptoms 
 
 1 Courvoisier, op, cit. 
 
2o6 RUPTURE OF THE GALL BLADDER. 
 
 of shock and collapse, together with signs of acute general 
 peritonitis, point to the existence of a gall stone which has per- 
 forated the wall of the gall bladder or bile duct, and passed into 
 the peritoneal cavity together with a quantity of bile and prob- 
 ably also purulent material. 
 
 A woman, aged 75, was recently admitted to the Metro- 
 politan Hospital (under Mr. Goodsall) with all the signs of 
 acute intestinal obstruction. The condition commenced with 
 a sudden severe attack of abdominal pain, which apparently was 
 not most marked in the right hypochondrium. Severe vomiting 
 followed, and persisted until three days later, when she was 
 brought to the Hospital. On examination, the abdomen was 
 distended, the coils of intestine being visible through the 
 anterior abdominal wall, the vomiting was feecal, and there was 
 no passage of air or faeces by the rectum. Acute peritonitis 
 was diagnosed, and it was thought to be due to a perforation of 
 the intestine, probably the vermiform appendix. There was no 
 jaundice. The abdomen was opened, when a large quantity of 
 bile-stained fluid escaped. This was examined, and found to 
 give the reactions for bile. The region of the gall bladder was 
 examined, and adhesions to the surrounding viscera were met 
 with. The condition of the patient being very serious, it was 
 thought best to empty as much fluid as possible from the 
 peritoneal cavity, and to pass a drainage tube down to the region 
 of the gall bladder. The patient did not recover from the 
 shock following the operation, but died shortly afterwards. 
 Post-mortem, a small perforation due to ulceration was found 
 at the apex of the fundus of the gall bladder. The viscus was 
 of ordinary size, and contained several small calculi. No calculi 
 were present in the peritoneal cavity. This is a most unusual 
 case, owing to the difficulty experienced in making a diagnosis, 
 since there were no symptoms which suggested that the gall 
 bladder was the seat of perforation. 
 
 Treatment. — In those cases of obscure abdominal injury in 
 which rupture of the gall bladder or one of the bile ducts is 
 suspected, but in which the diagnosis is uncertain, it is advisable 
 to keep the patient absolutely at rest in bed and not to allow 
 any movements, so that, if there has been any rupture, the 
 extravasation of bile or other fluid may be either prevented or at 
 least limited as far as is possible, and the formation of adhesions 
 induced. If there is a tendency to vomiting, small quantities 
 
TREATMENT. 207 
 
 of warm water may be given by tlie mouth to prevent it and to 
 allay thirst. Liquid food only must be given, and this must be 
 limited in amount. If constipation occur, the bowels may be 
 relieved by the administration of enemata, but not by aperients 
 given by the mouth. If a localised fluctuating swelling become 
 apparent in the abdominal region, it may be emptied either by 
 the needle of an aspirator, care being taken to avoid the puncture 
 of any of the important viscera or blood vessels, or by direct 
 incision and evacuation of the fluid. This latter operation has 
 been called Secondary Laparotomy. When the injury is followed 
 by the development of signs of acute peritonitis, together with 
 symptoms of jaundice and the appearance of bile in the urine, 
 a laparotomy ought to be immediately performed, the incision 
 being made above the umbilicus, either in the median line or 
 in the right linea semilunaris, and the hepatic region of the 
 abdomen explored. When the severity of the injury and the 
 point of its application suggest rupture of the biliary passages, 
 the hepatic region ought to be at once explored by an abdominal 
 operation (Immediate Laparotomy). 
 
 The gall bladder and the cystic duct should be first examined, 
 and then the structures which lie in the portal fissure of the liver 
 and in the lesser or gastro-hepatic omentum. If the gall bladder is 
 found to be ruptured, the injured portion should at once be dealt 
 with. If the rupture is small and is due to traumatism, whilst the gall 
 bladder is not the seat of a suppurative affection, it may be closed 
 by the application of several fine silk sutures applied in two tiers, 
 after the method of Lembert. If the rupture is due to ulceration, 
 either from the presence of a calculus or from the perforation 
 of an ulcer in the wall of the organ, and if it is situated near 
 the fundus, the margins of the aperture should be stitched to the 
 margins of the abdominal wound, a drainage-tube inserted, and 
 the injury allowed to close up gradually by granulation. If the 
 rupture is large, and involves the greater portion of the longi- 
 tudinal or transverse axis of the gall bladder, or if a calculus 
 has perforated the wall in the immediate neighbourhood of the 
 cystic duct, or if the cystic duct itself has been torn across, the 
 entire gall bladder should be removed (cholecystectomy), and the 
 distal end of the cystic duct closed by the application of a silk 
 ligature. When the common bile duct is the seat of the injury, 
 and the rupture is small and in the long axis of the duct, the 
 rent should be closed by several fine silk sutures applied close 
 
2o8 RUPTURE OF THE GALL BLADDER. 
 
 together, and by Lembert's method. If the common bile duct is 
 torn across, or if it is found impossible to close a rupture in it by 
 sutures, a silk ligature should be applied to each extremity, and 
 then an anastomosis between the fundus of the gall bladder and 
 the adjacent portion of the duodenum or other part of the 
 intestine (cholecystenterostomy) established, provided the cystic 
 duct is patent. If the common bile duct is torn across, and it 
 is found that the gall bladder has been the seat of a former 
 inflammatory affection which has caused it to shrink and be 
 represented by a mass of fibrous tissue, or the cystic duct has 
 been obliterated, then it is only possible to make an attempt to 
 establish an anastomosis between the two ends of the bile duct, 
 or between the proximal end of the bile duct and the adjacent 
 portion of the intestine, or failing both these, to apply a ligature 
 to the ruptured ends, and hope that a communication may 
 become established at a later period. When the common hepatic 
 duct, or either the right or left hepatic ducts are ruptured, it is 
 only possible to apply a ligature to both of the ruptured ends, 
 and hope that adhesions will be formed which will result in the 
 re-establishment of a communication between the two portions 
 of the duct, and the biliary canal again become patent, as was the 
 case in the dogs experimented upon by Tiedemann and Gmelin, 
 and in a eat which has been experimented upon by myself. The 
 exact methods of procedure in the performance of the surgical 
 operations are described later in Chapters XXV. and XXYI. 
 
 Prognosis. — If the nature of the injury can be diagnosed at 
 an early period after its reception, the prognosis ought to be 
 moderately good in uncomplicated cases. When the gall bladder 
 or the cystic duct is the seat of the rupture, the case is much 
 more likely to have a favourable termination than when either 
 the common bile duct or one of the hepatic ducts is involved. 
 When the common bile duct is ruptured, and the gall bladder is 
 represented by a mass of fibrous tissue, or is the seat of an 
 inflammatory affection, owing to the presence of gall stones, the 
 prognosis is worse than when this viscus is in its normal condition, 
 since, in the latter case, it is possible to re-establish the biliary 
 canal by making a communication between the intestine and the 
 fundus of the gall bladder. Kuptures and injuries of the 
 gall bladder and cystic duct are less dangerous to life than 
 similar affections of the common bile duct or one of the hepatic 
 ducts. In all cases, however, the injury must be regarded as of 
 
PROGNOSIS. 209 
 
 a serious nature, and a guarded prognosis given, but there is no 
 doubt that the danger of the entrance of bile into the peritoneal 
 cavity has been very much exaggerated. When the ruptured 
 portion of the biliary canal is the seat of a septic inflammation, 
 it is very liable to cause the development of a septic peritonitis, 
 and hence in this class of case the prognosis is much worse. 
 
 Courvoisier ^ says that in eighteeen instances out of thirty- 
 three cases which he has collected from surgical literature, 
 puncture was practised for the relief of a rupture of the biliary 
 passages. Purulent peritonitis was caused by the puncture in 
 four cases, each of which terminated fatally. In three the 
 puncture was not followed by septic complications, but death 
 resulted from exhaustion. Eleven of the patients recovered, 
 apparently owing to the puncture having been performed. In 
 one, however, a biliary fistula was established, which closed at a 
 later period. Terrier and Auvray ^ have collected three other 
 cases which have been treated by this method. One patient 
 died, and the other two recovered. When puncture has been 
 performed, it has been found that repeated puncture is necessary, 
 in some cases the collected bile having been emptied seven or 
 even ten times. Occasionally, however, a single puncture has 
 been sufficient. 
 
 Terrier and Auvray ^ state that " secondary laparotomy " 
 has been performed yseven times, with four cures and three 
 deaths. Death was udue in one of the fatal cases apparently 
 to exhaustion, and occurred a few hours after the operation ; in 
 a second, there was deep jaundice, and calculi were found in the 
 common bile duct after death ; whilst in the third, the patient 
 died from collapse after the operation had been performed. 
 
 1 Courvoisier, op. cit. 
 
 2 Terrier et Auvray, Rev. de chir., Paris, 1897, p. 36 et seq. 
 
 3 Ibid. 
 
 14 
 
CHAPTER XVIII. 
 
 CHOLELITHIASIS. 
 
 By the term Cholelithiasis we mean that pathological condition 
 of the liver and biliary system which tends to give rise to the 
 development of gall stones. Gall stones, biliary calculi, or biliary 
 concretions, are solid bodies of variable size and shape, which 
 have been formed as a result of pathological processes occurring 
 in some part or parts of the excretory apparatus of the liver. 
 A number of different conditions appear to be associated with a 
 tendency to the formation of calculi in both the intra-hepatic and 
 extra-hepatic biliary ducts. 
 
 Mode of formation and pathology. — In the majority, if not 
 in all cases of gall stones, the formation of these concretions is 
 associated with the presence of an obstruction to the free outflow 
 of the bile from the bile duct into the duodenum. This obstruc- 
 tion may be complete, but it is more usually only partial, and it is 
 often dependent upon the existence of inflammatory processes 
 within the intestine. The mere existence of an impediment to 
 the free flow of the bile into the intestine does not of itself 
 appear to be sufficient to give rise to the development of gall 
 stones within the gall bladder or the biliary ducts. The exciting 
 cause seems, in some of the cases which have been carefully 
 examined by Naunyn,^ to be an inflammatory condition of the 
 mucous membrane lining the interior of the biliary ducts and the 
 gall bladder, which has been caused by the presence of the Bac- 
 terium coli commune. This bacillus is a constant inhabitant of 
 the alimentary canal, and when the flow of bile through the 
 common bile duct has been slowed, owing to some abnormal con- 
 dition, it has been assumed that this micro-organism obtains an 
 entrance into the interior of the biliary system by passing 
 through the common opening of the bile duct and pancreatic duct 
 into the second portion of the duodenum, but the evidence upon 
 
 1 Naunyn, "Klinikd. Cholelithiasis," 1892. 
 
MODE OF FORMA TION AND PA THOL OGY. 211 
 
 which this assertion is based appears somewhat inconclasive. 
 This bacillus, however, is slightly motile, and it is possible that 
 it may obtain an entrance in the manner which has been sug- 
 gested. It also appears possible, if an obstruction to the lumen 
 of the alimentary canal, especially in the third portion of the 
 duodenum, becomes established even temporarily, owing to press- 
 ure from without or by tight-lacing, or when the colon is 
 loaded with fseces, that, when the ordinary movements of peri- 
 stalsis take place, the contents of the small intestine may be 
 forced a short distance along the common bile duct, and by this 
 means any micro-organisms which happened to be in the duode- 
 num would pass into the common bile duct. When these 
 organisms have effected an entrance into the bile duct, it is 
 probable, especially in those cases in which the current of bile 
 has been slowed, that they will pass into the gall bladder along 
 the cystic duct, and into the liver along the hepatic ducts. 
 There seems, however, in such cases a greater probability of 
 these organisms being carried to the gall bladder, since in the 
 intervals between the periods of digestion, the bile which has 
 been secreted by the liver passes along the cystic duct into the 
 gall bladder, where it is stored until it is required in the intestine 
 after the next meal. Naunyn ^ thinks that the sequence of events 
 in the formation of gall stones within the gall bladder is as 
 follows, namely : — After the bacilli {B. coli commune) have 
 obtained an entrance into the bile ducts and the gall bladder, 
 they grow and multiply, and induce the development of a 
 catarrhal condition of the mucous membrane, upon the existence 
 of which the formation of gall stones depends. The bacilli act 
 as an irritant to the mucous membrane lining the gall bladder, 
 either mechanically or owing to the production of chemical 
 products of the nature of ptomaines or toxins, and in this 
 manner produce an inflammatory condition of the epithelial cells 
 which cover the internal aspect of the mucous membrane. As a 
 result of this inflammatory condition, the metabolic processes of 
 the epithelial cells appear to undergo considerable modifications. 
 If the cells are examined with the microscope, many of them 
 will be seen to be swollen, and their interior to be occupied by 
 myelin-like masses, which are being extruded upon the internal 
 surface of the mucous membrane and there crystallising so as to 
 form small masses or clumps of cholesterin. In some places 
 
 1 Naunyn, loc. cit. 
 
2 1 2 CHOLELITHIA SIS. 
 
 these swollen cells may become aggregated together so as to form 
 a small mass, in which there may be a few blood corpuscles. 
 Crystals of cholesterin may be deposited on the surface of this 
 mass, and in this manner the formation of a biliary calculus 
 commences. As a calculus which has arisen in this way increases 
 in size, numerous layers of cholesterin, or of compounds of bili- 
 rubin and calcium, are deposited upon the exterior, and gradually 
 give rise to an enlargement in all the dimensions of the calculus. 
 Cholesterin which is deposited thus may come from that which 
 is in solution in the bile within the gall bladder, or it may come 
 from small masses which have been set free from the epithelial 
 cells in the manner described in the earl}" stages of the forma- 
 tion of the calculus. Frerichs,^ in his treatise upon the diseases 
 of the liver, says that the formation of gall stones is due to a 
 stagnation of the bile in the gall bladder. When this slowing of 
 the flow of bile has existed for a time, an excess of mucus is 
 secreted by the walls of the gall bladder, and this, he says, 
 undergoes decomposition, and gives rise to the development of 
 an acid reaction, which causes a precipitation of the cholesterin 
 and the bilirubin. The cholesterin is deposited in the form of 
 crystals, and the bilirubin in the form of an amorphous insoluble 
 calcium compound. Before gall stones were formed, Frerichs 
 thought that these precipitated substances remained in the cavity 
 of the gall bladder for a time, and became incorporated with the 
 mucus and shed epithelial cells, which resulted from the inflam- 
 matory condition of the mucous membrane. Many observations 
 have been made which tend to demonstrate that typhoid fever is 
 frequently followed by an attack of cholelithiasis. The pathology 
 of these cases is similar to that described above. The biliary 
 passages are infected with the bacillus of typhoid (the bacillus of 
 Eberth), and an inflammatory condition of the bile ducts and the 
 gall bladder becomes established. This angiocholitis and chole- 
 cystitis causes the cholesterin of the bile to be precipitated, and 
 calculi commence to form. In support of this view, some in- 
 vestigators have shown that the gall bladder often contains the 
 specific bacilli, and that the interior of small young calculi 
 frequently consists of numerous typhoid bacilli. This view of 
 the pathology of gall stones is said to be supported l)y the fact 
 that cholelithiasis often follows an attack of typhoid fever: and 
 inflammatory lesions of the gall bladder or the biln ducts not 
 
 J Frerichs, " Diseases of the Liver," New Syd. Society's Trans., 18G1. 
 
MODE OF FORMATION AND PATHOLOGY. 213 
 
 uncommonly occur as the result of infection of the biliary- 
 passages with the specific micro-organism of typhoid fever. 
 
 The micro-organisms of suppuration, streptococci and staphy- 
 lococci, have been found in the bile within the gall bladder 
 of patients suffering from gall stones and cholecystitis. No 
 explanation has yet been given why the bacillus of typhoid 
 fever, the B. coli commune, or the micro-organisms of 
 ordinary suppuration, when they have gained an entrance into 
 the interior of the bile ducts and the gall bladder, in some cases 
 cause the development of an acute cholecystitis and angiocholitis, 
 which may result in the formation either of an abscess of the 
 liver or an empyema of the gall bladder, or both, and in other 
 cases give rise to cholelithiasis and the formation of gall stones. 
 The degree of virulence of the bacteria when they infect the 
 biliary passages has been suggested as the explanation of the 
 different varieties of inflammation. When the micro-organisms 
 are very virulent, they cause an acute inflammation of the biliary 
 passages, and when they are attenuated, or have lost much of 
 their virulence, they set up a subacute inflammation which 
 terminates in the establishment of cholelithiasis. No trust- 
 worthy evidence has been brought forward in support of this 
 view of the pathology of the affection. 
 
 The amount of the bile acids present in the bile has been 
 thought to have some connection with the formation of gall 
 stones. The bile acids help to keep the cholesterin in solution, 
 and if from any cause the relative quantity of these acids is 
 diminished, either by an increase in the amount of cholesterin 
 secreted by the cells of the mucous membrane of the gall 
 bladder (as in inflammatory conditions of the membrane), or 
 owing to a diminution of the quantity secreted by the hepatic 
 cells (a condition which is said to be favoured by a non-nitrogenous 
 diet), the cholesterin which is in solution in the bile is pre- 
 cipitated and small calculi commence to form. The greater 
 frequency of cholelithiasis in Germany and Switzerland has been 
 explained on this hypothesis, namely, that Englishmen live on a 
 diet which is much more nitrogenous than that of the Germans. 
 A similar argument has also been adduced to explain the greater 
 frequency of gall stones in females and in old people. The 
 grounds upon which these arguments are based appear to be too 
 theoretical to afford a reasonable and correct explanation of the 
 occurrence of gall stones. 
 
214 CHOLELITHIASIS. 
 
 The present state of pathological knowledge concerning the 
 development of cholelithiasis appears to indicate that two con- 
 ditions are requisite for the formation of a gall stone, namely, 
 (a) the presence of an obstruction to the free flow of bile from 
 the gall bladder or the biliary ducts ; and (&) the infection of the 
 biliary ducts and gall bladder by a variety of micro-organism 
 which is able to induce a subacute inflammation of the mucous 
 membrane of the affected structures. 
 
 Further investigations on the causes of cholelithiasis will prob- 
 ably throw more light upon this somewhat obscure part of pathology. 
 
 When bile which is exposed to the atmosphere undergoes 
 decomposition, the cholesterin is not precipitated even when the 
 fluid has an acid reaction, hence the theory of Frerichs ^ cannot 
 be accepted in its entirety, although, in conjunction with the 
 observations of Naunyn,^ it appears probable that stagnation of 
 the bile first occurs, and then when the B. coli comimme 
 has obtained an entrance the conditions are favourable to the 
 development of a gall stone. 
 
 In a certain number of cases which have been recorded by 
 different observers, foreign bodies appear to have been important 
 agents in the formation of gall stones. Naucke described a 
 case in which a steel needle formed the nucleus of a gall stone, 
 and Lobstein ^ gives an illustration of a case in which a dried-up 
 round worm (Ascaris lumhricoides) was found in the interior of a 
 calculus, whilst Buisson ^ found the interior of a gall stone which 
 was obtained from the body of an ox to consist of a desiccated 
 liver fluke {Distoma hepaticum). In other cases small plugs of 
 mucus, collections of bacteria, and blood clots have been found to 
 form the interior of biliary calculi. A small shrivelled-up 
 hydatid cyst has also been discovered in the interior of a gall 
 stone. In other cases the core is composed of a group of crystals 
 of calcium carbonate, which have been formed as an excretion 
 from the epithelial cells of the wall of the gall bladder ; whilst 
 occasionally small casts of the intra -hepatic bile capillaries seem 
 to have been the nucleus around which a deposit has taken place, 
 with the resulting formation of a calculus. 
 
 The presence of a foreign body within the gall bladder does 
 not invariably cause the precipitation of cholesterin and the 
 
 1 Frerichs, Inc. cit. 2 Naunyii, loc. cit. 
 
 ^ Lobstein, " Nouveau catalogue de Musc'e Anatomifj^ue de Strasbourg," 1843. 
 
 ■* Euisson, "Ueber die Galle" (German translation). 
 
PLACE OF FORMATION. 215 
 
 formation of a gall stone. Mignot ^ has made some experiments 
 upon this point, and he finds that the presence of a foreign body 
 within the gall bladder, so long as the viscus remains in an 
 aseptic state, does not cause a condition of cholelithiasis, or a 
 deposition of cholesterin. When, however, the gall bladder 
 became infected with an attenuated microbe, cholesterin crystal- 
 lised out, and was deposited on the surface of the foreign body. 
 
 Flace of formation. — In nearly all cases of cholelithiasis 
 which are examined, it is found that the gall stones occupy either 
 the interior of the gall bladder or the lumen of the cystic or 
 common bile duct, and only much more rarely are calculi met 
 with in the right or left hepatic ducts or their smaller ramifica- 
 tions. In occasional cases a stone is found in the common 
 hepatic duct, but this condition is not common. I have recently 
 seen several cases, post-mortem, in which the right and left 
 hepatic ducts and their branches were enormously dilated, and 
 their lumen filled with numerous and large calculi, but in each 
 of these cases the gall bladder also contained a number of 
 calculi. In one case which I have seen, the intra-hepatic biliary 
 ducts were the seat of a deposit of a considerable amount of 
 bilirubin combined with calcium salts. No definite calculi could 
 be distinguished, but the interior of the intra-hepatic bile ducts 
 were dilated and had an incrustation of the bilirubin-calcium 
 compound upon their internal walls. The liver from which this 
 specimen was obtained is in the Museum of the Eoyal College of 
 Surgeons of England. The gall bladder appears to be the locality 
 where the great majority of biliary calculi take their origin, and in 
 most of those cases in which calculi are found in the right or left 
 hepatic ducts, and in the portal fissure of the liver, they have been 
 formed in the gall bladder, and have passed thence into the local- 
 ities where they have been found. It appears possible, however, in 
 some cases that the calculi have arisen in the commencement of 
 the intra-hepatic bile ducts. In the case which was mentioned 
 above, it seemed to be without doubt that the deposit of bilirubin 
 and calcium had taken place within the liver. If we accept 
 Naunyn's view of the mode of formation of gall stones, it is easy 
 to understand why gall stones in most cases commence within 
 the gall bladder, since this viscus is much more liable to be the 
 seat of an inflammatory process than the intra-hepatic bile ducts, 
 and stagnation of the bile can more readily occur. 
 
 1 Mignot, These de Paris, 1896, 
 
2l6 
 
 CHOLELITHIA SIS. 
 
 Structure. — A gall stone generally consists of three portions : 
 {a) a central core or nucleus ; (h) a middle layer of considerable 
 thickness, consisting of radiating crystals of cholesterin ; (c) an ex- 
 ternal, thin, dense laminated layer of bile pigment and cholesterin. 
 
 The composition of the nucleus has been already discussed. 
 It generally has a dark green or somewhat black appearance, 
 owing to the presence of a quantity of bile pigments. In some 
 nuclei large numbers of bacilli have been found. In most cases 
 the nucleus is solid ; but occasionally, owing to desiccation, a 
 honeycombed appearance is met with. The middle layer is 
 usually the thickest, and forms the greater part of the calculus. 
 
 Fig. 28. — Vai-ieties of gall stones. «, an oval-shaped single calculus ; h, section 
 of a round calculus showing lamination ; c, section of a calculus triangular 
 in shape, which shows from its lamination that it is prohalily part of a larger 
 calculus wliich has become broken up (this calculus was one of a large 
 numljer which were taken from the same gall bladder) ; d, an oval single 
 calculus showing the structure of its interior. 
 
 It consists of layers of crystals of cholesterin, the crystals being 
 arranged in a radiating manner and the laminse being super- 
 imposed. This layer may be white or light-coloured in appear- 
 ance, but in many cases it is somewhat yellow in tint, owing to 
 the permeation of a small quantity of bile colouring-matter. 
 This middle layer occasionally has a uniform soapy appearance, 
 and shows no sign of lamination or crystallisation. The external 
 layer is thin, dense, dark green or brown in colour, and has a 
 varied consistence. Sometimes it is composed of layers of 
 cholesterin or of calcium carbonate alternating with layers of 
 pigment, or it is made up of a compound of calcium carbonate 
 and bile pigment. This external layer may be absent ; the surface 
 
VARIE TIES — OCC URRENCE. 2 1 7 
 
 of the stone is then rough, and is formed by the free ends of the 
 radiating strifie of cholesterin, upon which has been deposited a 
 small amount of pigment. 
 
 Varieties. — The intra-hepatic calculi, which have their 
 primary origin within the liver, most commonly consist of a 
 compound of calcium and bilirubin, but in occasional cases they 
 consist of cholesterin. Those calculi which have their origin in 
 the gall bladder, have been classified by Naunyn ^ as follows, 
 namely — (a) Calculi composed of pure cholesterin. (5) Strati- 
 fied cholesterin calculi, (c) Common biliary calculi, which are 
 usually numerous, multiple, and faceted. {cV) Mixed bilirubin- 
 calcium calculi, which are single or few in number, and when 
 multiple may be faceted. Some of these calculi may possess a 
 nucleus of cholesterin, and in all cases there is a considerable 
 amount of cholesterin mixed with the bilirubin-calcium com- 
 pound, ie) Calculi of pure calcium-bilirubin. These calculi 
 are rare, and when met with they are usually of small size. They 
 do not consist of absolutely pure bilirubin-calcium compound, but 
 in some cases it is almost impossible to detect any other substance. 
 They often contain small quantities of cholesterin or biliverdin- 
 calcium, and in occasional cases small traces of the other kinds of 
 bile pigments. (/) Earer forms of biliary calculi, among which 
 are included the following — (1) small amorphous or imperfectly 
 crystallised cholesterin calculi; (2) calculi containing calcium 
 carbonate; (3) conglomerate calculi; (4) calculi which have the 
 form of casts of the intra-hepatic ducts. 
 
 Occurrence. — {a) Sex. — Biliary calculi are found to occur in 
 the female sex in a considerable majority of cases. Schroder,^ 
 in an investigation which he carried on in Strassburg, found 
 gall stones in 4*4 per cent, of all male subjects, and in 20 '6 per 
 cent, of all female subjects which were examined. From these 
 statistics it appears that gall stones occur about five times as 
 frequently in women as in men, a fact which has been noticed 
 by a number of observers. 
 
 (5) Period of life. — Children and young adults are only very 
 rarely the subjects of gall stones, in fact children may be said to 
 be quite free from the affection. According to the statistics 
 of Schroder, which have been mentioned above, he found in the 
 bodies of people under 20 that gall stones were present in 
 only 2*4 per cent, of cases. In the third decade (21 to 30) the 
 
 1 Naunyn, loc. cit. " Schroder, Inang. Diss., Strasburg, 1893. 
 
2l8 
 
 CHOLELITHIASIS. 
 
 percentage was 3'2, in the fourth (31 to 40) 11'5, in the fifth 
 (41 to 50) ll'l, in the sixth (51 to 60) 9-9, and in persons 
 over 60 the percentage was 2 5 '2. The more common occurrence 
 of gall stones in old people has been explained by asserting that 
 in old age the bile contains an increased amount of cholesterin, 
 but this explanation does not appear based upon a sufficient 
 number of trustworthy observations. Charcot and Pitres have 
 shown that in old people the unstriped muscular tissue which 
 under normal conditions forms a part of the wall of the bile 
 ducts, undergoes a transformation into fibrous tissue, or atrophies, 
 so that when this change has taken place a stagnation of the 
 bile is liable to occur, and if calculi are formed within the 
 gall bladder they will in all probability remain there, and their 
 presence will be associated with few symptoms, since the absence 
 of muscular tissue in the walls and duct of the viscus will 
 favour their retention in the locality where they have been first 
 formed. This theory offers a reasonable explanation of the fact 
 that gall stones are much more common in the gall bladder of 
 old people, and when they are present they are only occasionally 
 accompanied by the appearance of symptoms of biliary colic. 
 
 Brockbank ^ gives the following table of the frequency of the 
 occurrence of gall stones in Manchester. Eor the sake of con- 
 trast, Schroder's table is given as well : — 
 
 Table I. (Manchester Post-mortems). 
 
 Age. 
 
 Total number of 
 Post-mortems. 
 
 Number of Cases in which 
 Gall Stones were found. 
 
 Percentage. 
 
 0-20 
 21-30 
 31-40 
 41-50 
 51-60 
 61 and over 
 
 67 
 112 
 180 
 189 
 128 
 
 66 
 
 2 
 6 
 6 
 14 
 12 
 9 
 
 2-9 
 5-3 
 3-3 
 7-3 
 9-3 
 13-6 
 
 Total . . 
 
 742 
 
 49 
 
 
 Table II. — Schroder (Strassburg Post-mortems). 
 
 0-20 
 
 82 
 
 2 
 
 2-4 
 
 21-30 
 
 188 
 
 6 
 
 3-2 
 
 31-40 
 
 209 
 
 24 
 
 11-5 
 
 41-50 
 
 252 
 
 28 
 
 11-1 
 
 51-60 
 
 161 
 
 16 
 
 9-9 
 
 61 and over 
 
 258 
 
 65 
 
 25-2 
 
 Total . . 
 
 1150 
 
 141 
 
 
 ^ Brockbank, "Gall Stones," London, 1896, p. 44. 
 
PREDISPOSING CAUSES. 219 
 
 Sex. BiiocKBANK. Schkodeu. 
 
 Males . 2 "9 per cent, of all post-mortems. 4 "4 per cent, of all post-mortems. 
 Females . 13"3 jjer cent, of all post-mortems. 20*6 per cent, of all post-mortems. 
 
 Predisposing causes. — All those conditions which impede or 
 obstruct the free flow of bile along the biliary passages favour 
 the commencement of the formation of biliary calculi. The 
 movements of respiration, especially those of the abdominal type, 
 are important factors in the maintenance of the normal flow of 
 bile along the bile ducts, both intra-hepatic and extra-hepatic ; 
 hence it follows that when, owing to any cause, these movements 
 are interfered with, the possibility of the formation of gall stones 
 is increased. In pregnancy, for example, the free descent of the 
 diaphragm is impeded, and the intra-abdominal pressure is 
 increased, whilst in many cases the anatomical relations of the 
 abdominal viscera are altered. The presence of an intra- 
 abdominal tumour, such as a cyst of the kidney or of the ovary, 
 acts in a similar manner. The tendency to the formation of 
 biliary calculi in the female sex is also much increased by 
 " tight-lacing " and sedentary habits. Many authors consider 
 that this is the true explanation of the fact that gall stones 
 are much more frequently met with in women than in men. In 
 the majority of cases of women who suffer from gall stones, it 
 is found that they have borne children and usually have had 
 several pregnancies. The costal type of respiration, which is 
 normal in the adult female, does not tend to cause compression 
 of the liver to the same extent as the diaphragmatic movements 
 in the male, and when this is associated with a tumour of 
 the abdomen, which still further interferes with the free move- 
 ments of the abdominal viscera, it seems probable that this 
 combination of circumstances is one of the main predisposing 
 causes in the formation of gall stones. ^ In a similar manner the 
 practice of wearing tightly-laced corsets appears to predispose 
 to the development of a condition of cholelithiasis. In many of 
 these cases the liver becomes constricted, and often a distinct 
 furrow is formed upon its external surface which tends to divide 
 the gland into two superimposed halves. All these causes act 
 by inducing a condition of stasis of the bile within the biliary 
 passages which favours the commencement of the formation of a 
 calculus. Diseases of the intra-thoracic viscera, which tend to 
 impede or slow the normal free movements of respiration, also 
 act as predisposing causes. Age, as we have already seen, is an 
 
2 2 o CHOLELITHIA SIS. 
 
 important factor. The presence of distomata or ascarides in the 
 hepatic system or in the alimentary canal increases the prob- 
 ability of the development of gall stones, owing to the fact 
 that these parasites may cause an obstruction to the free flow 
 of bile, and may also be the means of introducing micro-organisms 
 into the bile ducts. The presence of a foreign body in the gall 
 bladder or in one of the larger bile ducts would also act as 
 a predisposing cause. The existence of any pathological con- 
 dition which tends to give rise to a temporary obstruction to the 
 upper portion of the small intestine, may also, as we have seen, 
 be an important factor in the formation of gall stones, owing 
 to the possibility of the peristaltic movements of the intestine 
 causing the contents of the duodenum to pass into the common 
 bile duct through the aperture upon the biliary papilla. 
 
 Cancer of the gall bladder has, by some authors, been said to 
 be an important cause in the formation of gall stones ; but 
 although this may be true in a small number of cases, it appears 
 much more probable that the gall stones are the inducing cause 
 of the carcinomatous condition. Cancer of the larger bile ducts 
 may also be a cause of the formation of gall stones, owing to 
 the obstruction to the free flow of bile which is induced, and 
 also to the possibility of the occurrence of infection of the biliary 
 passages by organisms from the adjacent portion of the alimentary 
 canal. In most cases of cancer, however, the calculi have been 
 developed before the onset of the malignant disease, but it is 
 possible, and even probable, in a few cases, that the occurrence of 
 a cancerous affection of some portion of the biliary passages is 
 followed by the development of gall stones (Fig. 29). 
 
 Symptoms. — Biliary calculi may exist in the gall bladder, or 
 occasionally in some portions of the bile ducts, without giving 
 rise to the manifestation of any symptoms by which their exist- 
 ence can be diagnosed or even surmised during life. Usually, the 
 first symptoms to be noticed are the occurrence of pains in the 
 upper portion and right side of the abdomen, in the right hypo- 
 chondriac and epigastric regions. These pains may be only 
 slight in character, and give rise to a more or less constant 
 feeling of fulness and heaviness in the right hypochondrium, 
 together with a dragging sensation over the hepatic area. In 
 most cases, however, there occur sooner or later paroxysms of 
 severe pain. The pain in these attacks is at first localised in 
 the right hypochondriac or the epigastric region, from which 
 
SYMPTOMS. 
 
 a little later it radiates forwards over the anterior area of the 
 abdomen, and especially towards the umbilicus, and also back- 
 wards towards the in- 
 ferior angle of the 
 right scapula. These 
 paroxysms of pain may 
 come on after tcaking 
 some variety of physical 
 exercise or after a 
 meal, but in many 
 cases they occur spon- 
 taneously without being 
 preceded by any ap- 
 parent exciting cause. 
 Usually they commence 
 during the daytime 
 when the patient is up 
 and about, but it 
 occasionally happens 
 that the patient wakes 
 in the night with a 
 paroxysm. An attack 
 of pain of this kind 
 may last for several 
 minutes or several 
 hours, and in severe 
 cases even longer ; but 
 in most cases it is 
 found to be of several 
 hours' duration. The 
 pains during an attack 
 are often very severe, 
 and may give rise to 
 collapse or to sickness 
 and vomiting. Fre- 
 quently, when an attack 
 of pain has lasted for 
 
 Fig. 29. — Carcinoma of the gall bladder (primary). 
 Section through the liver and gall bladder of a man 
 set. fifty-three. The gall bladder is greatly dimin- 
 ished in size, and contains a calculus ; its walls are 
 thickened and infiltrated with a malignant growth, 
 which spreads into the adjoining liver tissue in all 
 directions for about 1^ to 2J in. At the time of the 
 post-mortem examination the shrivelled gall l)ladder 
 contained a milky, thin, mucoid fluid. The bile 
 ducts (intra-hepatic) are enormously distended, and 
 contained a thin, yellow fluid. The liver was deeply 
 jaundiced. Microscopically, the new growth con- 
 sisted of fibrous tissue and alveoli lined with cubical 
 epithelium. 
 
 a short time, a feeling 
 of sickness followed by an attack of vomiting occurs, and 
 then the paroxysm comes to a termination, and the patient 
 is apparently well. These paroxysms of pain are often 
 
222 CHOLELITHIASIS. 
 
 called gall-stone colic, biliary colic, or hepatic colic. They 
 may be single or repeated. They are caused by the passage 
 of a calculus from the gall bladder into the cystic duct, and 
 thence into the common bile duct or other portion of the biliary 
 passages. When a calculus has been formed within the intra- 
 hepatic ducts, an attack of biliary colic may be caused by the 
 passage of the calculus downwards into a narrower portion of 
 the biliary canal. In general it may be said that symptoms of 
 biliary colic will appear when a calculus passes from one portion 
 of the biliary system into another in which the lumen of the 
 canal is somewhat narrower. In many cases, however, calculi 
 have passed from the gall bladder along the cystic and common 
 bile ducts into the alimentary canal, whence they have been 
 voided per anum, and their presence has not been surmised until 
 they have been discovered in the fseces, owing to an absence of any 
 painful symptoms which might have indicated their existence. 
 This condition appears to be more commonly met with in old 
 people, in whom the muscular tissue of the walls of the bile ducts 
 and the gall bladder has undergone a certain amount of de- 
 generation. The calculus, in a certain number of cases, becomes 
 arrested at some point in the course of the cystic or common 
 bile duct, or even in one of the hepatic ducts, and according to 
 the point of arrest there follows a train of symptoms which will 
 be considered in detail later. 
 
 Sickness. — A feeling of sickness and general malaise may 
 occur, which is quite independent and distinct from a paroxysmal 
 attack. It is usually associated with the occurrence of constant 
 pains in the right hypochondrium, and is often dependent upon 
 the irritation of calculi in the gall bladder, or is experienced when 
 a calculus passes into the neck of the gall bladder, but which is 
 too large to pass along the cystic duct. This symptom is much 
 more common in old people who suffer from biliary calculi, and 
 in whom the muscular tissue in the walls of the biliary system 
 has undergone a certain amount of atrophy or degeneration. In 
 many cases an intense feeling of nausea precedes the onset of an 
 attack of vomiting. 
 
 Vomiting. — An attack of vomiting often occurs towards the 
 end of a paroxysm of biliary colic. The vomited matters are at 
 first the contents of the stomach and then bile-stained material, 
 and in rare cases it happens that a biliary calculus is found. In 
 very rare cases, in whicli the vomiting is unusually persistent, 
 
COLLAPSE. 
 
 223 
 
 it may happen that the vomited matter has a stercoraceous 
 odour. 
 
 Collai^sc. — When the paroxysm of pain is very severe and 
 protracted in duration, or the fit of vomiting very persistent, a 
 condition of collapse, which is more or less marked according to 
 the severity of the preceding attack, is the result. A certain 
 
 '- rir^.. 
 
 Fig. 30. — A portion of the right lobe of the liver with the gall bladder. The 
 cystic duct and the gall bladder are both greatly distended, owing to the 
 impaction of a calculus in the former. — St. Barth. Hosp. Museu7)i. 
 
 amount of collapse is the usual sequence of a paroxysm of biliary 
 colic, the patient becoming weak and prostrated, with a small 
 feeble pulse, a cold clammy skin, and a lowered temperature. 
 Mayo Eobson^ has recorded a case in which the patient died 
 from the collapse which was induced by a protracted and severe 
 
 1 Mayo Robson, "Gall Stones," 1892. 
 
2 24 CHOLELITHIASIS. 
 
 paroxysm of pain due to a gall stone. After death a calculus 
 was discovered to be half expelled from the common bile duct 
 into the duodenum, and still grasped by the ring of muscular 
 tissue in the terminal portion of the wall of the common bile 
 duct. Cases of this kind are, however, exceedingly uncommon. 
 
 Calculi in the faeces. — If the stools of a patient are examined 
 after the occurrence of an attack of biliary colic, it occasionally 
 happens that small or large calculi are found in the excreta, 
 which have been passed per anum. In order to find these calculi, 
 the excreta should be mixed with a weak solution of carbolic acid 
 in water, then well mixed up, and finally passed through a fine 
 wire sieve, of which the meshes are about one-twelfth of an 
 inch square. When calculi are found after an examination of 
 this kind, their composition and structure should be carefully 
 ascertained, so as to make certain of their exact nature and 
 character. In many cases, after an attack of colic, no calculi 
 can be found in the heces. This is due to the fact that the 
 calculi which have been the cause of the pain have either become 
 lodged or arrested in some part of the biliary system or aliment- 
 ary canal, or the calculus may have slipped back from the cystic 
 duct into the cavity of the gall bladder. In other cases, where 
 the calculi are small and friable, they may have undergone dis- 
 integration in the alimentary canal, before they have arrived at 
 the anus. 
 
 Jaundice. — When a biliary calculus becomes impacted in the 
 common bile duct, an obstruction is produced to the flow of bile 
 along this channel, and consequently into the alimentary canal ; 
 and if the obstruction is either complete or almost complete, it 
 gives rise to the development of an attack of jaundice. In 
 these cases the conjunctiva?, become stained yellow, and soon 
 afterwards the skin acquires a similar tint, whilst the urine is 
 deep coloured, owing to the presence in this excretion of a certain 
 amount of bile pigment. In the majority of patients who suffer 
 from gall stones which become arrested in the common bile duct 
 and give rise to an attack of jaundice, the discoloration of the 
 skill lasts for several days after the paroxysm of pain has ceased, 
 while in those cases in which the calculus remains impacted, it 
 may last for a very long time. In rare cases, it may happen 
 that an attack of jaundice occurs in connection with and as the 
 result of the impaction of the biliary calculus, without being 
 preceded by or associated with an attaclc of colic. This con- 
 
JAUNDICE. 225 
 
 dition is much more commonly met with in old people, and is of 
 very rare occurrence in young persons who are the subjects of 
 gall stones. The usual course of events, however, is an attack 
 of severe pain or biliary colic, followed immediately by the 
 development of symptoms of jaundice, which may be more or 
 less intense according to the extent and duration of the 
 obstruction to the flow of bile along the common bile duct into 
 the duodenum. In these cases the calculus becomes impacted 
 either in the common bile duct or in the hepatic duct, and causes 
 a temporary obliteration of the lumen of the bile canal. The bile 
 which continues to be secreted by the liver after the occurrence 
 of the obstruction, collects in that portion of the canal which is 
 proximal to the seat of impaction, and when the intra-hepatic 
 pressure and the pressure within the bile duct have arisen to a 
 certain height, the bile passes into the lymphatic vessels of the 
 liver, by which it is carried into the thoracic duct and thence 
 into the general blood circulation, whence it is partially deposited 
 in the skin and conjunctivae, and partially excreted by the 
 kidneys to be got rid of with the urine. The faeces in this class 
 of case become clay-coloured, owing to the absence of bile-colour- 
 ing matters ; they undergo decomposition, and have a very foul 
 odour ; whilst constipation, which may alternate with occasional 
 attacks of diarrhoea, becomes a prominent symptom. In those 
 patients in whom the obstruction within the biliary canal is 
 only partial the fseces retain their normal colour, a condition 
 which also obtains when the obstruction is in the common bile 
 duct, and there is at the same time a fistulous communication 
 between the cavity of the gall bladder and the lumen of the 
 adjacent portion of the alimentary canal. This sequence of 
 events, namely, the occurrence of paroxysmal attacks of biliary 
 colic, followed by the development of jaundice and its accompany- 
 ing symptoms, is very suggestive and even diagnostic of the 
 presence of biliary calculi. When the calculus becomes impacted 
 in the cystic duct, jaundice does not usually appear, owing to the 
 non-interference with the course of the bile from the liver to 
 the duodenum ; but it may happen, when an obstruction of this 
 kind occurs, that pressure is exerted upon the common bile duct 
 from without, and jaundice results. Some authors have 
 attempted to divide cases of cholelithiasis into two main classes, 
 according to the occurrence or non-occurrence of jaundice. This 
 subdivision appears to be very artificial, and as it does not 
 IS 
 
226. CHOLELITHIASIS. 
 
 serve any practical purpose it is not adopted, A subdivision 
 of this kind may be of some use in establishing a diagnosis in 
 difficult cases, and on this account it will be referred to again 
 later. 
 
 Temperature. — It occasionally happens in cases of biliary 
 colic which are associated with the appearance of jaundice, that 
 an ague-like temperature develops which resembles in many 
 respects an attack of so-called urethral fever. In these patients 
 a rigor occurs soon after the termination of an attack of colic, 
 the temperature rises to 103° F. or more, the rigor lasting for a 
 variable length of time, but generally being of short duration. 
 The occurrence of a rigor of this nature is followed by a fall in 
 the body temperature, and the manifestation of symptoms of 
 prostration from which the patient soon recovers, only, how- 
 ever, to suffer at a later period from successive similar attacks. 
 These rigors may occur without the development of jaundice, 
 but they are much more common in those cases in which 
 jaundice is a prominent symptom. As regards the pathology of 
 this condition, little that is definite appears to be known. 
 Some authors such as Charcot^ have maintained that the 
 fever was due to the absorption of some kind of ferment, which 
 had been produced as the result of the pathological changes 
 occurring in the biliary passages, whilst Murchison ^ and Ord 
 think that it is nervous in character, and is due to irritation of 
 the mucous membrane of the common bile duct by the presence 
 of the calculus. From recent observations which have been 
 made concerning this subject, it appears probable that in most 
 cases of " hepatic fever," occurring in connection with the 
 impaction of a biliary calculus in some portion of the cystic 
 duct or the common bile duct, the intermittent fever is 
 dependent upon a septic condition which follows an ulceration 
 at the seat of impaction, owing to absorption of septic micro- 
 organisms or their chemical products into the blood stream. 
 In some cases the B. coli commune has been shown to be present, 
 and in others, either the streptococcus pyogenes or a variety of 
 staphylococcus, and in others a pneumococcus. The staphylococcus 
 was found to be present in the blood of the patient in one case 
 of this kind which was examined by Ortner. Septic endocarditis 
 has been induced in several cases of this nature, and the 
 
 1 Charcot, "Le9on.s sur les maladies du Foie," Paris, 1877. 
 
 - Murchison, " Lectures on Diseases of Liver," 1888, 3rd edition. 
 
TEMPERATURE 227 
 
 patient has died. Enlargement of the spleen is not uncommonly 
 met with in these patients, in the later stages. Ortner ^ 
 classifies cases of cholelithiasis into the aseptic variety and the 
 septic variety, placing in the former class those cases of gall 
 stones which are not associated with septic complications, and in 
 the latter those in which septic processes either commence in 
 the gall passages or affect them secondarily. The septic group of 
 cases is much more likely to be followed by severe and even 
 fatal complications than the aseptic ones. When a calculus 
 becomes impacted in the common bile duct, it is most commonly 
 arrested immediately above the ampulla of Yater, which is 
 situated just above the aperture into the duodenum. Two con- 
 ditions may arise as the result of the arrest of the calculus ; 
 either a catarrhal condition of the biliary passages, which 
 has fairly-defined symptoms, with ague-like attacks, rigors, 
 fever, etc., which are intermittent in character and are often 
 repeated, or biliary obstruction which is associated with the 
 development of a suppurative condition of the bile ducts. When 
 this latter condition occurs, the fever is in most cases of a 
 remittent type. 
 
 If the hepatic region of a patient who is suffering from 
 cholelithiasis be examined, the liver in some cases is found to be 
 tender to palpation and slightly enlarged, so as to project for a 
 short distance below the right chondral margin ; but much more 
 commonly it is possible to feel a localised swelling situated 
 behind the ninth or tenth costal cartilages of the right side. 
 This swelling tends to extend downwards and forwards towards 
 the umbilicus, or along a line which is drawn from the ninth 
 costal cartilage of the right side to a point one-third of the way 
 from the pubic spine, to the anterior-superior iliac spine of the 
 same side. The swelling is smooth and rounded, larger below 
 than above, moves with respiration, descending during each 
 inspiration and ascending during each expiration, and can be 
 moved laterally by pressure with the examining fingers ; it is 
 dull to percussion, and on auscultation nothing is audible. In 
 order to palpate the abdominal region, the patient should be 
 directed to lie upon his back, and with the knees in a slightly 
 flexed position. Then he should be told to breathe quietly, and 
 the palpatmg hand should be laid flat upon the abdominal wall over 
 the hepatic area, and pressure gradually increased, especially at 
 
 1 Ortner, "Zur Klinik der Cholelithiasis," 1894. 
 
228 
 
 CHOLELITHIA SIS. 
 
 A 
 
 the tips of the fingers. In this manner, if there is any enlarge- 
 ment in the hepatic region, it can in most cases 
 be easily felt. If, however, nothing can be 
 ascertained by this method of examination, the 
 patient may be directed to sit up and bend the 
 body slightly forwards (breathing as before). 
 The hand should now be applied to the hepatic 
 region, and pressure gradually exerted with the 
 fingers. In this way it is often possible to 
 palpate swellings in the region of the gall 
 bladder which cannot otherwise be made out. 
 It is possible in many patients, especially in 
 women with thin and lax abdominal walls, to 
 feel the normal notch in the anterior-inferior 
 border of the liver, at the bottom of which lies 
 the fundus of the non-distended gall bladder. 
 If both these methods fail to detect any ab- 
 normal condition, it will then be advisable to 
 aucesthetise the patient and to make an 
 examination of the abdomen. When the gall 
 bladder is the seat of an enlargement in a case 
 of cholelithiasis, the swelling may be due either 
 to a large collection of calculi, which completely 
 fills the organ and distends it beyond its normal 
 size, or to an accumulation of fluid in its 
 interior, which fluid may be the secretion of the 
 liver, that is to say, ordinary bile ; or it may be 
 purulent in character, owing to the establish- 
 lumeii of the gall j^^g^-^^ Qf g^ scptic process I or, again, it may be 
 
 bladder by a cal- ^ ^ j j o ' J 
 
 cuius. A gall due to an accumulation of calculi, together with 
 bile or purulent fluid, or both. If the calculus 
 which is the cause of the enlargement is 
 arrested in the common bile duct, it does not 
 necessarily follow that the gall bladder will 
 become dilated, since in some of these cases it 
 is found that the bile which is secreted accumul- 
 ates in the common bile duct and the hepatic 
 ducts, and does not pass along the cystic duct 
 to the gall bladder. In these cases the passage of 
 the bile to the gall bladder appears to be prevented 
 by the arrangement of the spiral valve in the interior of the 
 
 Fig. .31.— Total ob- 
 literation of the 
 
 bladder, cystic 
 duct, and com- 
 mon bile duct. 
 The cavity of tlie 
 gall bladder is 
 entirely filled by 
 a large single cal- 
 culus. The canal 
 of the cystic duct 
 is ratlier narrow, 
 but that of the 
 common bile 
 duct is dilated. 
 
TEMPERA TURE. 
 
 229 
 
 cystic duct. When a calcuhis becomes arrested in the cystic 
 duct, and a complete obliteration of the lumen of this canal 
 results, the gall bladder usually becomes enlarged and dilated on 
 account of accumulation of mucus (pseudo-mucus) in its interior. 
 This substance has been secreted by the mucus glands which are 
 
 Fig. 32. — Encysted calculus of neck of gall bladder and commencement of 
 cystic duct ; portion of liver and gall bladder. The gall bladder is con- 
 siderably dilated, and contains in its interior a large oval-shaped calculus. 
 The region of the neck of the viscus and the commencement of the cystic 
 duct are dilated, and surrounded by thickened inflammatory tissue. In 
 the interior of this dilated portion there is a large rounded calculus, firmly 
 embedded in the surrounding tissue. 
 
 found in the mucous membrane lining the gall bladder. In other 
 cases of this kind the mucous membrane of the cystic duct and 
 the impacted calculus form a kind of ball-valve, which allows 
 bile to pass from the cystic duct into the gall bladder, but does 
 not allow the fluid to pass in the reverse direction. When a 
 
230 CHOLELITHIASIS. 
 
 swelling is felt in the abdomen, which is due to an enlargement 
 of the gall bladder, it is attached above, and has the characters 
 which have already been mentioned. The swelling may or may 
 not show signs of fluctuation, according to whether the contents 
 of the distended viscus are solid or fluid ; in most cases there 
 is a certain amount of fluid, and it only occasionally happens 
 that the swelling is composed entirely of calculi. When the 
 distended gall bladder is filled with fluid, it is not always 
 possible to obtain definite evidence of fluctuation, owing to the 
 tenseness of the dilated viscus. When there are calculi only, no 
 evidence of fluctuation will be obtainable. It occasionally 
 happens that a large calculus of the gall bladder passes into the 
 lumen of the adjacent portion of the alimentary canal, owing to 
 the formation of a fistulous - communication between the two 
 viscera by a process of ulceration, without giving rise to 
 symptoms of biliary colic or any other train of symptoms by 
 which the pathological condition can be diagnosed. This fact 
 must be remembered in considering any case of intestinal 
 obstruction in which the diagnosis is not clear or apparent, and 
 the region of the gall bladder should be examined in order to 
 ascertain whether there are signs to be felt which may be of use 
 in establishing a correct diagnosis. If a gall stone is small 
 enough to pass along the common bile duct into the duodenum, 
 it is very unlikely that it will become a cause of intestinal 
 obstruction. 
 
 Diagnosis.- — The most important symptoms which point to the 
 existence of biliary calculi are the occurrence of paroxysmal 
 attacks of lancinating pains in the abdomen, accompanied by a 
 feeling of sickness, and terminating usually in a fit of vomiting. 
 The pains are most marked in the hypochondriac region, especi- 
 ally the right, and radiate from there downwards towards the 
 umbilical region, and backwards towards the inferior angle of the 
 right scapula. The duration of the attack may be, as we have 
 already seen, a few days or a few hours. When jaundice occurs, 
 it is an important symptom, and usually comes on from twelve to 
 thirty-six hours after the occurrence of the paroxysm of pain. 
 Jaundice does not occur, however, in those cases in which the 
 calculus becomes impacted in the cystic duct, or in which it 
 passes back again into the gall bladder, whilst, if the obstruction 
 in the common bile duct or the hepatic duct is not complete, no 
 jaundice occurs. When jaundice is present, it points, in those 
 
DIAGNOSIS. 231 
 
 cases in which it occurs in connection with an attack of coHc, to 
 the existence of an obstruction in the common bile duct or the 
 hepatic duct. The attack of jaundice is variable in intensity 
 and usually transient in its duration. It may, however, be per- 
 sistent and last for several months, in which case the possibility 
 of the occurrence of carcinoma of the bile ducts or the gall 
 bladder may be suspected, and an attempt should be made to 
 discover its existence. If a case of jaundice last for several 
 years, especially if it has been preceded by transient attacks, it 
 is probable that it is due to an impacted gall stone, or to a con- 
 dition of fibrous constriction of the common bile duct or some 
 other part of the biliary system, which has resulted from the 
 ulceration caused by an impacted gall stone. If calculi are 
 passed along with the faeces or vomited, and these bodies have 
 the structure and composition of biliary concretions, the diagnosis 
 becomes established. Collapse and exhaustion are symptoms 
 which follow the attacks of pain and vomiting, and if they are 
 severe, they usually indicate the presence of biliary calculi. 
 Biliary colic can in most cases be distinguished from renal colic, 
 which is due to the passage of a calculus along the right ureter, 
 by the fact that in the latter case the pain radiates downwards 
 along the right loin to the region of the pelvis or the thigh, and 
 is associated with the occurrence of symptoms of vesical mischief 
 and pathological conditions of the urine. In the colic which is 
 dependent upon lead poisoning, chronic constipation and a blue 
 line upon the gums point to the nature of the affection, whilst 
 the symptoms usually disappear under the treatment appropriate 
 for this disease. In gastric affections, such as an ulcer of the 
 stomach or dyspepsia, the pain is most intense on the left side 
 of the abdomen, and is accentuated by taking food. The 
 paroxysms of biliary colic, when they occur in relation to a 
 meal, usually come on several hours after food has been taken. 
 In cases of cancer of the head of the pancreas, involving the 
 common bile duct, a tumour can occasionally be felt in the 
 posterior part of the abdominal cavity in the region of the pan- 
 creas, which is fixed in position and does not ascend and descend 
 synchronously with the movements of respiration. In these 
 cases persistent jaundice is almost invariably met with. When 
 persistent jaundice is present and is not associated with the 
 occurrence of periodic attacks of pain or rise of temperature, 
 especially if rapid loss of flesh is also present, it is probable that 
 
232 CHOLELITHIASIS. 
 
 malignant disease of the biliary ducts, the gall bladder, or the 
 liver, is under consideration. Membranous enteritis may give 
 rise to a train of symptoms which, in many respects, are similar 
 to those caused by the presence of biliary calculi. If the faeces 
 are examined in these cases, casts or flakes of false membrane 
 may be discovered, which will serve to indicate the true nature 
 of the affection, and hence enable the surgeon to discriminate 
 between the two diseases. In abscess of the liver the attacks of 
 pain are not so severe as in cases of biliary colic, and they do 
 not occur in paroxysms or radiate over the abdominal area in the 
 same manner or so extensively as is the case in the latter class 
 of affections. The passage of an ascaris (or lumbricoid worm) 
 from the duodenum into the common bile duct gives rise to the 
 appearance of a series of symptoms exactly similar to those due 
 to a severe attack of biliary colic, and cannot usually be distin- 
 guished from them ; but this condition is usually met with in 
 young people, and at this time of life gall stones are not common, 
 whilst the individual affected may give a history of having, at a 
 previous period, passed one or more of these parasites, either per 
 rectum along with the faces, or by the mouth during an attack 
 of vomiting. The presence of a hydatid tumour in the liver, 
 which has burst into the hepatic duct or the common bile duct, 
 and the passage along these canals of some of the daughter cysts 
 or portions of the membrane, will give rise to paroxysms of pain 
 resembling those due to the passage of a biliary calculus. This 
 pathological condition may possibly be distinguished by the fact 
 that there have been symptoms of the previous existence of a 
 fluctuating hepatic tumour which has suddenly diminished in size, 
 and by the presence in the fjieces of booklets and portions of the 
 membrane which formed the wall of the parasitic cyst. In order 
 to distinguish a tumour which has arisen in connection with the 
 gall bladder from cases of renal, suprarenal, or ovarian tumour, 
 it may be requisite to apply what has been called " Ziemssen's 
 test." This is carried out by injecting a quantity of air per 
 anum, sufficient to dilate the rectum, the sigmoid flexure, and the 
 colon, and then percussing the region of the tumour. If, as a 
 result of this procedure, the tumour is pushed upwards towards 
 the thorax and the area of marked resonance is below it, then, in 
 all probability, it is either hepatic or in connection with the gall 
 bladder ; whilst, if it is pushed downwards and backwards, and 
 the area of increased resonance is above, it becomes very probable 
 
COMPLICATIONS AND SEQUELS. 233 
 
 that the tumour has no connection with the liver, the gall 
 bladder, or the biliary ducts. Some surgeons have advised that 
 the swelling should be punctured with a small trocar or an 
 aspirating needle, in order to determine the nature of the tumour 
 and the character of its contents if it is fluid. This proceeding 
 is, in most cases, not justifiable, since the aperture of puncture is 
 liable to leak subsequently, and the contents of the swelling escape 
 into the peritoneal cavity and set up a peritonitis which may 
 prove to be fatal. Sounding with a needle, a method which has 
 been recommended, is a very dangerous procedure, and ought 
 never to be resorted to. If it is requisite to explore a swelling 
 which is situated in the region of the gall bladder, and which is 
 probably an enlargement of that viscus, in order to be able to 
 make a diagnosis or to clear up the nature of an obscure case, 
 it is far safer to make a small incision over the swelling, either 
 in the middle line or in the right linea semilunaris just below 
 the ninth costal cartilage, through the anterior abdominal wall, 
 and large enough to admit the finger, and through this to make 
 a digital examination. This can be done without submitting the 
 patient to any serious risk, whilst the surgeon is not working 
 in the dark as is the case when a long exploring needle is being 
 used. When an examination of this kind is being made through 
 a small wound in the anterior abdominal wall, it is advisable to 
 examine first the region of the gall bladder, next the cystic duct 
 and the portal fissure of the liver, then the gastro-hepatic 
 omentum, the region of the duodenum, and the head of the 
 pancreas. . 
 
 Complications and sequelce. — The presence of biliary calculi in 
 the excretory ducts of the liver may give rise to symptoms 
 which may be used artificially to divide the cases into two main 
 groups. We have already seen that some authors have divided 
 them into groups according to the presence or absence of 
 jaundice, whilst others have divided them according to the 
 presence or absence of septic processes. It is proposed to divide 
 them into two main groups according to the occurrence of 
 paroxysms of biliary colic. It must be remembered, however, 
 that this is a purely artificial division, and is only made for 
 clinical purposes. 
 
 In the first group are included all those cases in which 
 calculi are present in the gall bladder, and in which periodical 
 attacks of pain occur, owing to the passage of a stone from the 
 
234 CHOLELITHIASIS. 
 
 gall bladder into the duodenum. These cases are characterised 
 by the occurrence of attacks of biliary colic, which may be slight 
 or severe and accompanied by sickness and vomiting, but since 
 the calculus does not become impacted in the ducts, jaundice 
 does not occur in most cases. After a calculus has passed along 
 the bile duct to the duodenum, the patient recovers, and no 
 further symptoms develop until another calculus passes along 
 the ducts towards the duodenum. If all the calculi which have 
 been formed in the gall bladder are extruded in this manner, the 
 patient may completely recover from the attack of cholelithiasis, 
 but it often happens that, sooner or later, a larger calculus 
 passes from the gall bladder into the cystic duct, becomes 
 arrested, and then causes symptoms which justify the inclusion 
 of the case in the next group. In some of these cases the gall 
 stone gives rise to an inflammatory condition in the walls of the 
 gall bladder, which persists for some time after the calculus has 
 passed into the duodenum, and is followed by the formation of 
 a number of adhesions between the gall bladder and the adjacent 
 portion of the abdominal wall, or one of the neighbouring 
 abdominal viscera. When these adhesions have been formed, 
 they are liable to cause the appearance of symptoms which 
 resemble to a certain extent those due to the presence of gall 
 stones themselves within the gall bladder. Usually, however, 
 the symptoms which are dependent upon these adhesions are 
 not so severe in character as those which are due to the 
 presence of calculi, and they do not cause attacks of true 
 biliary colic. 
 
 In the second group are included the remaining varieties of 
 cases. This group comprises a considerable number of allied 
 pathological conditions, which may be classified as follows, 
 namely — 
 
 (a) Cases in which impaction of a calculus takes place in some 
 part of its passage from the gall bladder to the duodenum. — This 
 impaction may take place in the following situations, namely, 
 (a) the neck of the gall bladder ; (b) some part of the cystic 
 duct ; (c) in the common bile duct, usually at the ampulla of 
 Vater ; (d) the hepatic duct, in which case the calculus has 
 passed backwards towards the liver. The nature of the impac- 
 tion may be such as to give rise to either partial or complete 
 obliteration of the lumen of the duct, and consequently partial 
 or complete obstruction to the ilow of bile along the affected 
 
COMPLICATIONS AND SEQUELAE. 
 
 235 
 
 portion of the biliary canal. In those cases in which the cystic 
 duct is the seat of the impaction, and the obstruction is complete, 
 the gall bladder usually becomes dilated and distended owing to 
 an accumulation of mucus, which is secreted by the glands lying 
 in the membrane which forms the internal lining of the gall 
 bladder. As a result of this accumulation of mucus the viscus 
 may attain considerable dimensions, and may occupy the greater 
 
 Fig. 33. — Enlarged gall bladder of a ■woman, the lower extremity of which 
 passed through the right femoral ring and formed the contents of the sac 
 of a right femoral hernia. «, part of gall bladder which occupied hernial 
 sac. — &t. Barth. Hosp. Museum. 
 
 part of the cavity of the abdomen. Usually, however, it does 
 not extend beyond the umbilicus. Fig. 33 is an illustration of 
 a gall bladder, the fundus of which occupied the sac of a right 
 femoral hernia. The enlargement of the gall bladder was not 
 discovered until an operation was performed. In these cases the 
 colouring matter which was present in the bile contained within 
 the gall bladder, at the time^of the establishment of the obstruc- 
 
236 
 
 CHOLELITHIASIS. 
 
 tion, becomes absorbed, and the contents of the distended organ 
 have the appearance of pure mucoid fluid. If the calculus 
 becomes impacted in the common bile duct, or in the common 
 hepatic duct, and the obstruction is complete, there will be an 
 accumulation of bile in those portions of the bile ducts which are 
 proximal to the seat of impaction, and this will be followed by 
 the development of jaundice. If, however, the obstruction is 
 
 Fig. 34. — Section of a liver showing the intra-hepatic bile ducts enormously 
 dilated, the result of obliteration of the lumen of the common bile duct by 
 a calculus. 
 
 located in the common bile duct, and owing to a previous 
 process of ulceration, by means of which a calculus has passed 
 from the gall bladder or the cystic duct into the adjacent 
 portion of the alimentary canal, a fistula has been established, 
 then there may be no symptoms beyond those which are due to 
 the irritation caused by the presence of the calculus in the 
 common bile duct. The gall bladder does not usually become 
 dilated in cases of obstruction of the common bile duct, owing to 
 
COMPLICATIONS AND SEQUELS. 237 
 
 the presence of the spiral valve in the interior of the cystic duct, 
 which tends to prevent the eas}^ passage of fluid along it towards 
 the gall bladder when the bile is under a high pressure. When 
 the common hepatic duct is the seat of the impaction of the 
 calculus, the gall bladder never becomes distended, unless a 
 second stone is lodged in the cystic duct. 
 
 (&) Gases in which impaction of a calculus occurs in some 
 portion of the hile ducts, and is followed by the development of an 
 infective suppurative inflammation of the mucous membrane which 
 lines the interior of the biliary passages. — As a result of a septic 
 process of this kind, the following different but closely allied 
 conditions may be induced — (a) inflammation of the gall bladder 
 and the bile ducts ; (b) empyema of the gall bladder ; (c) hepatic 
 abscess ; {d) abscesses in the structures which are in the im- 
 mediate neighbourhood of the gall bladder or bile ducts ; (e) 
 acute suppurative general peritonitis ; (/) perforation of the gall 
 bladder or one of the bile ducts, and passage of the gall stone 
 and the inflammatory products into the peritoneal cavity. These 
 cases may be called the septic class, and they are in most 
 instances due to the formation of one or more ulcers of the 
 mucous membrane of that portion of the bile duct in which the 
 calculus is located ; subsequently this becomes the seat of a septic 
 process owing to the absorption of some form of suppurative 
 micro-organism which has obtained an entrance into the bile 
 passages from the alimentary canal. The micro-organisms which 
 have been found in cases of this kind are Streptococcus 
 pyogenes, Staphylococcus pyogenes aureus, B. coli co7>imune, and 
 the Diplococcus pneumonim. When the inflammatory pro- 
 cess is limited to the mucous membrane of the bile ducts, 
 a condition of angiocholitis is established, which may extend to 
 the liver and cause the development of a hepatic abscess, or 
 through the walls of the bile canals into the adjacent tissues and 
 give rise to the formation of localised abscesses, or to a general 
 peritonitis. In those cases in which the calculus becomes 
 impacted in the cystic duct, and a septic condition follows, the 
 gall bladder may become distended owing to an accumulation of 
 purulent matter in its interior, a condition which is called 
 empyema of the gall bladder. In other cases the septic process 
 gives rise to ulceration of the biliary passages, especially in the 
 neighbourhood of the impacted calculus ; perforation takes place 
 with escape of pus, and the calculus passes either into the 
 
238 CHOLELITHIASIS. 
 
 peritoneal cavity or into the adjacent tissues. All these cases are 
 characterised by the appearance of changes in the temperature, 
 such as have been described above. 
 
 (c) Ulceration of the walls of the gall bladder or one of the 
 hile ducts, followed hy adhesion to a neighbouring portion of the 
 alimentary canal — duodenum, colon, small intestines, stomach — and 
 •perforation into the lumen of the gut, with passage of the calctdus 
 into the alimentary canal, and the establishment of an internal 
 biliary fistula. — In many of these cases the symptoms w^hich 
 accompany the passage of a calculus into the alimentary canal 
 are very indefinite, and do not permit of a diagnosis of the 
 pathological condition being made. It happens occasionally 
 that large biliary calculi are passed per anum w^ithout being 
 preceded by the occurrence of any symptoms suggestive of the 
 existence of gall stones. In other cases, vague abdominal pains 
 have been noticed. In these cases the fistulse which are 
 established as the result of inflammatory processes, usually close 
 spontaneously after a short time, if there is no obstruction to 
 the flow of bile along the common bile duct. 
 
 (d) Cases in which intestinal obstruction occurs otoing to the 
 imjMction of a gcdl stone in some part of the alimentary canal. — 
 This condition may be caused by the passage of a calculus into 
 the duodenum through the opening of the common bile duct 
 after this has been dilated, or by the passage of the calculus 
 through an abnormal opening which has been produced by a 
 process of ulceration, such as has been described above. It 
 rarely happens that a gall stone which has passed into the 
 duodenum through the normal opening of the bile duct, causes 
 an obstruction in the intestine, and it may be said that in 
 nearly all cases of obstruction of the intestine which are due 
 to the impaction of a gall stone, the calculus has obtained an 
 entrance into the alimentary canal through an internal biliary 
 fistula which has been induced by a process of ulceration and 
 perforation, preceded by the formation of adhesions between the 
 gall bladder or one of the bile ducts and a portion of the 
 intestine. It is difficult to diagnose a case of intestinal 
 obstruction as being due to this cause, but this subject will be 
 dealt with in greater detail later (Chap. XXIII.). 
 
 (e) Cases in which adhesions are formed between an inflamed 
 gall bladder and the posterior aspect of the adjacent portion of 
 the anterior abdominal wall, which condition is followed by the 
 
COMPLICATIONS AND SEQUELAE. 239 
 
 development of an abscess which 'jjoints on the surface of the body, 
 and may burst spontaneotisly, discharging pus and gall stones, and 
 leaving an external biliary ftstnla. — This condition will be dis- 
 cussed in the chapter on Biliary Fistulte (Chap. XXII.). 
 
 (/) Cases in which inflammation of the gall bladder occurs 
 and is followed by desiccation of the pus and conversion of the gall 
 bladder into a mass of fibrous tissue or into a calcareous nodule. — 
 This condition is associated with indefinite symptoms, and it is 
 almost impossible to diagnose its existence until an examination 
 of the part is made, either during a surgical operation or post- 
 mortem. 
 
 {g) Cases in which a localised ulceration of some part of the 
 mucous membrane lining the bile ducts is produced, owing to the 
 presence of an impacted calculus, vjhich calculus has passed 
 onwards into the duodenum, and this condition of ulceration is 
 followed by cicatriscdion of the affected area, and a stricture of the 
 lumen of the duct results. — From this condition a train of 
 symptoms may arise which are similar to those due to the 
 presence of an impacted calculus, but they come on much more 
 slowly, and are not usually associated with the occurrence of 
 attacks of severe biliary colic. In the early stages of this 
 condition, however, there are symptoms of hepatic colic depend- 
 ent upon the impaction of a calculus which has been the cause 
 of the ulceration. The jaundice which results from an obstruc- 
 tion of this kind may develop more slowly than in cases of 
 impaction of a calculus, but this is a distinction upon which 
 little reliance can be placed, since the jaundice which is due to 
 the obstruction caused by the calculus may run into that due 
 to the stricture. 
 
 (Ji) Cases in which the continued irritation of the mucous 
 membrctne of the gall bladder, or some p)ortion of the biliary ducts, 
 is succeeded by the development of a carcinomatous affection luhich 
 may involve either the gall bladder or one of the bile ducts. — The 
 symptoms associated with these conditions are given in the 
 chapters on malignant disease of the biliary system. Some 
 authors think that most cases of cancer of the gall bladder or 
 the bile ducts are due to the irritation which is produced by 
 the presence of calculi, whilst others maintain that the gall 
 stones are due to the presence of the cancerous affection. 
 EiedeF of Jena has recently described an inflammatory condition 
 
 1 Eiedel, Berl. klin. Wchnschr, 1896, Nos. 1 and 2. 
 
240 CHOLELITHIASIS. 
 
 of that portion of the pancreas adjacent to the lower part of 
 the common bile duct, which he thinks is dependent upon or 
 caused by the irritation due to the presence of one or more 
 gall stones in the common bile duct, especially in the ampulla 
 of Vater, or the opening of the duct into the duodenum. The 
 calculus apparently first establishes an inflammatory condition of 
 the wall of that portion of the duct in which it lies, and then 
 this inflammation spreads to the pancreas by direct extension, 
 a process which is rendered easy by the circumstance that in a 
 number of cases the lower segment of the common bile duct 
 perforates the substance of the head of the pancreas in its course 
 to the second part of the duodenum. The inflammation gives 
 rise to an interstitial infiltration of the affected portion of the 
 gland, and results in the formation of hard nodules or masses 
 of fibrous tissue which have undergone contraction. It occasion- 
 ally happens in this class of case that the head of the pancreas 
 becomes generally enlarged, and acquires appearances which are 
 suCTcrestive of carcinoma. An inflammation of the head of the 
 pancreas may be met with in cholelithiasis, when no trace of 
 the presence of calculi can be found in the lower segment of 
 the common bile duct. It is probable, when this condition 
 occurs, that a calculus has been arrested in the region of the 
 ampulla of Vater, and, having caused an inflammation, has then 
 passed onwards into the duodenum and been evacuated with the 
 faeces. Kiedel has recorded three cases of pancreatitis due to 
 cholelithiasis, which he submitted to operation ; two recovered, 
 and one terminated fatally. 
 
 Treatment. — The treatment of cases of cholelithiasis has to 
 be considered under two distinct headings — {a) medical and 
 general therapeutical measures ; and (h) operative procedures, 
 (a) The indications for the adoption of a course of medical 
 treatment differ according to whether the patient is suffering 
 from a paroxysm of biliary colic, or whether he is seen during 
 a quiescent interval. In the former case it is essential that an 
 attempt should be made to relieve the pain and to induce the 
 calculus to pass onwards into the duodenum. When the patient 
 is suffering from an attack of colic, placing the sufferer in a 
 hot bath, or the application of hot fomentations to the hepatic 
 region, may afford temporary benefit, and also by causing a 
 relaxation of the tissues may facilitate the onward passage of 
 the calculus into the duodenum. In many cases it is found that 
 
TREATMENT. 241 
 
 a subcutaneous injection of \ gr. of hydrochlorate of morphine 
 affords considerable relief. It may be requisite to repeat this 
 dose. Some authors have objected to the use of morphine, since 
 they say that it causes a diminution in the amount of bile which 
 is secreted by the liver ; this objection, however, can be got over 
 by combining the morphia with 1^0 %^- of sulphate of atrophine. 
 When there is no vomiting it may be advisable to give morphia 
 by the mouth. If the paroxysm of colic is very severe, and does 
 not yield to any of the above measures, it is advised that the in- 
 halation of chloroform should be tried. Burney Yeo^ recommends 
 the administration by the mouth of large quantities of warm 
 water, in which a small quantity of sodium bicarbonate and 
 sodium salicylate has been dissolved. He says that this is 
 especially useful when morphia has been given, since it increases 
 the flow of the bile, and hence helps to expel the calculus along 
 the bile ducts which have been relaxed by the morphine. Olive 
 oil has been given with the object of relieving an attack of 
 biliary colic and also of preventing the recurrrence of these 
 attacks. The amount of oil which has been given for a dose 
 has varied between 5 and 12 ounces. Willemin^ and See^ 
 have reported cases which have apparently derived considerable 
 benefit from this method of treatment. Other observers have, 
 however, failed to obtain any good results from the employment 
 of this remedial agent. Glycerine, in doses of a half to one 
 ounce, has been given by Ferrand,^ and he declares that it has 
 given good results. When a paroxysm has passed off, rest in 
 bed should be combined with the application of warmth and the 
 internal administration of some stimulant, such as brandy, ether, 
 or strychnine, in order to restore the patient from the state of 
 collapse and exhaustion which follows the attack of pain. The 
 removal, absorption, and solution of gall stones which are 
 already present appears to be almost impossible by therapeutic 
 measures. Some authorities have advised the internal adminis- 
 tration of belladonna, podophyllin, or olive oil, as remedies which 
 will cure gall stones. There is, however, very little evidence of 
 the value of these drugs. If there are only a few small calculi 
 present in the gall bladder, they may possibly be passed spon- 
 
 1 Burney Yeo, "Manual of Therapeutics," 1895, vol. ii. 
 
 2 Willemin, " Des coliques hepatiques," Paris, 1891. 
 
 3 See, " Medicaments cholagogues," Med. mod., Paris, Jan. 23, 1890, p. 88. 
 
 4 Ferrand, Semaine med., Paris, March 9, 1892, p. 96. 
 
 i6 
 
242 CHOLELITHIASIS. 
 
 taueously or with the aid of the drugs mentioned above. Courses 
 of mineral waters, especially those of Carlsbad, in many instances 
 appear to have facilitated the expulsion of gall stones. The 
 water of Carlsbad is a purgative and a cholagogue, and it tends 
 to cause a relaxation of the walls of the bile ducts, and at the 
 same time increases the flow of bile. It often happens in 
 patients who are suffering from cholelithiasis, and who undergo 
 the course of treatment at Carlsbad, that a few days after the 
 commencement of the treatment an attack of biliary colic occurs, 
 owing to the passage of a gall stone into the bile ducts. Other 
 waters have also been recommended, such as Wiesbaden, Ems, 
 Vichy, Marienbad, Neuenahr, Kissingen, and Homburg, but most 
 of these do not appear to be so efficacious as those of Carlsbad. 
 A course of treatment which is similar to that of Carlsbad may 
 be carried out at home, if the patient will take the imported 
 Carlsbad water and carry out the directions for the mode of 
 living. 
 
 The formation of gall stones may be prevented in great 
 measure by attention to the diet, exercise, and the general 
 hygienic condition of the patient. A moderate amount of 
 alcohol only should be allowed, whilst all indigestible foods 
 should be strictly forbidden. The bowels should be kept freely 
 open by the administration of alkalies and aloes ; Carlsbad salts 
 or sodium sulphate being also used for this purpose. A fair 
 amount of gentle physical exercise should also be enforced, and 
 if the patient be a woman attention should be paid to tight- 
 fitting corsets or any form of dress which may press upon the 
 hepatic region and impede the normal free movements of re- 
 spiration. Massage of the abdomen has been recommended as 
 a measure which facilitates the expulsion of calculi from the gall 
 bladder or the biliary ducts. This is not to be advised, owing 
 to the uncertainty of its effects and to the fact that ulceration 
 or perforation of the walls of the gall bladder or of the bile 
 ducts may be and has been induced. All the above measures, 
 however, can only be regarded as palliative or preventative 
 methods of treatment ; and in a considerable number of patients 
 it is necessary, in order to cure the patient of the diseased con- 
 dition which is dependent upon the cholelithiasis, to have recourse 
 to direct surgical operative interference. The signs and symp- 
 toms which point to the necessity of surgical interference in a 
 patient who is suffering from cholelithiasis are — {a) the presence 
 
TREATMENT. 243 
 
 of a tumour in the abdomen, which appears to be an abnormally 
 distended and large gall bladder ; (5) the existence of jaundice 
 which is persistent, together with other signs and symptoms 
 which point to complete obstruction of the common bile duct 
 or the common hepatic duct ; (c) the occurrence of successive 
 paroxysmal attacks of biliary colic, with short intervals between 
 the individual attacks, which are lowering the general health of 
 the patient, inducing a state of general exhaustion, and are not 
 amenable to medical measures ; {d) symptoms of localised in- 
 flammation in the region of the gall bladder, which are associated 
 with the occurrence of attacks of biliary colic ; (e) the occurrence 
 of acute peritonitis, which is probably due to perforation of the 
 gall bladder or of one of the biliary ducts, and escape of calculi 
 and purulent matter into the peritoneal cavity. When the per- 
 formance of an operation has been decided upon, it is not always 
 possible to say what is the best thing to be done until the 
 abdomen has been opened, and a careful examination has been 
 made of the abnormal conditions which are present. The objects 
 of the operation, however, may be said to be the removal of the 
 biliary calculi, the relief of any form of obstruction which is 
 present in the course of the bile canals, and the re-establishment 
 of the bile channel, the evacuation of any collection of purulent 
 matter which may have formed, and the relief of any com- 
 plications which have developed as the result of the affection 
 of the biliary system. It will thus be seen that a considerable 
 number of surgical procedures require discussion. In all cases 
 it is necessary, when an operation has to be performed, to open 
 the abdomen by an incision in the anterior abdominal wall, and 
 every operation must be carried out under the strictest aseptic 
 precautions, so as to avoid the possibility of the infection of the 
 peritoneum or any other anatomical structure in the area of the 
 operation. In most cases it is advisable to make the abdominal 
 incision in the right linea semilunaris, commencing immediately 
 below the costal margin ; but in some cases, especially those in 
 which the calculus is impacted in the lower portion of the 
 common bile duct, it is better to open the abdomen by an 
 incision in the linea alba above the umbilicus. 
 
 Some surgeons advise an incision which is parallel with the 
 right costal margin, but, according to my experience, very little 
 advantage is gained by this method. If, after the abdomen has 
 been opened, the gall bladder is found to be the seat of calculi, 
 
244 CHOLELITHIASIS. 
 
 the viscus should be brought into the abdominal wound, an 
 incision made in its fundus, and the contents removed. The 
 details of this operation, which is known as cholecystotomy, are 
 discussed in Chapters XXV. and XXVI., where also will be found 
 the methods of performing all other operations which are referred 
 to in the succeeding portions of this chapter, in every case of 
 cholecystotomy, after the calculi have been removed from the 
 cavity, a routine digital and visual examination of the entire 
 course of the bile ducts should be made, if possible, so that if any 
 stones are situated in the course of these canals they may be 
 discovered and removed. When a calculus is found to be im- 
 pacted in the cystic duct, an attempt should jfirst be made to 
 manipulate it backwards into the cavity of the gall bladder, from 
 which it can be removed through the incision in the fundus. If 
 this cannot be done without severely damaging the duct or 
 causing a rupture of its walls, an attempt should next be made 
 to break it up into fragments, either by crushing it between the 
 fingers or with padded forceps, or by needling it with a strong 
 steel needle, which is introduced into the stone, either along the 
 course of the cystic duct from the gall bladder or by piercing the 
 walls of the cystic duct in the proximity of the stone, care being 
 taken not to pass through any part of the cystic duct which is 
 distended and thinned by the presence of the calculus in its 
 interior. Some authors have advised that an attempt should be 
 made to dissolve the stone by ether, but this suggestion does not 
 appear to be a practicable one. When the calculus has been 
 broken up by one of these methods, the fragments are forced 
 along the cystic duct into the gall bladder, from which they are 
 removed. In a certain number of cases it is found to be im- 
 possible to extract the stone by any of the above methods, and 
 then it is necessary to incise the cystic duct and to remove the 
 calculus through the incision. The former operation of crushing 
 has been called cholecystico-lithotrity, and the latter incision 
 cystico-lithotomy. When the calculus has become impacted in 
 the common bile duct, an attempt may first be made either to 
 manipulate the stone backwards into the gall bladder or onwards 
 into the duodenum. If these manipulations fail, crushing, 
 needling, or incision of the wall of the common bile duct, must 
 be resorted to. Tliese operations are known as choledocho- 
 lithotrity and choledochotomy respectively. It has happened 
 that a calculus has become impacted at the entrance of the com- 
 
TREATMENT. 245 
 
 mon bile duct into the duodenum, and it has been found to be 
 impossible to extract the stone by any of the above methods. 
 For these cases Kocher ^ has performed an operation which he 
 designates " internal choledocho-duodenostomy." In this opera- 
 tion a transverse incision is made in the anterior wall of the 
 second portion of the duodenum, and the aperture of the com- 
 mon bile duct incised or dilated from within, and the stone 
 extracted from the lumen of the bowel. Terrier ^ of Paris has 
 proposed the performance of a lumbar operation, through which a 
 calculus impacted in the lower portion of the common bile duct 
 can be removed. The difficulties in the performance of this 
 operation appear to be so considerable that its adoption is not 
 recommended. After the calculus has been removed from the 
 cystic duct or the common bile duct, by an incision in its wall, 
 the margins of the incision should be approximated and united 
 by the introduction of fine silk sutures, a double tier being 
 introduced, if possible. In most cases of this kind it is advisable 
 to leave open a small part of the abdominal wound, and to pass 
 a tampon of gauze down to the site of the incised duct, so that 
 if any leakage takes place it may be recognised, and the fluid 
 may escape externally. When the gall bladder has been incised, 
 it is necessary, in most cases, to unite the margins of the wound 
 in the viscus to those of the abdominal incision, and only rarely 
 can the organ be sewn up and then dropped back into the 
 abdominal cavity. The only conditions under which this latter 
 proceeding is justifiable appear to be when the gall bladder is in 
 a perfectly healthy condition, and contains a few small calculi, 
 which can be extracted through a small aperture. This opera- 
 tion has been called " cholecystendysis," or " ideal cholecystotomy." 
 When a perforation of the gall bladder or one of the bile ducts 
 has occurred, and septic peritonitis has been set up, the peritoneal 
 cavity must be thoroughly washed out, so as to remove, as far as 
 possible, all infective matter ; and if the perforation is situated in 
 the region of the fundus of the gall bladder, its margins must be 
 united to those of the abdominal incision, and the cavity of the 
 viscus drained ; whilst, if the perforation is situated in the neck of 
 the gall bladder, or in the cystic duct, the entire gall bladder 
 and the involved portion of the cystic duct must be removed 
 by the performance of cholecystectomy. When the perforation 
 
 1 Kocher, Cor. -El. f. schweiz. Aerzte, Basel, April 1895. 
 - Terrier, fiiei;. de chir., Paris, 1896. 
 
246 CHOLELITHIASIS. 
 
 involves the common bile duct, an attempt should be made to 
 close it with sutures after it has been rendered as aseptic as 
 possible, and a drainage tube or gauze tampon passed down to 
 the region of the sutured duct and brought out of the abdominal 
 wound. 
 
 Prognosis. — The prognosis in cases of cholelithiasis is in many 
 cases good. During recent years the advances which have been 
 made in the surgical treatment of diseases of the liver and biliary 
 system have considerably lessened the rate of mortality from the 
 various complications which are liable to arise as the result of 
 the presence of biliary calculi. In septic and inflammatory 
 cases in which there is a perforation into the peritoneal cavity, 
 the prognosis is the worst ; but even in these cases, if radical 
 surgical treatment is immediately adopted, there is a chance of 
 the patient's recovery. The dangers and the complications 
 which may result from the performance of the different surgical 
 operations are discussed in connection with the description of the 
 operations themselves, and the main indications are also given as 
 to which variety of operation is advisable for any individual 
 case. 
 
CHAPTEE XIX. 
 
 NEOPLASMS OF THE GALL BLADDEE. 
 
 New growths which have their commencement in one of the 
 histological elements which form the walls of the gall bladder, 
 occasionally occur, but they are not common. They may be 
 either benign or malignant in character, usually the latter ; in 
 fact, non-malignant growths of this viscus have only been seen 
 by very few observers. 
 
 Benign Growths. — These affections are exceedingly rare, only 
 a few well-authenticated cases can be found to have been recorded 
 by trustworthy observers. Albers^ has described and figured a 
 case of fibroma of the gall bladder, which apparently took its 
 origin from the fibrous tissue which makes up the greater part of 
 the submucous layer. Pdedel has recorded a case of non-malignant 
 papilloma of the fundus of the gall bladder, which had been 
 diagnosed as a carcinomatous affection. Wiedemann has met with a 
 case of encysted swelling of the mucous membrane, and Schiippel ^ 
 has given details of a case in which the tumour was a form of 
 papilloma, the newly formed tissue having undergone a myxom- 
 atous degeneration. In the clinical and post-mortem records of 
 St. Bartholomew's Hospital for the past ten years (1886—1895), 
 I have been unable to find any evidence of the occurrence of any 
 variety of non-malignant tumour of the gall bladder. Guy's ^ 
 Hospital Museum contains two specimens of simple papillom- 
 atous growths of the gall bladder. These growths appear 
 to be of the nature of small multiple fibrous tumours, the 
 surface of each being covered with normal epithelium. When 
 these rare forms of growth are met with, they may be found to 
 be attached to any part of the walls of the gall bladder, and 
 
 1 Albers, " Fibroma of the Biliary Vesicle," "Atlas der Path. Anat.," Plate xxxviii. 
 Figs. 3 and 4. 
 
 2 Schiippel, "Ziemssen's Handbtich," Bd. vii. 
 
 3 Guy's Hosp. Museum Specs., 1404 aud 1405. 
 
248 NEOPLASMS OF THE GALL BLADDER. 
 
 when they grow from the mucous membrane in the region of 
 the point of exit of the cystic duct, they may overlap the 
 internal orifice of this duct, and cause an obstruction to the 
 outflow of the contents of the gall bladder, whilst they allow the 
 ingress of bile from the cystic duct, and thus act after the manner 
 of a ball valve. Hence it is possible that a tumour of this kind 
 might become the cause of a distension of the gall bladder with 
 bile, and so lead to the appearance of an abdominal swelling. 
 The mucous, membrane in the neighbourhood of the tumour may 
 be irritated by it in a mechanical manner, and become the seat 
 of an ulcerative process, which may cause a distension of the 
 gall bladder with purulent matter, or even give rise to a per- 
 foration of the wall of the viscus, in which event the purulent 
 matter collected within will pass through the aperture so formed 
 into the peritoneal cavity and become the exciting cause of an 
 attack of acute septic peritonitis. In most cases of tumour of 
 this kind no definite symptoms have become apparent, the 
 growth remaining in a quiescent condition. 
 
 Symptoms. — These growths in the majority of instances give 
 rise to no definite train of symptoms, especially in the early 
 stages of their development. When they are situated in the 
 region of the neck of the gall bladder they may cause obstruction 
 to the egress of fluid from this sac, and so give rise to the develop- 
 ment of an abdominal tumour, which is located in the right 
 hypochondriac region, and has all the characteristics of a distended 
 gall bladder. In those cases in which the mucous membrane of 
 the gall bladder becomes the seat of an ulcerative process, owing 
 to the mechanical irritation of the tumour and to the subsequent 
 septic infection of tlie biliary passages, symptoms of cholecystitis 
 will be established, and if perforation into the peritoneum occur, 
 there will be signs of acute peritonitis. Usually, however, these 
 tumours are only discovered in the course of a post-mortem ex- 
 amination. It is possible that, in very rare cases, they may be 
 an exciting or predisposing cause in the formation of gall stones 
 in the gall bladder. 
 
 Diagnosis. — This is impossible under ordinary circumstances, 
 and it can only be made with certainty when the interior of the 
 gall bladder is examined during the course of a cholecystotomy. 
 A tumour of tliis kind, if present, will be found as a small 
 pedunculated body, attached to some portion of the mucous 
 membrane lining the internal aspect of the viscus. 
 
MALIGNANT GROWTHS. 249 
 
 Treatment. — No treatment is called for unless the gall bladder 
 becomes distended owing to an accumulation of bile, mucus, or 
 pus, in which case an exploratory cholecystotoray will be indi- 
 cated. When a localised growth is discovered, after the abdomen 
 has been opened and the interior of the gall bladder examined, 
 it may sometimes be found possible to remove it locally by 
 applying a silk ligature to its base and excising the part of the 
 swelling which is distal to the ligature. It is advisable, in most 
 cases of this kind, to perform a complete cholecystectomy, since 
 it is quite conceivable that these growths may be the precursors 
 of tumours which are malignant in character. In some cases of 
 tumour of the gall bladder a malignant growth in the early stages 
 of its development may have the external characteristics of a 
 non-malignant tumour, and on this account the growth should 
 not be diagnosed as non-malignant until a microscopic examina- 
 tion of the removed tissue has been made. Small hydatid tumours 
 of the liver, in a few cases which have been seen, have projected 
 into the lumen of the gall bladder, and have given rise to the 
 supposition that a simple form of tumour was being dealt with. 
 When peritonitis has developed, as the result of perforation, it 
 must be treated in the usual manner. 
 
 Prognosis. — The prognosis of cases of benign tumour of the 
 gall bladder is very favourable if the gall bladder has not become 
 the seat of an ulcerative process which has caused perforation 
 and septic peritonitis. The prognosis is very serious if the latter 
 complication occur. 
 
 Malignant Geowths. — Malignant new growths of the gall 
 bladder which are primary in character, are derived either from 
 the epithelial elements of the mucous lining, or from the fibrous 
 and muscular tissues which form the outer layers of the wall of the 
 viscus. In the former case they are of the nature of carcinomata, 
 and in the latter of sarcomata. Those new formations which 
 commence in the lining epithelial membrane have the structure 
 of columnar-celled carcinomata, and those which arise in connec- 
 tion with the epithelium of the mucous glands are spheroidal- 
 celled or glandular carcinomata. Usually these growths have 
 the characteristics of scirrhous carcinomata, on account of the 
 large amount of fibrous tissue which binds together the carcino- 
 matous elements. In rare cases the cancers may be medullary 
 in nature, owing to the preponderance of the cellular elements, 
 or they may undergo colloid degeneration. Sarcomata of the 
 
25° 
 
 NEOPLASMS OF THE GALL BLADDER 
 
 gall bladder when they occur may be round-celled, spindle-celled, 
 or mixed-celled. They are exceedingly rare, but they have been 
 met with and recorded by a few surgical observers. Czerny and 
 Eiedel ^ have published cases of this nature. I have examined a 
 considerable number of malignant growths of the gall bladder, 
 and have not met with one in which a sarcomatous growth was 
 primary in that viscus. In one case a growth from the liver 
 encroached upon the cavity of the gall bladder and appeared to 
 be a primary sarcoma starting in the walls of the organ. Careful 
 search, however, showed that it was a secondary deposit, which 
 had resulted from the presence of a primary growth elsewhere. 
 
 Fig. 35. — Carcinoma of the gall bladder. A localised papillomatous growth 
 from the mucous membrane of the interior of the gall bladder. Microscopic- 
 ally this neoplasm had the structure of a scirrhous carcinoma. — St. Barth. 
 Hosp. Museum. 
 
 ISTearly all primary malignant new growths of the gall bladder 
 will be found to have the structure of carcinomata. When these 
 forms of malignant disease occur, the growth may be localised to 
 a small area in the wall of the organ and project into the interior 
 of the sac, as is the case in the specimens from which Figs. 35 
 and .3 6 were taken ; or it may involve the whole of the wall of 
 the gall bladder and give rise to the formation of a large swell- 
 ing or tumour, in the interior of wliich a number of gall stones 
 may be located. This was the condition of affairs in the patient 
 
 1 lliedel, " Erfahruugen der Gallensteiu-krankheiten," 1892. 
 
MALIGNANT GROWTHS. 
 
 251 
 
 from whom the gall bladder depicted in Fig. 37 was obtained. 
 In the great majority of cases of carcinoma of the gall bladder, 
 gall stones are found to be present in the interior of the growth. 
 Some authorities upon pathology regard the presence of gall 
 stones in the gall bladder as the causative agent in the production 
 of the disease, whilst others maintain that the formation of gall 
 stones is induced by the presence of the new growth. It has 
 been found in a considerable number of cases of carcinoma 
 of the gall bladder, that the patients so affected give a distinct 
 history of having suffered from gall stones for some time before 
 the appearance of symptoms dependent upon the existence of 
 malignant disease. Thus it is not uncommon to find that a 
 patient who is suffering from a carcinoma of the gall bladder has 
 
 Fig. 36. — Carcinoma of the gall bladder. A gall bladder exhibiting a small 
 localised growth of soft cancer from its lining membrane. Except at the 
 seat of growth, the organ appears to be healthy. — St. Barth. Hosp. Museum. 
 
 had for many years, at intervals, attacks of biliary or hepatic 
 colic, or of intermittent pains in the right hypochondriac region. 
 In more than ninety per cent, of cases of carcinoma of the gall 
 bladder which have been examined post-mortem, gall stones have 
 been found to be present, and in nearly all these cases the calculi 
 have been composed of cholesterin or bile pigments. These facts 
 are in favour of the correctness of the view that gall stones are 
 the causative agent in the production of carcinoma of the gall 
 bladder, or at least that the gall bladder has for a long time 
 been the seat of gall stones before the signs of a malignant growth 
 have become manifest. According to the present state of patho- 
 logical science, constant irritation is said to be frequently the 
 
252 
 
 NEOPLASMS OF THE GALL BLADDER. 
 
 inducing or exciting cause of a tissue taking on a malignant form 
 of growth. If, however, we take into consideration the fact that 
 a large number of people in whose gall bladders gall stones are 
 found to be present after death, do not exhibit any signs of the 
 development of a carcinomatous form of growth, it is difficult to 
 
 Fig. 37. — Carcinoma of the gall bladder. A gall bladder, the wall of which is 
 converted into a mass of medullary carcinoma ; it contains a number of 
 faceted gall stones. The growth around the gall bladder was continuous 
 with a mass of infiltrated lumbar glands. The duodenum was compressed, 
 and its walls infiltrated with growth. The neoplasm has the structure of a 
 columnar-celled carcinoma. The specimen was obtained from a woman, 
 ;et. 59, who had had an abdominal swelling for five years, but no inconvenience 
 arose from it until about one month before death. — Ht. Earth. Hosp. Museum. 
 
 accept the statement that the presence of gall stones in the gall 
 bladder is tlie sole cause of the epithelial cells which form the 
 lining membrane taking on or assuming a malignant form of 
 growth. In all probability there is some other condition, either 
 
MALIGNANT GROWTHS— SYMPTOMS. 253 
 
 local or general, which, together with the presence of gall stones 
 in the gall bladder, is necessary for the development of a car- 
 cinomatous form of growth. Many attempts have been made to 
 show that certain forms of parasites (sporozoa) play an important 
 role in the causation of carcinoma, but the evidence upon which 
 these theories have been based appears to be very meagre and 
 insufficient. We have already mentioned that, in most cases of 
 malignant disease of the gall bladder, the calculi which are 
 present consist of cholesterin and bile pigments, and on this 
 account it appears clear that in these cases the calculi must have 
 been present before the development of the carcinomatous pro- 
 cess, or at least before this process had advanced to the stage of 
 ulceration. In a small percentage of cases it is found that the 
 calculi consist of compounds of calcium and phosphates, and in 
 these it is possible or even probable that the gall stones have 
 been formed after the commencement of the carcinomatous 
 growth. In this connection, however, it must be remembered 
 that the gall bladder may have been the seat of an inflammatory 
 process previous to the commencement of the development of the 
 carcinoma, and that this condition may have been the cause of 
 the formation of calculi which consist of calcium compounds and 
 phosphates. In from 6 to 10 per cent, of the cases which have 
 been examined, there has been no evidence that biliary calculi 
 have been present in the gall bladder. It is quite possible, in 
 this class of case, that in the early stages of the affection gall 
 stones have been present in the gall bladder, but that they have 
 either become disintegrated and passed as detritus, or that they 
 have traversed the gall passages and obtained an entrance into 
 the alimentary canal, whence they have been extruded per anum, 
 without giving rise to the appearance of any symptoms by which 
 their existence has been recognised or suspected. 
 
 Symptoms. — In the early stages of carcinomatous affections of 
 the gall bladder there are in most cases no symptoms which can 
 be said to be pathognomonic of the disease. The early symptoms 
 are very obscure in nearly all cases. Often when the patients 
 are closely questioned concerning the early stages of their disease, 
 they will give a history of the occurrence of vague and indefinite 
 pains in the abdomen, which may have been localised in the 
 right hypochondriac region, or of severe attacks of pain which 
 resemble the paroxysms of hepatic or biliary colic. In 
 other cases attacks of diarrhoea, alternating with constipation. 
 
254 NEOPLASMS OF THE GALL BLADDER. 
 
 have been marked symptoms at the commencement of the 
 disease. Occasionally, symptoms of gastric disturbance or attacks 
 of vomiting have been the predominant external manifestations 
 of the affection. In one of the cases described by Markham 
 the vomit contained some blood-stained matter. The liepatic 
 region is often painful on palpation, but in many cases no 
 tenderness of this area of the abdomen is apparent. Jaundice 
 has been said to occur in 70 per cent, of cases, but in the early 
 stages of the disease it is usually absent. 
 
 When the affection has become well established, and the tumour 
 has extended to the bile ducts in the portal fissure of the liver or 
 in the gastro-hepatic omentum, the occurrence of jaundice is very 
 common ; the discoloration may be only slight in amount, or it may 
 gradually increase in intensity until the skin is of a dark greenish- 
 yellow colour. The development of jaundice is due to the exten- 
 sion of the new growth to one or other of the bile ducts, or to the 
 lumen of the ducts becoming obliterated by pressure from without, 
 or by the pressure from enlarged lymphatic glands in the portal 
 fissure of the liver and gastro-hepatic omentum, or by impacted 
 calculi and inflammatory processes which involve the mucous 
 membrane of the large bile ducts. In the later stages of the 
 affection pain is a frequent symptom, and is localised chiefly in 
 the right hypochondriac region, or in the epigastrium, whence it 
 may radiate towards the umbilicus or to the inferior angle of the 
 right scapula. The pain is variable in character; in one class of 
 case it is present as a constant gnawing pain which is localised 
 for the most part to the upper and right side of the abdomen, 
 and in another class it comes on in paroxysms of severe lancinat- 
 ing pains, which may last for several minutes or even hours. 
 In the latter variety of case the attacks of pain very much 
 resemble those of hepatic colic, which are due to the presence of 
 biliary calculi in the bile ducts. In those cases in which the 
 right hypochondrium is the seat of a local tenderness, this is 
 mcreased during an attack of pain. Clinically, carcinoma of the 
 gall bladder may be said to present two main forms in the later 
 stages. In the first class may be included those cases which 
 resemble in many respects a case of carcinoma of the liver (Fig. 
 38), whilst in the other class are placed those cases in which the 
 main symptoms are those of chronic jaundice, with retention of 
 the bile (Fig. 39). In both classes, however, a tumour can 
 usually be discovered in the abdomen, which is hard, solid, and 
 
SYMPTOMS. 
 
 255 
 
 situated iu the right hypochondriac region, extending downwards 
 to the umbilicus, or even into tlie right inguinal region when the 
 tumour has attained very 
 large dimensions. In 
 most cases the swelling 
 is small and rounded or 
 ovoid in shape, but it 
 may attain a diameter of 
 several inches. It is fixed 
 above to the inferior 
 border of the liver, and 
 part of the tumour may 
 be situated in the liver 
 itself, owing to a direct 
 extension of the growth 
 in that direction. The 
 margin of the tumour is 
 quite distinct below, but 
 above it cannot be separ- 
 ated from its connections 
 with the lower border of 
 the liver. It moves 
 upwards and downwards 
 synchronously with the 
 movements of respira- 
 tion. In nearly every 
 case the tumour appears 
 to be quite hard and solid 
 on palpation, and it does 
 not give the smooth and 
 elastic feeling which is 
 constantly met with when 
 the gall bladder is en- 
 larged on account of gall- 
 stone obstruction and 
 distension with bile or 
 pus. In the later stages 
 it is not uncommon to 
 
 Fig. 38.— Carcinoma of the gall bladder (cubical- 
 celled). Section through the liver and gall 
 bladder of a man, at. 53. The gall bladder 
 is greatly diminished iu size, and contains a 
 calculus ; its walls are thickened and infiltrated 
 with a malignant growth, which spreads into 
 the adjoining liver tissue in all directions for 
 about \\ to 1\ in. At the time of the post- 
 mortem examination the shrivelled gall bladder 
 contained a thin, milky, mucoid fluid. The 
 bile ducts (intra-hepatic) are enormously dis- 
 tended, and contained a thin yellow fluid. The 
 liver was deeply jaundiced. Microscopically, 
 the new growth consisted of fibrous tissue and 
 alveoli, lined with cubical-celled epithelium. — 
 St. Earth. Hosp. Museum. 
 
 find that the gall bladder 
 
 becomes the seat of suppuration, and an abscess is developed 
 
 in connection with the cancerous growth which extends 
 
256 
 
 NEOPLASMS OF THE GALL BLADDER. 
 
 towards the surface through the overlying abdominal walls. 
 I have recently seen three cases in which this complication 
 has occurred a considerable length of time after symptoms 
 of a carcinomatous affection have become apparent. The 
 
 Fig. 39. — Carcinoma of the gall bladder. A portion of the liver with half the 
 gall Ijladder attached to it. The wall of the gall bladder is considerably 
 thickened, and its internal aspect ragged and shaggy. The entire walls of 
 the organ are in a cancerous condition (colunniar-celled carcinoma). The 
 growth had extended into the cystic duct and tlie tissues around, so as 
 to block the common hepatic duct. The liver was jaundiced, but was free 
 from secondary growths. The lumbar glands contained secondary dejjosits. 
 — (SY. Barth. Hosp. Museum. 
 
 surface of the tumour is usually somewhat irregular, and pre- 
 .sents a distinct bossed outline, owing to the presence of eleva- 
 tions upon its surface. Wasting and loss of body weight are 
 generally very apparent symptoms, especially in the later stages 
 of the disease, but in some instances which have been placed on 
 
S YMPTOMS^SEX—A GE. 
 
 257 
 
 record this condition does not seem to have been of constant 
 occurrence. Diminution of the appetite, with symptoms of 
 gastro-intestinal disturbance, in most cases precede and accom- 
 pany the wasting and emaciation. Spontaneous haemorrhages, 
 which are either submucous, subcutaneous, or into the serous 
 cavities, have occasionally been observed. When the portal vein 
 is pressed upon from without by the tumour, or the growth in- 
 filtrates its walls and partially obliterates its lumen, ascites and 
 cedematous swelling of the lower extremities occur. Nausea and 
 vomiting are met with, and in these cases the vomiting is said to 
 be due to the direct pressure of the growth upon the duodenum. 
 When the large extra-hepatic bile ducts are obstructed, the liver 
 becomes generally enlarged, owing to the retention of the biliary 
 secretion, and the organ can be felt to extend for a variable dis- 
 tance below the costal margin. In these cases jaundice is in- 
 variably present ; it increases in intensity and is associated with 
 the occurrence of constipation and absence of colouring matter in 
 the stools. In a few cases diarrhoea has been noticed, which 
 may alternate with periods of constipation. In the late stages 
 of the disease the symptoms of cancerous cachexia become well 
 developed. 
 
 Bex. — Females are very much more liable to become the 
 subjects of carcinomatous disease of the gall bladder than males. 
 In Courvoisier's ^ list of ninety-eight cases, seventy-five were of 
 the female sex and twenty-three of the male. Statistics which 
 have been collected with reference to this point show that three 
 to five women are attacked to one male. 
 
 Siegert^ has collected all cases of carcinoma of the gall 
 bladder which have been recorded in medical literature up to 
 1891. He finds that one hundred and one cases had been 
 published. Of these, fourteen were males, seventy-nine were 
 females, and the sex of eight could not be ascertained. Eighty- 
 seven of these cases had calculi within the carcinomatous sail 
 bladder, in seven no gall stones could be found, and in seven 
 the presence or absence was not stated. Out of thirteen cases 
 in which the gall bladder was involved in a secondary carcinoma, 
 gall stones were found twice. 
 
 Age. — The disease appears to be most commonly met with in 
 patients between the age of forty-five and sixty- five, from fifty 
 
 1 Courvoisier, op. cit. 
 
 2 Siegert, Virchcnv's Archiv, Bd. cxxxii. s. 353. 
 
 17 
 
258 NEOPLASMS OP THE GALL BLADDER. 
 
 * 
 
 to sixty being the most frequent. Several cases have been 
 recorded which have occurred in persons between the ages of 
 twenty and thirty. 
 
 Diagnosis. — The presence of a hard, solid tumour in the 
 right hypochondriac region, and in the position of the normal 
 gall bladder, which is continuous with the lower edge of the right 
 lobe of the liver, is tender, painful, and associated with jaundice 
 and cachexia, indicates the existence of malignant disease of the 
 gall bladder. Musser^ has given an account of a series of a 
 hundred cases of cancer of the gall bladder which were examined 
 after death, and in these he found that a tumour was present 
 in sixty-eight instances. In twenty-seven cases it occupied the 
 right hypochondriac region, in twelve the umbilical region, in 
 four the iliac fossa, in two the inguinal region, and in one the 
 situation of the pylorus ; whilst in ten cases it was adherent to 
 the liver. The surface of the swelling may be irregular, and 
 present a number of localised elevations, in which case it may be 
 confused with carcinoma of the liver. In all cases of supposed 
 malignant disease of the gall bladder, the abdominal and pelvic 
 viscera must be carefully investigated before making a definite 
 diagnosis, so as to exclude as far as possible the occurrence of 
 secondary growths. I have seen a case with all the clinical 
 signs and symptoms of a carcinoma of the gall bladder, which 
 eventually proved to be a case of malignant disease of the upper 
 part of the rectum. The primary growth was very small and 
 localised, but it had given rise to the development of a secondary 
 growth in that portion of the liver which is adjacent to the gall 
 bladder, and this secondary growth protruded into the cavity of 
 that viscus, and infiltrated its walls with carcinomatous elements. 
 The occurrence of carcinomatous affections of the stomach and 
 the head of the pancreas must also be excluded before a definite 
 conclusion is arrived at. The possible occurrence of hydatid 
 cysts and abscesses of various kinds must be taken into con- 
 sideration when an examination is being made. 
 
 Complications. — The carcinomatous tumour may extend 
 directly into the adjacent portion of the liver, and there grow 
 and proliferate, so as to form a large malignant mass of tissue ; 
 or secondary growths may develop in more distant parts of the 
 organ. Secondary growths, which are dependent upon a primary 
 carcinoma of the gall bladder, may be met with in the liver ; 
 
 1 Musser, Boston Med. and S. Journ., Dec. 5, 1889. 
 
COMPLICA TIONS — TREA TMENT. 259 
 
 but they do not commonly occur in distant viscera, especially in 
 the earlier stages of the affection. The growth may also extend 
 to the neighbouring part of the abdominal wall, and involve its 
 entire thickness, so that it ultimately causes the formation of an 
 external biliary jfistula ; or it may extend along the suspensory 
 ligament of the liver and the ligamentum teres, and infiltrate the 
 tissues in the region of the umbilicus. In other cases it becomes 
 adherent to some portion of the alimentary canal, especially the 
 duodenum or the hepatic flexure of the colon or the stomach, 
 and ulcerates through the walls of the viscus to which it has 
 become adherent, so as to establish a fistulous communication 
 between the cavity of the gall bladder and the lumen of the 
 alimentary canal. When the cancerous process invades the 
 tissues of the abdominal wall, it is not uncommon for an inflam- 
 matory condition to be induced, which causes the formation of 
 an abscess in connection with the gall bladder. 
 
 Treatment. — Since the diagnosis of the disease in the early 
 stages of its development is very difficult and often impossible, 
 it is not uncommon to find that when the nature of the affection 
 has been recognised it is too late to adopt any method of operat- 
 ive treatment which off'ers a fair chance of being followed by a 
 cure. If, however, the disease has been recognised before it has 
 spread extensively to the adjacent tissues, and before it has given 
 rise to the formation of secondary growths, an attempt should be 
 made to eff'ect its total removal. The entire gall bladder must 
 be removed, together with the adjacent portion of the liver 
 tissue if it is involved in the pathological process, and that 
 portion of the cystic duct which is attached to the gall bladder. 
 The method of carrying out this operation is described in the 
 chapters on Cholecystectomy and Eesection of the Liver, or 
 Hepatectomy. Hochenegg^ has removed a carcinomatous gall 
 bladder, together with the adjacent portion of the liver, and six 
 months afterwards the patient had not suffered from a recurrence 
 of the disease. Similar cases have been recorded by Czerny,^ 
 Winiwarter,^ Eiedel,* Bardenhauer,^ d'Autona,*^ and Lawson Tait'' ; 
 
 1 Hochenegg, Wi&n. klin. Wchnschr. , 1889, No. 12. 
 
 2 Czerny, Deutsche med. Wchnschr., Leipzig, 1893, No. 23. 
 
 3 Winiwarter, "Zur Chirurgie d. Gallenwege," Jubildums Festschrift gervidnet Th. 
 Billroth, 1892. 
 
 4 Riedel, op. cit. 
 
 5 Bardenhauer, Mitth. a. d. Koln. Burgerhosp., 1887. 
 
 6 d'Autona, Riforma med., Roma, 1888. 
 
 ~ Lawson Tait, Edin. Med. Journ., 1889, Oct. and Nov. 
 
2 6o NEOPLASMS OF THE GALL BLADDER. 
 
 but in none of these cases was a permanent cure effected, death 
 generally occurring within a few months of the operation, on 
 account of a recurrence of the disease. In many of these cases, 
 however, the disease had become somewhat advanced before an 
 operation was done. Carcinomata of the gall bladder appear in 
 most cases to grow rather slowly, and not to give rise to the 
 development of secondary metastatic growths in the early stages 
 of the disease ; hence, if a diagnosis can be made early when the 
 neoplasm is strictly localised, local extirpation may offer a fair 
 chance of recovery. In every case where it is thought that a 
 carcinoma of the gall bladder exists, — and this opinion is based 
 upon a fair amount of clinical evidence, — it is recommended that 
 an exploratory laparotomy should be performed at an early 
 period ; so that, if the diagnosis prove to be correct, a radical 
 operation can be carried out, which, it may be reasonably hoped, 
 will result either in a cure of the patient, or at least a consider- 
 able retardation of the progress of the disease. In those cases 
 in which secondary growths have developed, or in which the 
 primary affection has extended widely into the surrounding 
 tissues, no surgical operation is advisable, as it will probably not 
 prolong the Ufe of the patient, and, owing to the severity of 
 the procedure, it may be followed immediately by a fatal 
 termination. 
 
 Prognosis. — The duration of the disease in those cases which 
 have not been submitted to operation has varied within consider- 
 able limits, in the practice of different observers. Thus Stiller 
 says, from a study of five cases, that the affection usually lasts 
 from five to six years ; whilst Courvoisier^ and Musser- say that 
 it only lasts for a few months from the time it has been 
 diagnosed. From an investigation of ten cases which have come 
 under my own observation at different times, it appears that in 
 these patients the disease had a duration from a few months to 
 nearly two years, from the time when definite symptoms became 
 apparent. Hence, according to these statistics, Stiller puts the 
 duration too long, and Courvoisier and Musser too short. If the 
 affection can be recognised in the early stages of its development, 
 and appropriate surgical measures be at once adopted, it seems 
 possible that in the future much better results will be obtained 
 than has been the case in the past. 
 
 1 Couivoisier, op. cit. ^ Musser, oj}. cit. 
 
CHAPTER XX. 
 
 TUMOUES OF THE BILE DUCTS. 
 
 The bile ducts may become the seat of tumours which have their 
 commencement in the tissues forming the histological elements 
 of the duct walls. In the majority of instances these tumours 
 are malignant in character, and usually commence as an atypical 
 proliferation, either of the epithelium which forms the lining 
 membrane of the ducts, or of the secreting cells in the acini 
 of the mucous glands. A few cases have been met with in 
 which the growth appeared to be of a non-malignant nature. 
 
 Non-malignant Growths. — Wilks and Moxon ^ have de- 
 scribed a case of papilloma of the common bile duct which occurred 
 in a child tet. 4. The duct in this case was dilated so as 
 to have the form and shape of a large and somewhat spherical 
 cyst, which had a diameter of several inches, and to the internal 
 surface a large number of pedunculated structures were attached, 
 each one of these bodies consisting of myxomatous tissue and 
 a small amount of muscular fibres. Bennett and Eolleston ^ have 
 reported the case of a woman who suffered from a non-malignant 
 papilloma of the common bile duct, which was met with during 
 the performance of a cholecystotomy for the removal of a gall 
 stone which had been impacted in the common bile duct for 
 about two months. This growth was in close contact with 
 the calculus, and both were removed at the operation. At this 
 time the growth was supposed to be a papilloma, due to the 
 irritation of the gall stone. When this patient was seen a few 
 months afterwards, symptoms of the recurrence of the tumour 
 were present, but it was not possible to ascertain their exact 
 nature, as the patient passed from under observation. These facts 
 render it probable that in this case the tumour was either 
 malignant in character from the first, or that it commenced as a 
 
 1 Wilks and Moxon, "Pathological Anatomy," 1875, p. 465. 
 
 2 Bennett and Eolleston, Trans. Path. Soc. London, 1894, p. 83. 
 
262 TUMOURS OF THE BILE DUCTS. 
 
 simple papilloma, which at a later period took on malignant 
 characteristics. Simple fibromata do not appear to have been 
 met with as local tumours involving the lumen of the bile ducts. 
 In the post-mortem records of St. Bartholomew's Hospital I have 
 found a description of a localised tumour of the common bile 
 duct which was situated in the submucous tissue, and obstructed 
 the lumen of the duct owing to its projection inwards ; this 
 growth was said to be a gumma. The symptoms which are 
 dependent upon the presence of a non-malignant tumour of the 
 bile duct are not sufficiently characteristic to enable the surgeon 
 to diagnose its existence before an ocular examination of the 
 affected portion of the duct can be made through an abdominal 
 incision. 
 
 Malignant Growths. — As we have already mentioned, these 
 growths are very much more commonly met with than the non- 
 malignant varieties. They are, however, somewhat rare in their 
 occurrence. A primary carcinoma of the bile ducts may com- 
 mence in any part of the ducts between the biliary papilla, 
 where the common duct opens into the second portion of the 
 duodenum, and the commencement of the ducts within the 
 hepatic substance. When the growth has its origin within the 
 liver, the affection resembles a primary carcinoma of that organ, 
 but on examination the tumour is found to have the structure of 
 a columnar-celled carcinoma. The common bile duct is most 
 frequently the seat of the affection, especially in that section 
 which lies in close connection with the duodenum and in the 
 ampulla of Yater, and also at the junction of the cystic and 
 common hepatic ducts. Occasionally that portion of the com- 
 mon bile duct which lies within the gastro-hepatic omentum is 
 the seat of the commencement of the affection. Very rarely 
 only one of the hepatic ducts or the cystic duct has been first 
 involved. According to the statistics of Musser,-^ which refer to 
 a collection of eighteen cases, the common bile duct was affected 
 in fourteen cases, the hepatic ducts in three cases, and the cystic 
 and hepatic ducts in one case ; whilst in the eleven cases which 
 have been collected by Dr. Kolleston the common bile duct was 
 the seat of the primary affection in all. In one case which 
 occurred in St. Bartholomew's Hospital, the carcinoma appeared 
 to have taken its origin in the epithelium of the cystic duct. 
 
 1 Muxser, "Primary Cancer of the Gall Bladder and tlie Bile Ducts," Boston Med. 
 and .S'. Joiirn., Dec. 5, 1889. 
 
MALIGNANT GROWTHS. 263 
 
 In some of the cases which have been recorded the tumour 
 has appeared to have commenced either underneath the mucous 
 membrane or in its deeper layers, and in the earlier stages 
 of development to have had the form of a small flattened mass, 
 round or oval in outline, situated in the wall of the duct, and 
 covered on its surface with mucous membrane. Usually, how- 
 ever, the tumour grows directly from the surface of the mucous 
 membrane lining the interior of the diseased bile duct, and tends 
 to cause partial or complete obliteration of the lumen of the 
 duct owing to the blocking up of the canal with the new growth. 
 The carcinomatous infiltration tends to implicate the entire 
 circumference of the duct, and hence to cause the formation of an 
 annular constriction, and to spread along the long axis of the 
 duct, either in the submucous layer or in this layer as well as the 
 muscular coats which have also become affected. In the earlier 
 stages of the disease the carcinomatous infiltration tends to 
 be limited to the tissues which form the walls of the bile ducts, 
 and it is only later that the surrounding tissues become invaded 
 by a direct extension of the pathological process. The primary 
 growth does not usually attain a very large size, in many cases 
 not being greater than a hazel-nut or a walnut. When the 
 growth commences in the cystic duct it may extend into and 
 infiltrate the adjacent portion of the liver ; and when that 
 portion of the common bile duct which lies close to the 
 duodenum is the first to be affected, the disease may spread 
 to this portion of the intestine and to the head of the pancreas. 
 In those rare cases in which the tumour is localised to that 
 portion of the common bile duct which lies within the gastro- 
 hepatic omentum, the portal vein may become invaded, owing 
 either to infiltration of the carcinomatous elements or to direct 
 pressure of the malignant mass from without, and as a result 
 ascites may be induced. In those cases of carcinoma of the 
 gall ducts which have been examined microscopically, the 
 growth has been found to have either the structure of a columnar- 
 celled epithelioma or that of a spheroidal-celled carcinoma. 
 The former variety is by far the most common, and, according to 
 Musser,^ all his eighteen cases were of this nature. Dr. 
 Eolleston's ^ list of eleven cases contains nine in which it is 
 
 1 Musser, op. cit. 
 
 2 Rollestou, "Primary Carcinoma of the Larger Bile Ducts," Med. Chron., Man- 
 chester, Jan. 1896. 
 
264 
 
 TUMOURS OF THE BILE DUCTS. 
 
 expressly stated that the tumour had the structure of a 
 cylindrical-celled growth. Carcinomatous growths of the head 
 of the pancreas, of that portion of the duodenum which is in 
 the neighbourhood of the biliary papilla, and also of the ampulla 
 of Vater, and the duct of Wirsung, may, when present, give 
 rise to a clinical condition which in almost every respect 
 resembles that which is due to the presence of primary 
 
 Fig. 40. — Carcinoma of the common bile duct. The interior surface of the liver 
 showing a new growth springing from the raucous membrane of the common 
 bile duct. Immediately below the junction of the cystic with the common 
 heijatic duct, the common bile duct is blocked by an annular-shaped mass 
 of soft, whitish new growth. Microscopically, the neoplasm was found to 
 be an encephaloid carcinoma. — Ht, Earth. Hosp. Museum. 
 
 malignant disease of the common bile duct. When the affection 
 commences in the head of the pancreas it has the structure 
 of a spheroidal-celled carcinoma, and hence can usually be 
 distinguished when a histological examination has been made. 
 The symptoms are very similar, but the disease of the pancreas 
 does not always cause complete obstruction to the flow of 
 the bile into the duodenum, although in most cases it gives rise 
 to an obliteration of the common bile duct, either by direct 
 
MALIGNANT GROWTHS. 
 
 265 
 
 infiltraticdi or by pressure from without. Fig. 41 is an illustra- 
 tion of a malignant growth of that portion of the duodenum 
 which surrounds the biliary papilla ; it appears to grow from the 
 mucous membrane of the 
 intestine. The patient was a 
 woman, fet. 27, who was 
 intensely jaundiced for three 
 months before her death, and 
 for the nine days which pre- 
 ceded her death she suffered 
 from copious haemorrhages 
 from the gums, nose, and in- 
 testines. When the carcinoma 
 commences in the neighbour- 
 hood of the ampulla of Vater 
 and the duct of Wirsung, it 
 is practically impossible to 
 distinguish it from a similar 
 growth from the lowest por- 
 tion of the common bile duct, 
 which has extended down- 
 wards and affected these por- 
 tions of the biliary canal. 
 This form of growth may 
 extend to the head of the 
 pancreas, in which case on 
 microscopical examination it 
 will be found to have the 
 structure of a cylindrical- 
 celled epithelioma. When 
 secondary deposits develop, 
 they are met with most com- 
 monly in the liver or in the 
 lymphatic glands which nor- 
 mally exist in the gastro- 
 hepatic omentum and in the 
 
 Fig. 41. — Carcinoma of the aperUire of the 
 commou bile duct. Portion of a duodenum 
 cut open, so as to show a small, soft 
 medullary tumour, papillomatous in ap- 
 pearance, surrounding and closing the 
 orifice of the common bile duct. The 
 tumour has grown from the mucous mem- 
 brane, and has the structure of a columnar- 
 celled carcinoma. — St. Barth. Hosp. 
 Mxiseum. 
 
 portal fissure of the liver. 
 
 In rarer instances they' may appear in the adjacent peri- 
 toneum, the gall bladder, and the suspensory ligament of 
 the liver, and at the umbilicus. Gall stones do not occur 
 so commonly in cases of carcinoma of the bile ducts as in 
 
2 66 TUMOURS OF THE BILE DUCTS. 
 
 similar affections of the gall bladder. In the eighteen cases 
 which have been referred to by Musser,^ calculi were present 
 seven times ; and in the eleven cases which have been collected 
 by Dr. Eolleston,^ they were met with on four occasions. It is 
 probable that the formation of the cancerous growth is not 
 directly dependent upon the existence of gall stones, although 
 they may in some cases act as a predisposing cause. 
 
 8ex. — Carcinomatous affections of the bile ducts do not 
 appear to occur more commonly in one sex than the other. 
 According to Musser's list of eighteen cases, the disease affected 
 the sexes in equal proportions, whilst in Dr. Eollestori's 
 table of eleven cases six were males and five females. The 
 disease affects, for the most part, middle-aged and old people, the 
 commonest decade being 50—60, but occasionally cases have 
 occurred in persons between 20 and 30. 
 
 Symptoms. — The symptoms of malignant disease of the bile 
 ducts in the early stages are usually very obscure, and not 
 sufficiently definite to justify a diagnosis of the existence of the 
 affection. In those cases in which the common hepatic duct or 
 the common bile duct is the seat of the primary affection, the 
 first symptoms which become manifest are those which are 
 dependent upon an obstruction to the free flow of bile along the 
 main channels into the intestine. These symptoms may be 
 preceded by the occurrence of indefinite pains in the epigastric 
 or right hypochondriac region, and even on both sides of the 
 middle line. According to Head,^ the " visceral area " which 
 corresponds to the gall bladder and the common bile duct is 
 that of the eighth dorsal segment. When an obstruction to the 
 passage of bile along the common bile duct has been established, 
 jaundice becomes a prominent symptom, and gradually increases 
 in intensity as the disease progresses, until the skin of the 
 patient assumes a dark green or even almost a black colour. 
 Occasionally when the growth presses upon the duodenum or the 
 stomach, attacks of nausea and vomiting appear, and may be very 
 troublesome phenomena. As the obstruction in the bile duct 
 becomes complete, in addition to the increasing intensity of the 
 jaundice, there is a disappearance of bile from the alimentary 
 canal, so that the stools become clay- coloured. At the same time 
 bile pigments can be recognised in the urine, and a constant 
 
 1 Musser, op. cit. - Rolleston, o/j. cit. 
 
 3 Head, Brain, Londou, 1893, p. 75. 
 
SYMPTOMS. 267 
 
 itching of the skin often becomes manifest, and is a source of 
 much annoyance to the patient. Constipation and symptoms of 
 gastro-intestinal disturbance are not uncommon in this stage, 
 whilst haemorrhages, which may be subcutaneous, submucous, or 
 in the tissues, may occur. Attacks of pain also occur, but as a rule 
 do not have the paroxysmal character of the hepatic colic which 
 is due to the presence of gall stones, although in some cases 
 where a calculus is also present in the duct such a condition 
 may happen. Ascites develops when the portal vein is pressed 
 upon by the tumour or directly involved in the growth. When the 
 obstruction is complete the bile collects in the bile ducts which are 
 proximal to the tumour, and in the gall bladder and liver, so as to 
 cause a. distension of the gall bladder with bile, and the production 
 of a smooth swelling in the right hypochondriac region, and also 
 an enlargement of the liver, which extends downwards below the 
 costal margin for a variable distance, where it is demonstrable to 
 palpation. If the cystic duct is the seat of the primary growth, 
 a condition which is of very rare occurrence, jaundice is not 
 usually present in the early stages, and only appears when the 
 tumour has extended to the common bile duct or the hepatic 
 ducts, or these structures have been pressed upon from without. 
 As the disease progresses the patient loses weight, owing to a 
 general wasting of the tissues, and muscular weakness appears, 
 together with the signs of general cachexia. The primary 
 growth cannot, in most cases, be distinguished as a definite 
 abdominal tumour, on account of its small size and the depth 
 from the surface at which it is placed. In the later stages, 
 when secondary deposits occur in the liver or in the lymphatic 
 glands in the portal fissure, it may be possible to distinguish 
 these tumours as swellings in connection with the liver, but in 
 most of the cases which have been recorded the occurrence of 
 tumours of this kind does not appear to have been noticed. I 
 have seen one case in which the growth appeared to have com- 
 menced in the cystic duct, and to have spread thence to the 
 liver, and so caused the formation of a tumour which could be 
 felt during life as a distinct prominence attached to the liver, 
 immediately below the costal margin to the right of the middle 
 line. The pulse is said to be slowed in these affections, owing to 
 the absorption of large quantities of the bile salts. When the 
 obstruction has existed for some time, poisoning with the sub- 
 stances of the bile, or what has been called biliary toxaemia or 
 
2 68 TUMOURS OF THE BILE DUCTS. 
 
 cholffimia, becomes apparent, and all the general symptoms 
 become more marked. In the final stages, coma, delirium, and 
 general exhaustion usually usher in the fatal termination. 
 Death appears to be due much more to the poisoning which 
 results from the continued retention of the biliary substances, 
 than from the absorption of deleterious materials from the 
 primary or secondary growths. In one case which has been 
 recorded by Coats and rinlayson,^ extreme distension of the gall 
 bladder with bile occurred, and this was followed by ulceration 
 and rupture of the viscus, with escape of the contents into the 
 peritoneal cavity and the development of peritonitis, which 
 terminated in death. 
 
 i?t!a^?iosis.— Carcinoma of the head of the pancreas, and 
 chronic jaundice due to an impacted gall stone in the common 
 bile duct, are the most usual pathological and clinical conditions 
 which are liable to be confused with carcinoma of the common 
 bile duct or the hepatic ducts, whilst carcinoma of the cystic 
 duct may, in its symptoms, resemble carcinoma of the gall 
 bladder. Jaundice which is due to a catarrhal condition of the 
 bile ducts, and the later stages of carcinoma of the gall bladder, 
 when the primary growth has extended to the common bile duct, 
 may also require to be taken into consideration in making a 
 diagnosis. In those cases of chronic jaundice which are due to 
 the impaction of a gall stone, there can usually be obtained a history 
 of the occurrence of biliary colic, occurring either immediately 
 before the commencement of the attack of jaundice, or at some 
 previous period when a similar, though less severe, attack of 
 jaundice resulted. The occurrence of biliary colic is not, 
 however, a definite indication that the disease is due to the 
 presence of a gall stone alone, since in a certain number of cases 
 of carcinoma of the bile ducts biliary calculi are found to be 
 present, whilst a patient may be the subject of an impacted gall 
 stone without any signs of colic becoming manifest, and slight 
 attacks of colicky pains may occur in a case of carcinoma of the 
 bile ducts. When a well-marked attack of biliary colic 
 immediately precedes the development of jaundice, it may be 
 concluded that in all probability the jaundice is due to the 
 impaction of a gall stone in the common bile duct or in the 
 common hepatic duct ; and if there is a distinct history that 
 the patient at former periods has been the subject of gall 
 
 1 Coats and Finlayson, Ulasgoio Med. Journ., 1890, vol. ii. p. 84. 
 
DIAGNOSIS. 269 
 
 stones, a similar conclusion will be justifiable in most cases. 
 When, however, the attack of jaundice is not preceded by 
 these conditions, the condition of the alimentary canal should 
 be carefully investigated, in order to eliminate as far as 
 possible the occurrence of catarrhal jaundice. The appearance 
 of an attack of catarrhal jaundice is usually preceded by 
 symptoms of gastro-intestinal disturbance, such as diarrhoea and 
 vomiting, and the attack in most cases passes off in a few weeks, 
 or occasionally in even a shorter time, so that it ought not to be 
 difficult to differentiate between an attack of jaundice of this 
 kind and one which is due to malignant disease of the bile ducts. 
 The duration of the attack of jaundice is of much importance in 
 the diagnosis between obstruction which is due to malignant 
 disease, and that which is due to an impacted gall stone. In 
 the former case the affection rarely lasts more than a few 
 months before terminating fatally, whilst in the latter it 
 may last for a much longer time, even years, before a fatal result 
 follows. When this does occur, it is generally due either to an 
 intercurrent affection or to some complication, and not to chronic 
 poisoning with bile. The obstruction in these cases does not 
 remain complete, and, after the impaction of the calculus has 
 existed for some time, the duct becomes dilated, so as to allow 
 the passage of a small quantity of bile into the intestine, and in 
 some cases the jaundice may either vanish partially or almost 
 completely. In those cases which are due to a primary 
 carcinoma of the head of the pancreas, it is occasionally possible 
 to distinguish a tumour situated upon the posterior wall of the 
 abdomen and in the epigastric region, but in people with thick 
 abdominal walls this is exceedingly difficult. When jaundice 
 occurs in this class of disease, it has the characteristics of that 
 which is due to obstruction of the common bile duct with a 
 carcinomatous tumour, but occasionally it is found to be absent. 
 The pain which is associated with a pancreatic tumour tends to 
 be located in the epigastric region, but this is not constant, 
 owing to the fact that the affection so commonly spreads to the 
 common bile ducts, and gives rise to the appearance of pain in 
 the right hypochondrium. Carcinoma of the gall bladder appears 
 to be more commonly the cause of the development of secondary 
 growths in the liver than when the bile ducts are the seat of the 
 primary disease. The tumour of the head of the pancreas may 
 press upon or invade the duct of Wirsung, and cause an obstruc- 
 
2 70 TUMOURS OF THE BILE DUCTS. 
 
 tion to the passage of the pancreatic secretion into the duodenum, 
 in which case an excess of fat is said to be found in the faeces. 
 Other diseases may be the cause of the appearance of chronic 
 jaundice, such as cancer of the pyloric portion of the stomach, 
 secondary malignant growths in the lymphatic glands, in the 
 gastro-hepatic omentum, or the portal fissure of the liver, or in 
 the liver itself ; inflammatory conditions of the liver which are 
 followed by the production of scars, such as tertiary syphilis, 
 and cystic and other tumours of the liver or the neighbouring 
 structures, which, by their size, cause compression of the common 
 bile duct and obstruction to the free passage of the bile. Cases 
 of aneurism of the hepatic artery and the upper portion of the 
 abdominal aorta have been known to act in this manner. It can 
 be said that chronic persistent jaundice occurring in middle-aged 
 or old people, which gradually increases in intensity, is in almost 
 half the cases due to some form of malignant disease. 
 
 Treatment. — On account of the great difficulty which is 
 experienced in making a correct diagnosis in the early stages 
 of carcinoma of the larger bile ducts, it is not possible in the 
 majority of cases for surgery to offer any strong hope that a 
 cure will be effected as the result of the performance of 
 operative measures. When a patient has suffered from chronic 
 jaundice for a considerable period, the tissues do not appear to 
 be very tolerable of surgical interference. In one case of this 
 kind which I recently operated upon, haemorrhage followed 
 which was very difficult to arrest ; but in a second case in which 
 an exploratory laparotomy was performed, the abdominal wound 
 healed in a few days without any unpleasant symptoms occur- 
 ring. When it appears probable that a localised carcinomatous 
 affection of the common bile duct exists, and there are no 
 manifestations of the presence of secondary growths, and the 
 patient is in other respects a fair subject for the performance 
 of an operation, an exploratory laparotomy should be carried out, 
 so that the course of the bile ducts may be examined digitally 
 and visually. In most cases of this kind it is found advisable 
 to make the abdominal incision in the linea alba and above the 
 umbilicus. If the cystic duct is found to be the seat of the 
 growth, that portion of the duct which is implicated together 
 with the gall bladder should be removed ; and if the liver is 
 found to be affected owing to a slight extension of the carcino- 
 matous process, the involved part should be resected, if this 
 
TREATMENT. 271 
 
 can be done with safety, and there are no signs of secondary 
 deposits in other parts of the organ. In those cases in which 
 the common bile dact is found to be the seat of the disease, 
 the affected portion should be excised and the ends closed with 
 sutures. The fundus of the gall bladder is afterwards made to 
 communicate with the duodenum or other portion of the intes- 
 tine by the performance of a cholecystenterostomy. Usually, 
 however, it is not possible to remove the diseased portion of 
 the common bile duct, owing to the fact that the adjacent 
 structures are infiltrated with the growth and cannot be removed. 
 The method of treatment which is advisable in these cases consists 
 in the establishment of a communication between the gall 
 bladder and the alimentary canal. By this means the continua- 
 tion of the condition of cholaemia will be avoided at least for 
 a time, and life will in all probability be prolonged. If the 
 carcinomatous process is found to have commenced in the 
 common hepatic duct, or in the cystic duct at its junction with 
 the common bile duct, it is not possible to perform an opera- 
 tion which will be of any avail. When the growth involves 
 the head of the pancreas, and invades the common bile duct, it 
 is not advisable to attempt the local removal of the growth, on 
 account of the deep and important anatomical connections, and 
 the impossibility of removing the entire disease. In these cases, 
 also, it is only possible to perform the palliative operation of 
 cholecystenterostomy. This operation has been followed in 
 such patients by very fatal results in the past, and therefore 
 some surgeons think that its performance is imjustifiable. In 
 one case of this kind, where I performed a cholecystenterostomy 
 for the temporary relief of a patient who was suffering from 
 chronic cholaemia, the result of an obstruction of the common 
 bile duct by a cancerous growth in the head of the pancreas, 
 the patient died ten days afterwards, owing to constant haemor- 
 rhage from the line of adhesion after a Murphy's button had 
 separated. As this method of treatment, however, is the only 
 one which offers any chance to the patient of the prolongation 
 of life, I think that it is to be recommended, especially in 
 those cases in which the jaundice has not lasted for a very long 
 time. If, after the abdomen has been opened and examined, the 
 obstruction is found to be due to the impaction of a biliary 
 calculus, it should be removed in the manner which has been 
 described in the chapter on Cholelithiasis. 
 
2 72 TUMOURS OF THE BILE DUCTS. 
 
 Prognosis. — In most of the cases of malignant disease of 
 the bile ducts which come under observation, the prognosis is 
 very unfavourable. The patients usually die within a few 
 months from the time when the disease has become thoroughly 
 established. Life may be prolonged for some time in those 
 cases in which it is found possible to perform a palliative 
 cholecystenterostomy. In one case of this kind which has 
 been recorded by Eeclus, the patient lived for twenty-one 
 months after the fistulous communication had been established, 
 and similar cases have been met with by Murphy of Chicago. 
 It is possible that in the future, if more attention is paid to 
 the diagnosis of the disease in its early stages of development, 
 and appropriate surgical measures are at once adopted for its 
 cure, the prognosis will not be so unfavourable as it is con- 
 sidered at the present time. 
 
CHAPTER XXL 
 
 SUBPHRENIC OR SUBDIAPHRAGMATIC ABSCESS. 
 
 SuBPHEENic or subdiaphragmatic abscess is an affection which 
 is characterised by the development of a localised collection of 
 pus, or pus and gas, between the lower surface of the diaphragm 
 and the adjacent surface of the liver. As we have seen in the 
 section which is devoted to anatomy that the liver is not com- 
 pletely covered with peritoneum, and that the greater portion of 
 the uncovered area lies in close relation with the inferior aspect 
 of the diaphragm, it necessarily follows that an abscess .within 
 the limits mentioned may be formed in connection with the 
 peritoneal cavity, as a localised purulent peritonitis ; or it may 
 arise in the extraperitoneal tissues, and be limited as regards its 
 hepatic boundary to that portion of the surface of the liver which 
 is destitute of a peritoneal covering. Thus there are two varieties 
 of subdiaphragmatic abscess, one being called intraperitoneal and 
 the other extraperitoneal. In the former variety the internal 
 surface of the abscess wall is covered at first with a layer of 
 endothelium which represents the endothelium of the serous 
 membrane, and in the latter the inner surface of the abscess is 
 connective tissue which represents subperitoneal tissue, the fascia 
 covering the lower aspect of the diaphragm or the fibrous tissue 
 capsule of the liver. The intraperitoneal variety is more fre- 
 quently met with than the extraperitoneal. In most cases the 
 right lobe of the liver is the inferior boundary of the abscess, 
 but in a certain number of cases the affection is confined to the 
 superior aspect of the left lobe, whilst occasionally both lobes 
 are involved. When both lobes form part of the boundaries of 
 an abscess the affection is usually extraperitoneal, although in 
 rare instances it may be intraperitoneal, and the inflammatory 
 process then spreads through the suspensory ligament, which 
 divides the upper aspect of the liver into right and left lobes. 
 Etiology. — An abscess between the diaphragm and the liver 
 
2 74 SUBPHRENIC ABSCESS. 
 
 may result from a variety of pathological causes. In the majority 
 of cases it is due to the extension of an inflammatory process 
 from a focus of disease in one of the adjacent viscera, but occa- 
 sionally distant viscera may be the seat of the primary affection. 
 The pathological causes of the disease may be arranged in the 
 following groups, viz. : — 
 
 (1) Cases clue to traumatic causes. — Injuries which result in 
 the establishment of a subdiaphragmatic abscess are either 
 penetrating or non-penetrating. When the hepatic region is 
 the seat of an injury, it may happen that a contusion or small 
 rupture of the liver is produced, and this is followed by haemor- 
 rhage, and at a later period suppuration occurs. This is probably 
 due to the activity of micro-organisms which have been carried 
 to the seat of injury by the blood stream, or have passed there 
 directly from the neighbouring portion of the alimentary canal. 
 The impaired vitality of the injured tissues and the presence of a 
 blood clot favour the growth and multiplication of the micro- 
 organisms of suppuration when they have once efiected an 
 entrance. In several recorded cases a small rupture of the 
 upper portion of the spleen has been the cause of a subdia- 
 phragmatic abscess, owing to the development of a localised col- 
 lection of blood in the region of the liver, and subsequent 
 suppuration. Blows and kicks in the hepatic region, falls from 
 a height, crushes of the abdomen, as in buffer accidents, and 
 contusions from spent cannon balls, have all been the cause of 
 the formation of an abscess in the subphrenic region. Perforat- 
 ing wounds of the thoracic or abdominal wall, which lead 
 inwards to the subdiaphragmatic space, may be succeeded by 
 the establishment of a subdiaphragmatic abscess, and when this 
 occurs it is usual for the wound to be infected by the micro- 
 organisms of suppuration, either at the time of reception of the 
 injury or very shortly afterwards. Most of the recorded cases 
 of this nature have been caused by gun-shot wounds or by stabs 
 with a sharp instrument, and the liver or one of the thoracic 
 viscera has also been injured. 
 
 (2) Gases due to patJiological conditions of some portion of the 
 alimentary canal. — {a) The stomach. — The stomach has been 
 found, in a considerable number of cases, to have been the 
 starting-point in the development of a subdiaphragmatic abscess. 
 Chronic gastric ulcers, which are non-malignant in character, 
 have been found to be more commonly the cause than those 
 
ETIOLOGY. 275 
 
 which are malignant. The ulcer extends through the walls of 
 the organ, often causing adhesions between the walls and the 
 adjacent structures, especially the posterior aspect of the anterior 
 abdominal wall ; and a perforation is estEiblished which is followed 
 by inflammation and suppuration, and the formation of a localised 
 collection of purulent material between the lower surface of the 
 diaphragm and the superior aspect of the liver, stomach, or 
 adjacent structures. The perforation may become closed after 
 the inflammation has extended to the under surface of the 
 diaphragm, the hole being represented only by a small scar, in 
 which case the resulting abscess will contain only fluid matter. 
 If the perforation remains open, the resulting abscess will contain 
 a quantity of air or gas in addition to purulent matter. In some 
 cases an abscess contains gas which does not come from the 
 lumen of the stomach, but is produced by the agency of gas- 
 producing micro-organisms. Cases have been recorded in which 
 it seems probable that an ulcer of the stomach has been the 
 cause of the development of a subdiaphragmatic abscess, owing 
 to the absorption of septic material from the ulcerative surface 
 and its conveyance by lymphatic channels, but in the majority of 
 these cases a perforation has taken place and infective material 
 has passed from the cavity of the stomach into the surrounding 
 tissues. The formation of adhesions and subsequent perforation 
 may occur on either the anterior or posterior aspects of the 
 stomach. When the ulcer of the stomach is situated on the 
 posterior aspect, adhesions take place between the stomach and 
 the peritoneum forming the posterior boundary of the lesser sac, 
 and the development of the abscess commences on the posterior 
 abdominal wall in the region of the postero-inferior border of 
 the liver. 
 
 (&) Tlu duodenum. — Ulcers of the duodenum or the pylorus 
 may perforate the wall of the intestine and become the cause 
 of the formation of a subdiaphragmatic abscess in a manner 
 which is similar to that of ulcers of the stomach. When the 
 duodenum is the seat of the perforation it is usual for the result- 
 ing abscess to be developed upon the right side, but when the 
 abscess is extraperitoneal it extends to both sides of the middle 
 line ; this condition was observed recently in a case which I saw 
 in St. Bartholomew's Hospital. Ulcers of the duodenum which 
 are followed by subdiaphragmatic abscess, are usually situated in 
 the upper portion and not in that part which lies below the 
 
2 76 SUBPHRENIC ABSCESS. 
 
 pancreas. A case has been recorded by Maydl in which a 
 foreign body perforated the wall of the duodenum and caused 
 a subdiaphragmatic abscess. In the remaining recorded cases a 
 non-malignant perforating ulcer has been the cause. When 
 rupture of the duodenum occurs owing to some form of 
 mechanical injury, the lower portion of this section of the intes- 
 tine is injured, and if extravasation of the contents takes place, 
 an abscess is formed which tends to spread downwards and not 
 into the subphrenic region. 
 
 ((?) The small intestine (beyond the duodenum). — This portion 
 of the alimentary canal rarely becomes the cause of the develop- 
 ment of a subdiaphragmatic abscess, but a case has been recorded 
 by Blocq where an ulcer of the lower part of the ileum in 
 typhoid fever was the direct cause of an abscess of this kind. 
 
 {d) The large intestine. — The caecum and the vermiform 
 appfendix are frequently the seat of ulceration and perforation, 
 which are followed by appendicitis or perityphlitis, and these 
 conditions have, in many cases, been the cause of the formation 
 of subdiaphragmatic abscesses. It has been shown by the experi- 
 ments of Sanger, that material which has been injected into the 
 tissues which lie behind the caecum tends to extend upwards 
 behind the ascending colon and in front of the right kidney until 
 it reaches the subphrenic space of the right side. Collections 
 of fluid in the retrocecal region were shown also to have little 
 tendency to pass downwards into the inguinal canal or into the 
 transverse mesocolon and the mesentery. These experiments 
 of Sanger showed that the region of the caecum, the ascending 
 colon, and the duodenum, were the parts of the intestinal canal 
 which would in all probability, when the seat of perforative 
 affections, be the starting-points in the development of a sub- 
 phrenic al;)scess, and such, in fact, has been found to be the case 
 clinically. Ulceration and perforation of the descending colon or 
 of the transverse colon are much less frequently the cause of a 
 subphrenic abscess. 
 
 (3) Cases ivhich are due to 'pO'thological conditions of the kidney 
 and perinephric tissues. — The kidney is normally situated in the 
 lumbar region, and has the colon lying directly in front of it. 
 When the viscus itself is the seat of a suppurative affection, the 
 perinephric tissue which surrounds it becomes involved in most 
 cases, and when this occurs it follows that the collection of pus 
 will tend to track upwards into the subphrenic space and thus 
 
ETIOLOGY. 277 
 
 become the cause of the establishment of an abscess in this 
 region. A number of cases have been recorded in which the 
 sequence of events has been as above. Cases have also been 
 recorded in which the kidney has been injured by traumatism, 
 haemorrhage has followed into the perinephric tissue, and later 
 the collection of blood has become infected with the micro- 
 organisms of suppuration, and an abscess has been produced 
 which has extended upwards and involved the subphrenic 
 space. Calculi of the kidney, tuberculosis and suppurative 
 processes in the kidney, which have spread from the lower portions 
 of the urinary passages, have been noted as the causes of a sub- 
 phrenic abscess. 
 
 (4) Cases ivhich are due to inflammatory affections oftlicgall Mad- 
 der or liliary ducts. — The fundus of the gall bladder lies in close 
 relation to the posterior aspect of the ninth costal cartilage and 
 the diaphragm which is attached to it. When it becomes the 
 seat of gall stones and inflammation, the viscus may become fixed 
 to the diaphragm, and if perforation occur, the extravasated 
 material will tend to pass into the subphrenic space and start 
 the development of an abscess. In a similar manner, when the 
 intra-hepatic bile ducts are involved in a suppurative process, 
 one of them may become dilated and burst upwards upon the 
 superior or anterior aspect of the liver, and give rise to a like 
 state of affairs. A suppurative inflammation of the extra-hepatic 
 bile ducts may also be followed by rupture and the formation of 
 a subphrenic abscess. 
 
 (5) Cases lohich are due to affections ivithin the thorax. — 
 Localised collections of pus in the lower portions of a pleural 
 cavity, especially the right, as well as gangrene or chronic tuber- 
 culosis of the base of a lung, have been the cause of the develop- 
 ment of a subphrenic abscess, owing to perforation of the 
 diaphragm and direct extension of the inflammatory process. 
 When the lungs are the seat of the primary affection, perfora- 
 tion of the diaphragm is preceded by adhesive inflammation 
 of the pleura covering the base of the lung and the upper 
 surface of the diaphragm. Suppurative conditions of the peri- 
 cardium are so soon fatal that they do not exist long enough 
 before death to cause perforation of the diaphragm and sub- 
 phrenic abscess. 
 
 (6) Cases which are due to caries of the overlying ribs or 
 costal cartilages. — Tubercular disease of one of the ribs or costal 
 
2 78 SUBPHRENIC ABSCESS. 
 
 cartilages which He in relation with the diaphragm may be the 
 exciting cause of a subphrenic abscess. Maydl ^ and Lannelongue 
 have recorded such cases, but it is exceedingly rare. 
 
 (7) Cases which are clue to siq^^^uintiooi in hydatid cysts. — 
 Hydatid cysts which are situated in the subphrenic space, or, in 
 rarer cases, in the liver immediately underneath the capsule, may 
 become the seat of suppuration, and become converted into a fluid 
 swelling which has all the symptoms of a subphrenic abscess. 
 Maydl, in his work on subphrenic abscess, has collected seven- 
 teen of these cases from surgical literature, and he also gives 
 details of them. In some of the recorded cases the hydatid cyst 
 has been situated between the lower surface of the left side of 
 the diaphragm and the upper aspect of the spleen or the left 
 kidney, and then the resulting abscess has been usually limited 
 to the left side of the body. 
 
 (8) Cctses which are due to metastatic causes. — Metastasis is 
 a frequent cause of the development of a subphrenic abscess. 
 It is observed more frequently in tropical countries, this increased 
 frequency being associated with the more common occurrence of 
 dysentery. In this country, however, this form of abscess is not 
 very uncommon, as during the past few years I have seen two 
 cases which have arisen in this manner. In the majority of 
 cases which arise as a result of metastasis, it is found that the 
 abscess is secondary to an ulcerative affection of some portion of 
 the abdominal or pelvic part of the alimentary canal. I have 
 seen one case in which the affection followed an ulceration of 
 the vermiform appendix, and another in which it followed a 
 secondary pyaemic abscess of the liver. Abscess of the spleen, 
 suppurative processes in the mesentery, and fistula in ano, have 
 been noted as causes of metastatic subphrenic abscess, and also 
 general pysemic conditions. The pus from some of these cases 
 has been examined, and in it have been found the various micro- 
 organisms of ordinary suppuration, and in the cases which have 
 followed dysentery the amoebae coli are said to have been seen. 
 Cases have also been recorded in which septic and suppurative 
 affections of the female pelvic generative organs have been the 
 primary causes of the development of subphrenic abscesses. 
 
 Nearly all cases of subphrenic abscess will be found to fall 
 under one or other of the above classes, but there are occasional 
 examples of the disease in which the exact pathology of the 
 
 1 Mayt.ll, " Ueber subphrenische Abscesse," 1894. 
 
E TIOL O G Y—S YMPTOMS. 279 
 
 affection does not appear clear, and the case cannot be grouped 
 in one of the above classes. 
 
 Maydl in his work has collected from surgical literature 179 
 cases of subphrenic abscess, and of these seventy-three were due 
 to affections of the alimentary canal, twenty-four to traumatic 
 causes, twenty to affections of the biliary system, seventeen to 
 hydatid cysts, eleven each to perinephritic and metastatic causes 
 respectively, nine to thoracic diseases, three to caries of the ribs, 
 and eleven in which the cause was either uncertain or was due 
 to causes other than the above. I have examined the records 
 of St. Bartholomew's Hospital for the past ten years, and have 
 found that ten cases have occurred. Carl Beck ^ has recently 
 recorded four fresh cases of this affection. 
 
 Symjjtoms. — The onset and development of a subphrenic 
 abscess may be either gradual or sudden. When gradual, the 
 symptoms are usually indefinite, and the early manifestations of 
 the disease are attributed to indigestion or slight gastric or bilious 
 affections. The adjacent pleura in many cases becomes the seat 
 of a pleurisy, and, on auscultation, friction sounds can be heard 
 in the region of the base of the lung, and at the same time the 
 patient complains of pain localised to the lower part of the 
 thorax, and worse during the movements of respiration. In 
 other cases pain may be felt over the apex of the right shoulder, 
 and this when present is said to be a referred pain due to 
 irritation of the sensory branches of the phrenic nerve, which 
 come from the third and fourth cervical nerves, whilst the 
 sensory nerve to the shoulder comes from the same place. 
 Cough may be noticed as a frequent and somewhat distressing 
 symptom. The temperature is in many cases raised, and tends 
 to be " hectic " in character. When the onset of the affection is 
 sudden, it is most usually due to the perforation of one or other 
 of the abdominal viscera, and is associated with an attack of 
 violent localised abdominal pain. This is due in most cases to 
 the rupture of an ulcer of the stomach or duodenum, or to the 
 rupture of a collection of pus in the csecal or perinephric region. 
 When the abscess is due to traumatism, a distinct history of 
 this can generally be obtained. The attack of pain which 
 accompanies the rupture may be localised in one or other 
 hypochondriac region, or it may tend to spread over the whole 
 abdominal area, in which case it will suggest the occurrence of 
 
 1 Carl Beck, Med. Rec, N. Y., 1896, Feb. 15. 
 
28o 
 
 SUBPHRENIC ABSCESS. 
 
 perforative peritonitis. In cases of subphrenic abscess, the 
 tenderness of the abdominal area which follows the rupture, 
 soon becomes localised to the subdiaphragmatic region. Vomit- 
 ing is frequently met with in cases which are due to rupture 
 or perforation. When a subphrenic abscess is secondary to a 
 primary affection elsewhere, it is not uncommon to find, either 
 in the history or in the condition of the patient, that there are 
 signs and symptoms of this primary disease. Thus symptoms 
 
 Fig. 42. — Subdiaphragmatic abscess. Semidiagrainmatic illustration of a subdia- 
 phragmatic abscess of tlie right side. The aljscess cavity is filled entirely 
 with pus. 
 
 of preceding inflammation in the ctecal or renal regions are not 
 uncommon, and often give valuable help in making a correct 
 diagnosis. As regards the general symptoms, the temperature is 
 usually raised and " hectic " in character, and often this increase 
 in the temperature is associated with alternating attacks of 
 diarrhoea and constipation. In many, pain and difficulty in 
 breathing are experienced, whilst in advanced cases considerable 
 loss of ilesh, wasting, enfeeblement of the appetite, and a general 
 
SYMPTOMS. 281 
 
 loss of strength and mental power, are noticed. These cases 
 often develop the typhoid state. In addition to symptoms, a 
 subphrenic abscess gives rise to a certain number of physical 
 signs, which are of great value in establishing a correct diagnosis. 
 These signs vary according to whether the abscess is situated on 
 the right, the left, or both sides, and whether it contains pus 
 alone, or a mixture of gas and purulent matter. When the 
 abscess contains only pus, the liver is in most cases thrust down- 
 wards to a variable extent, so that its inferior margin can be 
 
 Fig. 4-3. — Subdiaphragmatic abscess. Semidiagrammatic illustration of a sub- 
 diaphragmatic abscess of the left side. The contents are pus and gas. 
 
 felt below the costal arch. This depression of the liver is 
 not pathognomonic of the disease, since it is not always 
 present in cases of subphrenic abscess, and when it is met 
 with it may be due to other conditions, such as empyema 
 and effusion into the right pleural cavity, or hydatid disease of 
 the liver or the subphrenic region. When the hepatic region is 
 palpated, the overlying tissues in cases of subphrenic abscess are 
 more resistant than usual, the respiratory movements of the 
 part are less than normal, and the liver itself and the adjacent 
 portion of the thoracic and abdominal walls are more fixed than 
 usual. When the abscess is located in the left hypochondrium, 
 an abnormal swelling will be found to occupy this region with 
 
282 SUBPHRENIC ABSCESS. 
 
 the physical characters of a collection of pus. On percussion, 
 dulness is found at the base of the thorax, which is similar to 
 that met with in cases of localised pleural effusion. In some 
 cases there is slight displacement of the heart, usually to the 
 left, but this is not constant, and some observers have even 
 denied its existence. There is no doubt, however, that in some 
 instances slight displacement of the apex beat of the heart is to 
 be noted. When the abscess contains gas mixed with purulent 
 matter, the physical signs are somewhat different. The liver 
 may be thrust downwards as in the former case, and usually 
 this depression is more distinct, and the lower margin of the 
 liver can be felt some distance below the costal arch. On 
 percussion the liver dulness is found to be considerably 
 diminished or even to be almost absent, and to be replaced by a 
 note which is " amphoric " in character. This is caused by 
 the presence of gas within the abscess cavity. On auscultation 
 the vesicular breath sound is heard down to the third or fourth 
 rib, but below that a distinct " amphoric " sound is heard. The 
 percussion sound over the abscess cavity may be very tympanitic, 
 or, according to Gee, the " bell sound " may be met with. On 
 shaking the patient a succussion splash will usually be elicited, 
 but in many cases the general condition of the patient will not 
 allow this to be sought for. 
 
 Com'plications. — When an abscess is situated in the sub- 
 phrenic space, it occasionally happens that a communication is 
 established with the overlying pleural cavity owing to perfora- 
 tion of the diaphragm, and if this abscess contain gas as well as 
 purulent matter a pyopneumothorax will be produced. Per- 
 foration into the pleura is usually accompanied by severe pain, 
 difficulty in breathing, and a certain amount of shock, whilst the 
 physical signs which are met with in the chest indicate the 
 presence of gas in the pleura and collapse of the lung. Perfora- 
 tion may also take place into the pericardium, in which case 
 there will be signs of pericarditis, and if the abscess contained 
 gas there will be signs of gas in the pericardial space. In other 
 cases the inflammatory process may spread slowly through the 
 diaphragm and cause localised pleurisy and subsequent adhesion 
 of the paiietal and visceral layers of the pleura, where they lie in 
 contact upon the upper surface of the diaphragm, and then per- 
 foration of the abscess wall may take place, and the purulent 
 matter pass into the lung and be expectorated. In rare cases 
 
COMPLICATIONS— DJAGNOSIS. 283 
 
 the abscess may burst into the peritoneal cavity and set up a 
 general septic peritonitis. Occasionally the abscess may extend 
 to the surface of the body, either through the anterior abdominal 
 wall or through one of the intercostal spaces, and its contents be 
 discharged owing to a spontaneous rupture. In still other cases 
 perforation may take place in some part of the alimentary canal, 
 most commonly the stomach or the adjacent portion of the colon, 
 and then the contents are passed per anum or even vomited when 
 the stomach is the seat of the perforation. When a communication 
 is established between the cavity of a subphrenic abscess and the 
 lung or the lumen of the alimentary canal, unpleasant symptoms 
 result. When the lung is the seat of the communication, foetid 
 expectoration is a marked symptom ; and when the stomach is 
 involved, unpleasant eructations of foul gas occur. When an 
 empyema follows as a result of rupture into the pleura, or 
 pleurisy is set up owing to extension of the inflammatory 
 process through the diaphragm, difficulty in breathing and other 
 thoracic symptoms are usually accentuated. 
 
 Diagnosis and differential diagnosis. — Many cases of sub- 
 phrenic abscess present considerable difficulties in diagnosis. 
 The affection is liable to be mistaken for an abscess of the upper 
 aspect of the liver, a solid tumour of the liver, a subphrenic 
 hydatid cyst, a pleural effusion, or an empyema, and when it con- 
 tains gas as well , as purulent matter it may be mistaken for 
 a pneumothorax or a pyopneumothorax. The history of the 
 affection often affords great assistance in locating the abscess. 
 In subphrenic abscess there is often a history of abdominal 
 symptoms and absence of cough or expectoration, whilst in 
 pleural effusion the reverse history is usually obtained. The 
 heart also is not displaced to so considerable an extent as in 
 cases of pleural effusion or empyema. On auscultation the 
 vesicular breath sound can be heard for a variable distance 
 below the clavicle, usually as far as the lower border of the 
 third rib, and in deep inspiration it can be distinguished at 
 a lower level, and below this there is an " amphoric sound," 
 whilst in the case of pneumothorax vesicular breath sounds 
 cannot be distinguished on the affected side. In many cases it 
 is necessary to explore the region of the swelling vdt\\ the 
 needle of an aspirator. When purulent matter and gas are 
 withdrawn, it is certain that an abscess cavity exists in the 
 region of the diaphragm, and, according to Fiirbringer and other 
 
284 SUBPHRENIC ABSCESS. 
 
 observers, if the needle moves upwards and downwards with the 
 movements of respiration, it is clear that a subphrenic abscess is 
 present. This sign is, however, not pathognomonic of the 
 affection, since the needle may become fixed in the walls of an 
 abscess, and not in the diaphragm, or, if the diaphragm has been 
 thrust upwards to a considerable extent, the needle may pass 
 into the abscess cavity and have no movements communicated 
 to it. If an encysted purulent pleural effusion of the basal 
 portion of the chest is present, it will usually be quite impossible 
 to distinguish it from a subphrenic abscess. If, however, the 
 swelling has been shown to contain pus by means of the 
 aspirating needle, it does not make any material difference, since 
 the treatment of both affections is similar. If there is any 
 doubt of the nature of a swelling which is situated in the sub- 
 diaphragmatic region, it is always advisable to explore it with 
 the needle of an aspirator, adopting in every case strict aseptic 
 precautions. 
 
 Treatment. — When the diagnosis that a collection of pus 
 exists on the under surface of the diaphragm has been established, 
 it is indicated in every case that surgical measures should at 
 once be adopted for its evacuation and the subsequent drainage 
 of its cavity. The collection of pus may be reached by three 
 different routes, either through the anterior abdominal wall, 
 immediately below the margin of the costal arch, or through the 
 thoracic wall by resection of portions of one or more ribs, or 
 from the lumbar region by means of an incision which follows 
 the lower border of the last rib. The location and connec- 
 tions of the abscess determine which of these methods sliould 
 be adopted. When the abscess protrudes from beneath the 
 costal margin, an incision should be made over its most 
 prominent part in the anterior abdominal wall, and, whenever 
 it is possible, it is advisable that this method of evacuation 
 shoidd be adopted, since it offers better chances of recovery than 
 either of the other methods. When, however, there is also an 
 empyema, or if the aljscess is situated entirely underneath the 
 costal arch, it is necessary that an incision should be made 
 through the thoracic wall, and portions of one or more ribs 
 resected, and the pleural cavity opened. Then the diapln-agm is 
 incised and the abscess is evacuated and drained by tlie trans- 
 pleural method. When the suljphrenic abscess is due to a 
 perinephric affection, it is advisable to make an incision along 
 
TREA TMENT—rR O GNOSIS. 2 8 5 
 
 the lower border of the last rib in the lumlmr region, and to 
 drain the purulent collection Ijy this route. When the abscess 
 cavity has been evacuated, — and it should be borne in mind that 
 the evacuation ought to be carried out slowly so as to cause as 
 little shock as possible, — it is irrigated with an antiseptic solution 
 and drained with a large rubber drainage-tube. The details 
 which are to be observed in the performance of these operations 
 are given in the chapters which are devoted to ojjerative 
 procedures. 
 
 Prognosis. — The prognosis in cases of subphrenic abscess 
 depends to a very great extent upon the cause of the affection. 
 In those cases which are associated with or are dependent upon 
 a malignant ulcer of the stomach or some other part of the 
 alimentary canal, the prognosis is very grave. When the 
 disease is recognised at an early stage, and it is possible to 
 treat the primary affection by radical measures, it is possible that 
 a cure may be effected. If, however, the primary disease is not 
 amenable to direct surgical interference, the treatment of the 
 subphrenic abscess can only be regarded as a palliative measure 
 which may prolong life to a limited extent. When the abscess 
 is due to an inflammatory affection elsewhere, and the presence 
 of the disease is recognised early, and suitable operative treat- 
 ment is carried out without delay, the prognosis is much better. 
 In some cases in which perforation of the abscess has occurred, 
 either into the alimentary canal or into the lung, a spontaneous 
 cure has followed, but cases of this kind are very rare. Carl 
 Beck^ refers to six cases of this kind which he has found in 
 the literature of 104 cases. It has not been possible to gauge 
 the nature of the prognosis from the microscopical examination 
 of the purulent matter evacuated from the abscess. In it there 
 have been found many varieties of micro-organisms, especially 
 those of ordinary suppuration, but in a certain proportion of the 
 cases no living organisms have been met with. 
 
 1 Beck, op. cit. 
 
CHAPTER XXII. 
 
 BILIAEY FISTULiE. 
 
 A BILIARY fistula is an abnormal communication or opening in 
 connection with either the gall bladder or one of the biliary- 
 ducts through which bile passes. These fistulas are of two 
 kinds : those which open upon the external surface of the body, 
 and are called external fistulas, and those in which there is a 
 communication between the lumen of one of the hollow abdominal 
 viscera and the cavity of either the gall bladder or one of the 
 biliary ducts, and which are known as internal fistulfe. 
 
 ExTEENAL Fistula. — An external biliary fistula is character- 
 ised by the presence of an aperture upon the surface of the body, 
 usually in some part of the abdominal area, which leads into a 
 tract which communicates with the gall bladder or one of the 
 bile ducts, and from this aperture bile exudes. In the majority 
 of cases it is found that the fistula communicates with the cavity 
 of the gall bladder. Gall stones are a frequent cause of the 
 formation of a biliary fistula, owing to the fact that they are 
 prone to give rise to the development of inflammatory processes 
 which affect the gall bladder or biliary ducts, and cause these 
 structures to become adherent to the posterior aspect of the 
 anterior abdominal wall ; and when an abscess arises in this 
 position it makes its way through the substance of the overlying 
 abdominal wall, and opens upon the surface and discharges its 
 contents. If this abscess also involves the gall bladder or the 
 bile ducts, a communication will then be established between 
 the lumen of these structures and the surface of the body, and 
 in many cases a biliary fistula will result. The gall stones which 
 have been the cause of the inflammatory process are often dis- 
 charged with the contents of the abscess, and in some cases it 
 is found that calculi may be discharged at intervals for a long 
 time after the development of the fistula. If all the calculi are 
 discharged from the fistula, or pass along the cystic and common 
 
EXTERNAL FISTUL.E. 287 
 
 bile ducts into the alimentary canal, the aperture may close up 
 spontaneously ; but usually some of them remain either in the 
 cavity of the gall bladder, or in some part of the fistulous tract, 
 and become the cause of a chronic irritation which keeps open 
 the fistula, from which these calculi may be discharged at 
 periodical intervals. I have recently seen a case of this kind, 
 in which a collection of gall stones in the gall bladder gave rise 
 to the formation of an abscess which opened on the surface of 
 the abdomen a short distance above the umbilicus, and from the 
 aperture a gall stone was occasionally discharged. When a gall 
 stone has passed into one of the bile ducts, and subsequently 
 caused inflammation, it usually gives rise to the formation of 
 adhesions between the duct and some part of the alimentary 
 canal, and may pass through the wall of the adherent viscus and 
 so cause the development of an internal fistula. An external 
 biliary fistula, however, occasionally follows an inflammatory 
 process in connection with one of the bile ducts, but this is not 
 common. Penetrating wounds of the abdomen, and occasionally 
 of the lower portion of the right side of the thorax, which involve 
 the liver or the biliary system, may be the direct cause of the 
 establishment of a biliary fistula. Thus it occasionally happens 
 that a gunshot wound, or a stab which penetrates the liver or 
 gall bladder, is followed by the formation of a fistula, owing to 
 the non-closure of the external wound and the escape from it 
 of a quantity of bile. Hepatic abscesses of traumatic origin are 
 said to be very liable to result in the formation of a biliary 
 fistula ; and abscesses of the liver due to other causes may also 
 give rise to the same result, owing to the affected portion of the 
 liver having become adherent to the abdominal wall, and the 
 abscess discharged externally. In some cases which have been 
 recorded, a fistula has arisen as the result of the surgical treat- 
 ment of a hydatid cyst or an abscess of the liver. The operation 
 of cholecystotomy is in some cases followed by the formation of 
 a temporary or permanent biliary fistula. Actinomycosis of the 
 liver may gave rise to the formation of an abscess which bursts 
 externally, and is followed by the appearance of a fistula from 
 which pus and bile exude. I have seen one case of this kind, 
 but the amount of bile which was mixed with the purulent 
 matter was quite small. Cancer of the gall bladder may extend 
 to the adjacent portion of the abdominal wall and terminate in 
 the formation of a fistula. One or two cases have also been 
 
288 B I LIAR Y FISTULA. 
 
 recorded in which an infant has been said to suffer from a con- 
 genital umbilical biliary fistula, which was supposed to be due 
 to non-obliteration of the lumen of the umbilical vein and the 
 establishment of a communication between this vein and one 
 of the smaller intra-hepatic bile ducts. When external biliary 
 fistulffi are met with, the fistulous aperture is usually found to 
 be situated in the right hypochondriac region or at the umbilicus, 
 but it may be in the inguinal region, the hypogastrium, or be- 
 tween two of the lower ribs, especially on the right side. The 
 greater frequency of the fistula at the umbilicus and in the right 
 hypochondriac region is due, in the first case, to the ease by 
 which an inflammatory collection of purulent matter can pass 
 between the two layers of the falciform ligament, and along the 
 ligamentum teres to the posterior aspect of the umbilicus ; and 
 in the latter, to the fact that the gall bladder normally comes 
 into contact with the posterior aspect of the anterior abdominal 
 wall in the right hypochondriac region, immediately below the 
 ninth costal arch, and when it becomes enlarged and inflamed 
 it tends to become adherent to this area. When the aperture 
 is situated between the ribs or costal cartilages, it is due either 
 to an abscess having opened on the surface in that position, or 
 to the fact that a perforating injury has been inflicted there. 
 External biliary fistulse usually have only one aperture, but it 
 occasionally happens that two or more openings are met with. 
 
 Syiwptoms. — Every case of external biliary fistula is charac- 
 terised by the presence of one or more apertures upon the ex- 
 ternal surface of the body, and situated in one of the regions 
 which have been mentioned above, and from these apertures there 
 exudes a fluid which consists either of pure bile, or of purulent 
 matter mixed with bile, or blood mixed with bile, or with both 
 and pus ; or the fluid may consist of either pus or mucus or 
 muco-pus, in those cases in which the fistula communicates with 
 the cavity of the gall bladder, and the lumen of this viscus 
 has been shut off from its normal communication with the bile 
 duct by the obliteration of the canal of the cystic duct. Gall 
 stones may be discharged through the fistulous aperture, and 
 cases have been recorded in which a hundred or more 
 calculi have been extruded in this manner. The amount of 
 fluid which is exuded from the opening of the fistula varies 
 considerably, and this variation is due to the condition of the 
 other portions of the biliary ducts. When the cystic duct is 
 
S YMPTOMS—DIA GNOSIS. 289 
 
 occluded, the amount which is discharged is small, whilst it 
 consists of mucus, of pus, or of muco-pus. If the cystic duct 
 is patent, the common bile duct occluded, and the fistula com- 
 municates with the cavity of the gall bladder, large quantities 
 of more or less pure bile will be passed. The quantity which 
 may be discharged in this way may be several pints daily. 
 In this class of case, it generally happens that severe jaundice 
 precedes the formation of the fistula, a condition which dis- 
 appears gradually after the fistula has been established. When 
 the common bile duct is occluded, and there is no communication 
 between the other portions of the bile ducts and the alimentary 
 canal, no bile will be found in the alvine evacuations. In 
 those cases in which the common bile duct is patent, it rarely 
 happens that much bile passes through the fistulous aperture, 
 owing to the fact that the greater part passes along the bile 
 duct into the duodenum. If the entire amount of bile secreted 
 by the liver is discharged through the fistula, the patient 
 usually emaciates, and sooner or later dies, unless measures are 
 adopted which establish a canal for the passage of bile into the 
 intestine. When the fistula develops as the result of an in- 
 flammatory condition induced by the presence of gall stones, 
 attacks of colic and pain in the hepatic region of the abdomen 
 precede the formation of the fistula ; after this has been 
 established, improvement in the general condition of the patient 
 usually occurs, whilst in those cases in which the gall stone is 
 extruded through the fistulous opening the patient may recover 
 completely and the fistula close spontaneously. If the fistula 
 is dependent upon malignant disease of the gall bladder or bile 
 ducts, cancerous cachexia will usually become manifest, and the 
 patient die at an early period after the fistula has become 
 established. The external aperture of the fistula may be 
 situated, as we have already seen, in various parts of the 
 abdomen and thorax, and the length of the sinus is dependent 
 upon the distance of this external aperture from the gall bladder 
 or the liver. In many cases the fistulous canal has a tortuous 
 course through the overlying tissues betwen the biliary system 
 and the surface of the body. 
 
 Diagnosis. — When an aperture or opening is situated upon 
 
 the external surface of the body in one of the regions which 
 
 have been enumerated above, and from this opening there exudes 
 
 either bile or a fluid which is mixed with bile, the diagnosis 
 
 19 
 
290 B I LIAR V FISTULy^. 
 
 of the pathological condition is easy and certain. In those 
 cases in which the fistula is in connection with the liver, the 
 amount of the fluid which is discharged will, in most patients, 
 be found to be small, and to consist of purulent material mixed 
 with a small quantity of bile, and possibly some blood ; whilst 
 if it is in connection with the gall bladder or one of the larger 
 biliary ducts, the discharge will consist of bile or bile mixed 
 with muco-pus. In the latter class of case it occasionally 
 happens that calculi which have the composition and structure 
 of gall stones, are found in the exudate. When the discharges 
 from the fistula consist of mucus or muco-pus, and the tract 
 of the sinus leads towards the region of the gall bladder, it is 
 probable that the cavity of the gall bladder communicates with 
 the sinus, and that the lumen of the cystic duct has become 
 obliterated either by fibrous constriction or by the impaction 
 of a calculus. In those cases in which the walls of the sinus 
 are thickened and hard on palpation, and the surrounding 
 tissues infiltrated with a similar hard substance, the existence 
 of malignant disease of the gall bladder will be suggested, 
 especially when this hard infiltration extends into the region 
 of the normal gall bladder, and is associated with the occurrence 
 of a cancerous cachexia. In the majority of cases where the 
 sinus has resulted from some variety of traumatism, it will be 
 found that it is in connection with the hepatic substance ; 
 whilst if it is dependent upon an inflammatory process, or upon 
 the occurrence of malignant disease, the gall bladder or the 
 biliary ducts will be the seat of the primary affection. It 
 occasionally happens, however, that the sinus follows an abscess 
 of the liver. When the formation of the sinus is due to 
 actinomycosis of the liver, the characteristic yellow granules 
 of actinomyces, which microscopically are found to contain the 
 mycelium and spores of the ray fungus, will be found in the 
 fluid which is discharged. 
 
 Treatment. — External biliary fistulse present many diffi- 
 culties in their satisfactory surgical treatment. In all cases 
 the neighbourhood of the external aperture must be kept 
 scrupulously clean, so as to prevent as far as possible any 
 collection of purulent material which may act as a further 
 irritant and aggravate the pathological condition. If a calculus 
 can be felt to be impacted in the sinus, it should be removed 
 at once, either simply through the external aperture, or by 
 
TREATMENT. 291 
 
 opening up the sinus by a surgical operation, if this is found to 
 be requisite. In those cases in which the sinus leads towards 
 the gall bladder, and there is only a small amount of fluid 
 exudation, the neighbourhood of the organ must be examined ; 
 and if it is found to be shrunken or almost obliterated by the 
 contraction of fibrous tissue, and to be represented by a small 
 sac with thickened and contracted walls, removal of the diseased 
 structure should be effected by performing the operation of 
 cholecystectomy. In many of the cases of this nature, small 
 calculi are found to be embedded in the mass of contracted 
 fibrous tissue, and these concretions are important factors in 
 keeping up the constant condition of chronic irritation which 
 results in the continuous discharge of purulent exudation from 
 the external opening of the fistula. When it is impossible 
 to remove the contracted gall bladder completely, or if it seems 
 likely that the organ may regain its normal physiological 
 functions, all concretions which may be present in the sinus, 
 the gall bladder, or the cystic duct, should be removed, and the 
 cavity of the gall bladder irrigated with an antiseptic solution 
 and drained by the introduction of a small rubber drainage- 
 tube. If the communication between the cavity of the gall 
 bladder and the lumen of the cystic duct has been destroyed, 
 the gall bladder should be removed in every case where it can 
 safely be done. When large quantities of bile issue from the 
 fistula, it is found that in most cases some kind of obstruction, 
 complete or partial, to the flow of bile along the common bile 
 duct exists. In these cases a thorough examination of the 
 course of the common bile duct must be made, and any abnormal 
 condition which is discovered must be dealt with in an appro- 
 priate manner. Thus, if a calculus is found to be impacted in 
 the common duct, it must be removed, either by direct 
 incision of the duct, or by forcing it onwards into the duodenum 
 or backwards into the region of the gall bladder, whence it can 
 be easily extracted. When a stone is found to be the cause of 
 obstruction in the common duct, and it can be removed, this 
 procedure will be followed in most cases by a cure. When, however, 
 the common bile duct is obliterated by an impermeable fibrous 
 constriction, the only chance of permanent cure which remains 
 open is the possibility of establishing an anastomosis between 
 the lumen of the gall bladder, or that of the dilated upper 
 portion of the common bile duct proximal to the stricture and 
 
2 92 BILIARY FISTULA. 
 
 the cavity of the adjacent portion of the alimentary canal. 
 This can be done by performing the operation of cholecyst- 
 enterostomy or cholecyst-duodenostomy. When a communica- 
 tion of this kind has been successfully established, the external 
 aperture of the fistula will usually close spontaneously. In 
 cases of carcinoma of the gall bladder which have given rise to 
 the development of an external biliary fistula, owing to adhesion 
 of the diseased structure to the anterior abdominal wall and 
 subsequent perforation on account of ulceration and the forma- 
 tion of an abscess, it is rarely feasible or possible to give any 
 permanent assistance by the performance of a surgical operation. 
 If, however, it is found on examination that the pathological 
 process is localised to the gall bladder and the walls of the 
 sinus, an attempt may be made to remove the sinus with its 
 infiltrated walls, together with the diseased gall bladder. 
 When the fistula is in communication with the hepatic substance, 
 and is dependent upon a pathological condition of this organ, 
 the external aperture of the sinus should be kept very clean and 
 open, and in many cases of this kind it will be found that the 
 fistulous track will gradually close. In some cases, however, 
 iiiv which the above method of treatment is not followed by a 
 good result, it is advisable to slit open the sinus to its base, 
 to scrape its walls and bottom thoroughly, and then to pack it 
 with tampons of sterilised gauze which are daily renewed, or to 
 insert a small rubber drainage-tube which is gradually shortened. 
 These cases of external biliary fistulse terminate in most instances 
 in a permanent cure. 
 
 Prognosis. — Those cases which are due to the presence of 
 gall stones, or dependent upon inflammatory processes which 
 have resulted from them, are generally amenable to direct 
 surgical interference, and present a very good chance of per- 
 manent recovery. In some of these cases, however, when the 
 gall stones have caused a complete obliteration of the common 
 bile duct, the prognosis is not so hopeful. When the fistulse 
 result from an hepatic abscess which has either been treated 
 surgically, or has opened spontaneously upon the surface, the 
 prognosis depends upon the depth, situation, and size of the 
 abscess. Thus, when the abscess has been small and more or 
 less superficial, the sinuses and fistulffi in most cases can be in- 
 duced to close by one of the methods mentioned above ; but when 
 the abscess has been large, and has been situated in the deeper 
 
PROGNOSIS. :293 
 
 portion of the liver, then the sinuses may resist all forms of 
 treatment, and, after lasting for many years, ultimately cause the 
 death of the patient, owing to the occurrence of amyloid disease 
 or to the development of fresh abscesses. When the common 
 bile duct has become the seat of an impermeable fibrous stricture, 
 and a cholecyst-enterostomy can be successfully performed, a 
 permanent cure may be hoped for. Carcinoma of the gall 
 bladder which has resulted in the formation of an external 
 biliary fistula, owing to an extension of the disease, is probably 
 in the great majority of cases fatal, although it is possible in a 
 few cases to afford relief by an extensive surgical operation. 
 Points in favour of this are the slowness of growth of a car- 
 cinoma of the gall bladder, and the rarity of cases in which the 
 disease causes the development of secondary growths in the liver 
 in the early stages of the affection. When the fistula is depend- 
 ent upon actinomycosis of the liver, the prognosis is almost 
 hopeless, since in this disease, if the liver is affected, the case 
 nearly always goes on to a fatal termination. 
 
 Inteenal Biliary Fistula. — An internal biliary fistula is 
 an abnormal communication between the lumen of the gall 
 bladder or one of the bile ducts, and that of some portion of the 
 alimentary canal or other hollow viscus. It is caused in nearly 
 all cases, either by the perforation of a gall stone or by the 
 extension of a carcinoma of the gall bladder or bile ducts to the 
 adjacent portion of the stomach or intestine. A fistulous com- 
 munication between the gall bladder or one of the bile ducts and 
 one of the hollow abdominal viscera, may be established as the 
 result of an adhesion having formed between the external sur- 
 faces of approximated viscera, owing to the inflammation which 
 is induced by the presence of a calculus. The constant irritation 
 of this calculus gives rise to the development of an ulcerative 
 process which terminates in the passage of the calculus from the 
 cavity of the gall bladder or biliary duct to that of the organ to 
 which it has become adherent. In this manner fistulse have 
 been established between the gall bladder or the biliary ducts 
 and the stomach, colon, duodenum, left pleural cavity, pelvis of 
 the right kidney, vagina, portal vein, and encysted peritoneal 
 cavities which have been formed by adhesions. In a manner 
 similar to the above, carcinoma of the gall bladder or the bile 
 ducts may extend to some part of the alimentary canal, and by 
 a process of ulceration form a fistulous communication. 
 
2 94 BILIARY FISTULA. 
 
 Symptoms. — The symptoms of these fistulse are very obscure, 
 but in rare cases a gall stone may pass in this manner into the 
 intestine and cause acute or chronic intestinal obstruction, which 
 necessitates for its relief the performance of a laparotomy and 
 the removal of the calculus from the seat of the obstruction. 
 Occasionally a gall stone of large size is extruded per anum, and 
 when this is the case the assumption can be made that a fistula 
 must have been formed so as to allow the passage of the stone 
 from the gall bladder into the intestine, since it is too large to 
 have passed by the cystic and common bile ducts. ]t is not 
 generally possible to diagnose the existence of abnormal com- 
 munications between the gall bladder or bile ducts and one of 
 the hollow abdominal viscera. In a few cases gall stones have 
 been the cause of the formation of encysted peritoneal collections 
 of fluid which have contained calculi, owing to the passage of 
 these bodies through the walls of their containing organ into the 
 adjacent part of the peritoneal cavity. If an encysted peri- 
 tonitis of this kind is operated upon, the fistulous communication 
 may be found and closed. If it is found to be impossible to 
 close the fistulous opening in the gall bladder, it may be requisite 
 to remove the entire organ. Carcinoma of the gall bladder or 
 biliary ducts, which has given rise to the formation of fistulous 
 communications with the adjacent viscera, in the great majority 
 of instances does not admit of surgical treatment, on account of 
 the extensive connections of the disease. 
 
 Since the diagnosis of these cases is so difficult, and in nearly 
 all cases very uncertain, no definite indications can be given con- 
 cerning the methods which should be adopted in their treatment. 
 In most cases, however, it will be found that, even if the exact 
 nature of the affection can be diagnosed, little can be done in 
 the way of surgical treatment. 
 
CHAPTER XXIII. 
 
 GALLSTONE ILEUS OE INTESTINAL OBSTRUCTION DUE TO 
 
 GALL STONES. 
 
 Gallstone ileus, or intestinal obstruction due directly to one or 
 more gall stones, or indirectly to an abnormal state induced by 
 the presence of these concretions, is a pathological condition only 
 very occasionally met with. Several varieties of intestinal 
 obstruction caused by cholelithiasis have been described, the 
 distinctions between the separate forms being dependent upon 
 the manner in which the obstruction to the lumen of the 
 affected portion of the alimentary canal has been produced. In- 
 most cases the obstruction is acute, but a form of chronic obstruc- 
 tion may develop as a sequel of chronic inflammatory processes 
 which have terminated in the formation of numerous fibrous 
 adhesions, one or more of these having involved the alimentary 
 canal. The commonest form of obstruction is due to the impac- 
 tion of a gall stone in some part of the intestine. When a gall 
 stone becomes impacted in this manner, it is usually found that 
 the concretion has gained an entrance into the alimentary canal 
 by passing from the cavity of the gall bladder, where it has 
 been formed, into the interior of an adjacent loop of intestine, 
 through an abnormal aperture which has arisen as the result of 
 inflammatory and ulcerative processes. The presence of a large 
 calculus within the bladder may be associated with the occurrence 
 of an inflammatory condition of the mucous membrane which 
 spreads through the walls of the viscus, and causes a localised 
 form of peritonitis and the development of adhesions between 
 the gall bladder and a coil of intestine. When the gall bladder 
 and intestine have become adherent in this manner, the gall 
 stone may cause ulceration and perforation of the septum which 
 separates the cavity of the gall bladder from the lumen of the 
 adherent portion of the intestine, and through the aperture 
 which is thus produced the gall stone may pass into the interior 
 
296 GALLSTONE LLEUS DUE TO GALL STONES. 
 
 of the Lowel, where, sooner or later, it may become a cause of 
 obstruction owing to impaction taking place. Impaction of a 
 gall stone may occur in different parts of the intestine, and may be 
 dependent upon several causes. In some cases the large size of 
 the calculus is the immediate cause of the obstruction ; in others, 
 a kink or abnormal bend of the intestine, which is due to the 
 presence of a fibrous band exerting tension or pressure from the 
 exterior ; in others, the presence of a fibrous stricture, or a stric- 
 ture which is due to some form of new growth ; and in others 
 again, the deposit of solid material upon the exterior of the cal- 
 culus, from the contents of the alimentary canal, as a result of 
 which it increases in size, is the determining factor in the causa- 
 tion of the arrest and impaction of the calculus. The part of the 
 intestine in which the calculus becomes impacted varies to a 
 certain extent according to the situation of the aperture through 
 which the calculus has passed from the gall bladder. In most 
 cases this aperture is located in some part of the small intestine, 
 often the duodenum or the upper portion of the jejunum, but it 
 is not uncommon to find that the transverse colon is the seat of 
 the fistulous communication. The impaction usually takes place 
 in the lower portion of the ileum, or at the ileo-caecal valve, and 
 only rarely in some part of the large intestine. Out of thirty- 
 five cases of intestinal obstruction due to the impaction of gall 
 stones, which have been analysed by Lobstein,^ the seat of the 
 impaction was at the ileo-csecal valve in seven cases, the lower 
 portion of the ileum in ten cases, the upper part of the ileum in 
 six cases, the jejunum in seven cases, the duodenum in two cases, 
 and in the colon or rectum in three cases. A gall stone has 
 been found in a coil of intestine which has formed the contents 
 of a hernial sac, and has been the cause of obstruction. When 
 intestinal obstruction is due to an impacted gall stone, the 
 obliteration of the lumen of the affected portion of the intestine 
 is caused by a blocking of the interior by the calculus itself, and 
 it is not due to the establishment of strangulation, such as occurs 
 in a case of strangulated hernia. The gall bladder is not invari- 
 ably the seat of the perforation, and it occasionally happens that 
 a gall stone is arrested in the cystic duct or the common bile 
 duct, this portion of the duct becoming dilated, inflamed, and 
 adherent to a coil of intestine, in which case an abnormal aper- 
 ture may be formed as a result of ulceration, and the calculus 
 
 1 Lolstein, " Gallenstein-Ileus," Beitr. z. klin. Chir., Tiibiugen, 1896, s. 390. 
 
ETIOLOGY. 297 
 
 pass into the interior of the adherent portion of the bowel. In 
 other cases the bile ducts become considerably dilated, so as to 
 allow the passage of large calculi along them into the interior oi: 
 the duodenum. Gall stones which have passed into the intestine 
 in either of these ways may become arrested and impacted in 
 their passage along the intestine, and so be the cause of intestinal 
 obstruction. It must not be thought that when a gall stone 
 passes into the intestine by one of the routes which have been 
 mentioned, that intestinal obstruction is a common result. It is 
 probable that in nearly all cases in which the calculi pass along 
 a dilated common bile duct into the duodenum, they are extruded 
 from the anus along with the faeces ; but it is possible in cases of 
 narrowing of the lumen of the bowel by bands and fibrous 
 adhesions, or by malignant growths, that impaction followed by 
 obstruction may result, or the calculus may increase in size 
 owing to the deposit on its exterior of solid matter from the 
 contents of the bowel, and then become impacted. Calculi of a 
 considerable size may pass along the intestine and be voided per 
 anum, and when intestinal obstruction follows the passage of a 
 gall stone into the intestine, there is, in most cases, some abnor- 
 mal condition of the intestine at the seat of impaction, or the 
 calculus itself is of very large size, or the patient is suffering 
 from chronic constipation, a condition which favours arrest of the 
 calculus, owing to the increase in size of 
 the gall stone by deposit of material on its 
 exterior. The size of the impacted cal- 
 culus may be considerable, or it may be 
 only of moderate or even small dimensions. 
 In the Museum of St. Bartholomew's 
 Hospital ^ there is a calculus which was 
 removed by operation from a patient in 
 whom it had caused an attack of intestinal 
 obstruction. This calculus measured \\ in. 
 in length, and 3^ in. in circumference; Fig. 44.— a large gall stone 
 rig. 44 shows its shape and size. In the ''^^}''\. "r^^^f , ^',!^*' 
 
 " ^ _ intestinal obstruction 
 
 same museum there is a gall stone measuring owing to its impaction 
 
 2 in. in length and 4i in circumference, i^i the ileum. — ^<. 
 
 , . , 1 p" ,1 i c Bartli.Hosp. Museum. 
 
 which was removed from the rectum or 
 
 a patient through the anus. Both these cases recovered. 
 
 The passage of a gall stone along the intestinal canal may 
 
 1 St. Earth. Hosp. Museum, Spec. 1353. 
 
298 GALLSTONE LLEUS DUE TO GALL STONES. 
 
 set up irregular and violent contractions of the muscular coats, 
 and, as a result of these contractions, a part of the small 
 intestine may become twisted upon itself, and a volvulus of this 
 portion of the alimentary canal induced. In most cases in 
 which this condition arises, it is found that the calculus which is 
 the cause of the mischief is located in the cojivexity of the 
 twisted loop of intestine, although it may occasionally happen 
 that the concretion is not included within that section of the 
 intestine which has become twisted. It has been stated that the 
 presence of a calculus in the gall bladder, or more especially in 
 the cystic or common bile duct, when it is the direct cause of an 
 attack of biliary colic, may give rise to spasmodic contractions of 
 the small intestines, which are followed by the establishment of 
 a volvulus, owing to a section of the tube becoming twisted upon 
 itself, but this condition must be of very rare occurrence. Mayo 
 Eobson^ has recorded two cases in which a volvulus of the small 
 intestine was due to gall stones ; in each case an operation was 
 performed (the volvulus was untwisted), and the patient recovered. 
 The occurrence of localised peritonitis in the region of the gall 
 bladder, owing to the presence of calculi within this viscus, has 
 .been said to cause an attack of acute intestinal obstruction, by 
 the inflammatory condition extending to a section of the adjacent 
 portion of the alimentary canal, and causing a temporary paralysis 
 of the muscular coats of the involved part of the intestine. It 
 is somewhat doubtful whether this is the true explanation of this 
 pathological condition. In cases of this kind which have been 
 submitted to operation, it has generally been found that the 
 structures in the region of the gall bladder and the common bile 
 duct have been firmly bound down to one another by fibrous 
 adhesions. It appears to be more probable that in these patients 
 a small calculus passes along the bile duct into the alimentary 
 canal ; and when this concretion arrives at that portion of the 
 intestine which is involved in the fibrous adhesions, a temporary 
 arrest occurs which causes the development of symptoms of 
 intestinal obstruction, but when the kink which causes the 
 arrest becomes obliterated or diminished, the calculus passes 
 onwards and is ultimately voided per anum. Several calculi may 
 be passed in close succession from the gall bladder or bile ducts 
 into the intestine, and form a conglomeration of calculi and 
 intestinal contents, which conglomeration may be broken up and 
 
 ^ Mayo Rolison, Mcd.-i'hiT. Trann., London, 1895, p. 117. 
 
SYMPTOMS. 299 
 
 the obstruction set free. In that form of chronic intestinal obstruc- 
 tion which develops as the result of fibrous bands and adhesions 
 which have been formed after a localised peritonitis, due to in- 
 flammation spreading from a gall bladder, the seat of calculi can 
 only be diagnosed with very great difficulty, and its considera- 
 tion is best included in a book dealing with the different forms 
 and varieties of intestinal obstruction. 
 
 Symptoms. — The symptoms of an attack of intestinal obstruc- 
 tion due to gall stones do not differ in any essential respect from 
 those which are dependent upon intestinal obstruction caused by 
 other pathological conditions. Abdominal pain is often an early 
 symptom, and becomes apparent soon after the establishment of 
 the obstruction. It is usually referred to the right inguinal 
 region, or to the position of the duodenum, more commonly the 
 former, on account of the frequency of impaction of the calculus 
 in the lower part of the ileum or the ileo-crecal valve ; but it may 
 be experienced in any part of the abdomen. Vomiting frequently 
 occurs, the nature of the ejecta varying according to the situation 
 of the obstruction in the intestine. When the impacted gall 
 stone is located in the duodenum or the upper portion of the 
 small intestine, the vomiting is usually profuse, and the vomited 
 matter contains a considerable proportion of bile. If the pylorus 
 is obstructed, acute dilatation of the stomach may result at an 
 early stage of the affection. Hsematemesis may occur if a 
 calculus has ulcerated its way through into the stomach or upper 
 portion of the duodenum, especially the former, the blood coming 
 from the vessels in the margins of the fistulous aperture. The 
 vomiting rarely becomes faecal in character in those cases in 
 which the obstruction is situated in the duodenum or the upper 
 portion of the jejunum. When the obstruction involves the 
 lower part of the ileum, or some part of the large intestine, the 
 vomiting usually commences somewhat later ; whilst the vomited 
 material at first consists of the contents of the stomach, then of 
 bile or bile-stained matter (when bile is passing into the 
 duodenum), and then it becomes feculent. Constipation is an 
 important symptom, and comes on soon after the commencement 
 of the obstruction. There may be, however, one or two evacua- 
 tions of the rectum after the other symptoms of obstruction 
 have become established. Naunyn says that in his experience 
 flatus is more commonly passed in intestinal obstruction which 
 is due to an impacted gall stone, than when it is dependent on 
 
300 GALLSTONE LLEUS DUE TO GALL STONES. 
 
 other causes. The circulation in the blood vessels of that 
 portion of the intestine which is the seat of the obstruction is 
 not seriously impeded in most cases of obstruction of this kind, 
 especially in the early stages, and this may explain the frequency 
 of the passage of flatus, and also of the contents of that portion 
 of the intestine which lies distal to the obstruction. Diarrhoea 
 may be present in cases in which the obstruction is not complete, 
 but this condition is of very rare occurrence. Palpation of the 
 abdomen may reveal the presence of a localised swelling or 
 tumour, or of one or more areas which are tender or painful. 
 The tumour, when present, is most commonly found in the region 
 of the right inguinal fossa, or below and to the right of the 
 umbilicus, owing to the fact that the lower portion of the ileum 
 or the ileo-csecal valve is the commonest seat of the impacted 
 calculus. It is, however, only in occasional cases that a tumour 
 of this kind can be felt. Dessauer, Kostlin, Jeaffreson, and 
 Sick have described such cases. The size and shape of the 
 tumour depends upon the characters of the calculus and the 
 contents of the intestine in the region of the impaction. When 
 the obstruction is due to the impaction of a calculus in the lower 
 portion of the sigmoid flexure, or in the rectum, it will be possible 
 to detect its presence by a digital examination per anum. 
 Distension of the abdomen is a frequent symptom, and is due to 
 an accumulation of gas and fluid intestinal contents in that 
 portion of the alimentary canal which is proximal to the obstruc- 
 tion. It is limited to the epigastric and left hypochondriac 
 regions in those cases in which the obstruction is situated in the 
 duodenum or the upper portion of the jejunum, the other parts 
 of the abdomen being retracted. When the lower part of the 
 ileum or the ileo-cffical valve is the seat of the impacted gall 
 stone, the distended intestines occupy the inferior and anterior 
 portions of the abdomen ; whilst, if the obstruction is in the 
 sigmoid flexure, there is a general distension of the entire 
 abdomen. If, during the passage of the gall stone from the 
 biliary system into the intestine, a communication is established 
 between one of the hollow viscera and the peritoneum, infection 
 will usually occur, and be followed by the development of acute 
 peritonitis, and the appearance of symptoms which are charac- 
 teristic of this condition. Such a complication is rare in the 
 early stages. When, however, the oljstruction has lasted for 
 some time, and the portion of the intestine which grasps the 
 
SYMPTOMS. 301 
 
 calculus has become ulcerated and gangrenous, then perforation 
 and septic peritonitis are very likely to happen. 
 
 A biliary calculus may remain in the intestinal canal for 
 some time without giving rise to the development of symptoms 
 from the presence of which its existence can be diagnosed. 
 Smith has recorded a case in which the calculus probably passed 
 into the intestine from the gall bladder fifteen years before the 
 occurrence of obstruction. Eve has also published a somewhat 
 similar case. Usually obstruction comes on within a short period 
 from the time when the calculus has gained an entrance into the 
 interior of the alimentary canal. It rarely happens that a calculus 
 causes obstruction when it has passed along the common bile 
 duct into the duodenum, since these calculi are of small size and 
 can easily pass along the intestine, and be voided along with the 
 fcTces. Several small calculi may, however, become united 
 together by the contents of the intestine, and then increase in 
 bulk by the deposition upon their exterior of solid constituents 
 derived from the food. A single calculus may increase in size 
 in a similar manner, and so become a direct cause of obstruction. 
 
 Thorowgood^ has described the case of a girl, set. 10, in 
 whom an abscess formed in the right groin, and from this a small 
 gall stone, consisting of cholesterin, escaped when an incision was 
 made to evacuate the collection of pus. It is probable that in 
 this case a gall stone had passed from the biliary duct into the 
 intestine, and thence into the vermiform appendix, where it gave 
 rise to inflammation, suppuration, and the development of an 
 abscess which pointed in the groin. The patient recovered. 
 
 It occasionally happens during an examination of the 
 abdomen, that the impacted calculus which is the cause of the 
 obstruction becomes dislodged, and passes onwards to be voided per 
 anum. The symptoms of obstruction in these cases at once 
 become less marked, and soon disappear. Schiiller ^ has described 
 four cases of this nature, in each of which relief followed a 
 manual examination, and a short time afterwards a calculus was 
 found to have been discharged with the fteces. 
 
 Intestinal obstruction dependent upon gall stones occurs 
 much more frequently in women than in men. According to 
 Naunyn,^ it is five times more frequent in women than in men. 
 
 1 Thorowgood, Trans. Path. Soc. London, 1877, p. 130. 
 
 2 Schiiller, " Gallensteine als Ursache der Darmobstruktion," Inaug. Diss., Stras- 
 burg, 1891. 3 Naunj'n, loc. cit. 
 
302 GALLSTONE LLEUS DUE TO GALL STONES. 
 
 In Lobstein's^ statistics, out of sixty-six cases in which the sex 
 was stated, forty-sLx were females ; and in Schiiller's table there 
 are 74 per cent, of women (139 cases). The majority of cases 
 occur in individuals who are over 40 years of age ; this is to 
 be expected, since gall stones are more common after this age. 
 In a hundred and eight of Schiiller's cases in which the age 
 was stated; four occurred under 30, five between 30 and 40, 
 and ninety-nine after 40. Out of forty-nine cases collected by 
 Lobstein, thirty-one were 60 or more. 
 
 Diagnosis. — It is often very difficult to diagnose gall stone 
 ileus, since in most cases the symptoms are very similar to those 
 of intestinal obstruction due to other causes. The previous 
 history of the patient may, however, often help in leading the 
 surgeon to a correct diagnosis of the pathological condition. 
 Former attacks of cholelithiasis, during which gall stones have 
 passed from the biliary system into the alimentary canal, whence 
 they have been extruded per anum, when a clear history of their 
 occurrence is given, will point to the possibility or even prob- 
 ability of the present attack being of a similar nature ; or the 
 occurrence of one or more attacks of jaundice may have a like 
 import. Naunyn was able to trace a connection of this kind in 
 forty-one cases out of a total of 120. The sex of the patient is 
 of importance, since the affection is much more common in women 
 than in men. It is especially frequent in old women ; and when 
 an obscure case of intestinal obstruction in an old female is being 
 examined, the possibility of the obstruction being due to an im- 
 pacted gall stone must not be forgotten. The presence of a 
 tumour which can easily be felt, in the region of the ileo-cwcal 
 valve, will also indicate the probability of a gall stone being the 
 cause of the obstruction. The ordinary hernial apertures should 
 always be carefully examined so as to exclude the possibility of 
 the obstruction being due to an external hernia. In a consider- 
 able number of the cases it is not possible to make a diagnosis 
 of the cause of the obstruction before the peritoneal cavity has 
 been opened and its contents examined through a median 
 incision in the abdominal wall. When it is thought that a 
 gall stone is the cause of an attack of intestinal obstruction, 
 some authorities have advised that the situation of the impacted 
 calculus should be sought for by sounding the abdomen with a 
 long fine steel needle pushed through the abdominal wall. This 
 
 1 Lobstein, loc. cit. 
 
TREATMENT. 303 
 
 is a very dangerous method of procedure, and ought never to be 
 practised. The intestines and other important anatomical 
 structures are liable to be injured, whilst septic material may 
 exude from the puncture holes in the intestinal wall, and acute 
 septic peritonitis be induced, which soon leads to a fatal termina- 
 tion. It is far safer in cases of this nature to open the abdomen 
 at an early stage, and then to examine the obstructed intestine, 
 and deal with it according to the pathological condition 
 which is discovered. 
 
 Treatment. — The treatment of intestinal obstruction due to 
 gall stones may be either medical or surgical, or both. In the 
 early stages of the obstruction it is advisable to adopt medical 
 and palliative measures. The patient should be kept in bed and 
 small quantities of opium administered. If the abdominal pains 
 are severe it will be best to give a hypodermic injection of 
 morphia. In most cases it will also be desirable to give a soap 
 and water enema, in order to empty the lower portion of the 
 intestine. Kussmaul has advised that the stomach should be 
 washed out so as to avoid the absorption of the products of 
 decomposition of the food which may be present. If a tumour 
 can be felt through the abdominal wall, it may be advisable to 
 manipulate it carefully, in order, if possible, to induce its move- 
 ment onwards, and so remove the obstruction. Dufort recommends 
 stimulation of the abdominal region with the faradic current 
 in these cases, and he has published a successful case. The 
 patient's strength should be maintained by the administration of 
 small quantities of peptonised milk, and of brandy and other 
 stimulants, by the mouth, if the vomiting is not too frequent, and 
 in severe cases it may be necessary and advisable to give nutrient 
 enemata. If measures of this kind do not quickly give rise to a 
 disappearance of the obstruction and an amelioration of the 
 symptoms, it will be necessary to perform a surgical operation for 
 the relief of the patient. It is often a difficult matter to decide 
 when to have recourse to surgical treatment, but it is much better 
 to operate early than late, when the patient's general condition 
 has become enfeebled and she is not capable of withstanding a 
 severe surgical operation. In all cases of intestinal obstruction 
 due to the impaction of a gall stone, the abdomen should be 
 opened in the middle line when the locality of the obstruction is 
 not known, and the situation of the impacted calculus sought for. 
 In order to do this, it may be necessary to bring out successive 
 
304 GALLSTONE LLEUS DUE TO GALL STONES. 
 
 portions of the intestine until the affected loop is discovered. 
 When this has been done, the loop of intestine is brought well 
 out through the abdominal wound and surrounded with warm 
 sterilised compresses. An incision is then made along the con- 
 vexity of the gut in a longitudinal direction, and the calculus 
 extracted. If the gall stone is large, it may be advisable to 
 break it up into several fragments before extraction, so as to 
 avoid making a large hole in the intestine. When the calculus 
 has been removed, all intestinal contents are removed from the 
 area of the operation by washing and sponging with sterilised 
 water or dilute aseptic solution, and then the aperture in the 
 intestine is closed by the insertion of two or three tiers of fine 
 silk sutures. The first tier unites the mucous membrane on each 
 margin of the incision, the second approximates the muscular 
 coats, whilst the third fixes in contact the peritoneal surfaces of 
 the intestine on each side of the incision. The first tier is a 
 continuous suture, the second is an ordinary interrupted one, and 
 the third is inserted after Lembert's method. When this has 
 been done, the intestine is again sponged and then returned into 
 the peritoneal cavity, and the abdominal wound closed. When 
 the obstruction has existed for some time, and the general con- 
 dition of the patient will not permit a prolonged operation, a 
 median laparotomy should be performed, the affected portion of 
 intestine brought into the wound and then opened, the margins 
 of the incision in the gut being fixed to those of the external 
 wound. In this manner an artificial anus is established, and if 
 the condition of the patient improves this may be closed at a 
 later period. In those cases in which a perforation of the in- 
 testine has been formed, or in which there is a communication 
 between the interior of the bile passages and the peritoneum, the 
 perforation must be sought for and closed, and then the peritoneal 
 cavity irrigated, so as to remove as far as possible all septic matter 
 and prevent the development of acute peritonitis. If peritonitis 
 has become established, a similar method of treatment should be 
 adopted, and the peritoneal cavity drained. When the intestine 
 in the region of the impacted calculus has become gangrenous, a 
 condition which rarely happens, it may be necessary to remove 
 the dead portion and then to unite the two ends by some method 
 of intestinal anastomosis. Usually, however, in cases of this 
 kind the general condition of the patient is very serious, and it 
 is advisable to establish an artificial anus, and if improvement 
 
PROGNOSIS. 305 
 
 occurs to unite the open ends of the intestinal loop at a later 
 period, in this manner giving the^ patient a better chance of 
 recovery. If, after the peritoneal cavity has been opened, it is 
 found that the obstruction is of the nature of a volvulus, this 
 should be untwisted, and, when the calculus is within the twisted 
 loop and of small size, it should be manipulated onwards with 
 the fingers, but if large it will in most cases be advisable to make 
 an incision in the long axis of the bowel and opposite the attach- 
 ment of the mesentery in order to extract it. The incision is 
 closed in the manner described above. The after-treatment of 
 all cases of gallstone ileus is similar to that of other varieties 
 of intestinal obstruction. 
 
 Prognosis. — Intestinal obstruction due to a gall stone is a very 
 serious pathological condition, a considerable number of cases 
 terminating fatally. Lobstein ^ has collected the statistics of 
 ninety-two cases, of which thirty-one were submitted to a surgical 
 operation, and sixty-one were treated by medical measures alone. 
 Twelve of the cases operated upon recovered, and nineteen died, 
 whilst of those not submitted to operation thirty-two recovered 
 and twenty-nine terminated fatally. The percentage of recoveries 
 in these cases was 38'7 for those operated upon, and 52'4 for 
 those treated by medical measures only. According to Cour- 
 voisier, the mortality is 44 per cent. (125 cases), while Schiiller 
 places it at 56 per cent. (82 cases). In these cases, however, 
 the operation cases are not separated from the non-operation 
 ones. Mr. Jonathan Hutchinson says that the mortality in those 
 cases which are treated surgically is about 50 per cent., and he 
 thinks that the question of the advisability of a surgical operation 
 in intestinal obstruction, due to an impacted biliary calculus, is not 
 yet definitely decided. 
 
 When a person has suffered from one attack of intestinal 
 obstruction, caused by the arrest of a gall stone in the alimentary 
 canal, and has recovered from it, he is always liable to have a 
 recurrence of the affection, caused by another calculus passing 
 from the bile passages into the intestine, and becoming arrested 
 at the ileo-csecal valve or other part of the course of the 
 alimentary canal towards the anus. 
 
 1 Lobstein, ''Zur Kasuistik ties Galleusteiu-Ileus," Beitr. z. klin. Chir., Bd. xiii. s. 
 406. 
 
CHAPTER XXIV. 
 
 OPERATIONS UPON THE LIVER. 
 
 Aspiration. — The aspirator can only be made use of, in the 
 treatment of pathological conditions of the liver, under restricted 
 circumstances. It is very useful in the diagnosis of the character 
 of the contents of an obscure collection of fluid, but its applica- 
 tion in this respect should be very limited. The strictest 
 antiseptic precautions should be practised in every case in v^^hich 
 the needle of an aspirator is used to explore a hepatic swell- 
 ing. The skin over the affected area must be rendered free from 
 septic micro-organisms, by washing it with soap and water, 
 ether, and finally with a solution of perchloride of mercury 
 (1 in 500), before a puncture is made. Before introducing the 
 needle, it is essential to have it carefully boiled, so as to render 
 it aseptic. It is plunged inwards over the most prominent 
 portion of the swelling. Some authorities have recommended 
 that the needle should be filled with a solution of carbolic acid 
 (1 in 20), but it appears to me that careful boiling is quite 
 sufficient. When the collection of fluid has been reached, the 
 point of the needle should be permitted to move with the liver 
 during respiration, so as to avoid unnecessary laceration of the 
 hepatic substance along the line of puncture ; since, when this 
 happens, the escape of pus or other fluid into the adjacent 
 portion of the peritoneal cavity is facilitated. After the point of 
 the needle has entered the abscess or cyst, a small quantity of the 
 fluid can be withdrawn and examined, and its nature determined. 
 Some surgeons have advocated the treatment of hepatic abscesses 
 by aspiration and removal of the pus through the needle. When 
 this treatment is adopted, it is generally necessary to perform 
 aspiration several times before a cure is effected. Many cases of 
 failure, however, have been reported, and it has been found that 
 septic peritonitis may result, owing to the escape of pus along the 
 tract of the needle into the peritoneal cavity. On account of 
 
PUNCTURE — HEP A TOTOM Y. 307 
 
 the liability to failure and the occurrence of septic peritonitis, 
 and also the possibility of injury to one or other of the neigh- 
 bouring abdominal viscera, it is advised that an abscess of 
 the liver should not be treated by aspiration alone. When 
 the situation of the pus has been determined by the aspirator, an 
 incision should be made into the pus-containing cavity, the 
 contents evacuated, and the interior drained after the manner 
 described in a succeeding paragraph. 
 
 Some authors have advised that non-suppurating hydatid cysts 
 of the liver should be treated either by simple puncture, or by 
 puncture, withdrawal of a small quantity of the fluid contents, 
 and injection of tincture of iodine, perchloride of mercury, or 
 other drug. The advisability of the performance of these pro- 
 cedures is discussed in the chapter on hydatids. 
 
 Pimdure. — Puncture by a trocar and cannula, the cannula 
 being left in so as to allow drainage, has been recommended by 
 different surgeons, but, owing to the serious complications which are 
 liable to occur as the result of this method of treatment, the 
 operation is now very rarely, or practically never adopted. Un- 
 pleasant results are liable to follow the use of the trocar similar 
 to those which have been mentioned in connection with the use of 
 the aspirator ; but since the trocar is much larger than the needle 
 of an aspirator, leakage along the tract of its entrance more 
 frequently happens, and on this account its use is said to be 
 more dangerous. When an abscess of the liver is tending to 
 point on the surface of the body, a trocar is a very useful instru- 
 ment for its puncture and evacuation ; but in cases of this kind 
 it must be remembered that even when an abscess is apparently 
 close to the surface, that portion of the peritoneal cavity which 
 intervenes between the surface of the affected part of the liver 
 and the adjacent portion of the abdominal wall, may not have 
 been obliterated by the formation of inflammatory adhesions, and 
 consequently pus may escape into the peritoneum. A trocar is 
 a most valuable instrument for the location and partial evacua- 
 tion of an abscess or cyst of the liver, after the surface of the 
 gland has been exposed by an incision, and it is to this class of 
 case that the use of the trocar should be restricted. 
 
 Hepatotomy. — By the term hepatotomy is generally under- 
 stood the making of an incision into the liver ; and hence the 
 operation which is designated by this name has for its object an 
 incision into the hepatic substance. This surgical procedure 
 
3o8 OPERATIONS UPON THE LIVER. 
 
 may be performed in a variety of ways, but in all cases it is 
 necessary to make an incision through the overlying parietes 
 before the liver itself is reached. The following are the difter- 
 ent methods which have been employed in the performance of 
 hepatotomy : — 
 
 (a) Direct incision extending into the liver. — This operation 
 can only be performed when the peritoneal surface of the liver 
 has become adherent to the parietal peritoneum which covers 
 the posterior or deep aspect of the adjacent portion of 
 the anterior abdominal wall, and that part of the peri- 
 toneal cavity which intervenes between the surface of the 
 liver and the abdominal parietes has become obliterated. In 
 the case of abscesses of the liver which are pointing on the 
 surface of the body, and are accompanied by the appearance of 
 redness, oedema, tenderness, and superficial fluctuation over the 
 most prominent part of the abdominal swelling, it may be 
 assumed in most instances that adhesions have been formed as 
 the result of the inflammatory process, and that there is no risk 
 of opening and contaminating the peritoneal cavity. The above 
 clinical appearances may, however, be present in cases of abscess 
 of the liver, without the simultaneous obliteration of the over- 
 lying portion of the peritoneum by the formation of adhesions ; 
 hence, when cases of this nature are being operated upon, it is 
 necessary to proceed cautiously, in order to ascertain whether or 
 not adhesions have been formed. In performing the operation, 
 an incision, which is about one and a half to two inches in 
 length, is made over the most prominent portion of the 
 swelling, the direction of the cut in most cases being vertical to 
 the long axis of the body ; this incision is extended carefully 
 through the tissues of the abdominal wall, until the surface of 
 the liver is reached. If it is found that adhesions have 
 been formed which shut off the whole length of the incision 
 from the adjacent part of the peritoneal cavity, the liver 
 substance is at once incised, until the abscess cavity, hydatid 
 cyst, or other pathological focus is reached. In most cases 
 this variety of operation is performed for abscess of the liver 
 or hydatid disease, and when the affected portion of the 
 viscus is met with, it is cut into, and then the margins of the 
 wound are held well apart, so as to allow the contents of the 
 cavity to escape. After the swelling has been evacuated in the 
 above manner, the interior is carefully examined with the 
 
HE PA TO TOM Y. 309 
 
 forefinger. If other abscesses can be felt in the neighbourhood 
 of the one which has been opened, the intervening liver tissue is 
 broken down with the finger, and the contents are allowed to 
 pass out through the opening in the abdominal wall. Great 
 care must be taken in breaking down the hepatic tissue with 
 the fingers, so as to avoid the rupture of any large branch of the 
 vessels within the liver, which might lead to the occurrence of 
 severe hiemorrhage, If the contents of the swelling do not 
 readily pass out through the wound when the margins are held 
 apart, it will be advisable to apply manual pressure to the abdomen 
 in the region of the wound, and at the sides of the swelling in 
 the liver. After an abscess of this kind has been evacuated as 
 far as possible, the cavity should be irrigated with warm 
 sterilised water, or a dilute solution of perchloride of mercury 
 (1—2000), so as to remove any debris and other septic matter 
 which may have been left at the bottom or in the recesses of 
 the cavity. If haemorrhage occurs, irrigation with water at a 
 temperature of 112-115° F. will help in its arrest. After the 
 irrigation has been carried out, a moderate-sized red rubber 
 drainage-tube, which has a number of perforations in its deeper 
 part, is inserted into the bottom of the abscess cavity, and an 
 aseptic absorbent dressing not too tightly applied. 
 
 This operation can only be performed in those cases of 
 abscess or hydatid cyst of the liver in which the diseased 
 part of the organ has become directly fixed to the parietal 
 peritoneum and the abdominal wall, by the formation of fibrous 
 adhesions which completely shut off the area of operation from 
 the peritoneal cavity. When this is the case, the possibility of 
 the occurrence of septic peritonitis, as the result of contamina- 
 tion of the peritoneum with the contents of the abscess, are very 
 much diminished, and hence the prognosis is better as regards 
 recovery. 
 
 (&) Immediate incision hy an abdominal operation. — In this 
 operation the abdominal wall and the liver are incised at the 
 same sitting, and in addition any other treatment which may 
 be requisite is done at the same time. A vertical incision is 
 made over the most prominent portion of the hepatic swelling, 
 commencing above at the costal margin, and extending down- 
 wards for three or four inches. When the peritoneum is reached 
 it is divided for the whole length of the incision. The surface 
 of the liver will then be seen at the bottom of the wound, and 
 
3IO OPERATIONS UPON THE LIVER. 
 
 the situation of the enlargement should be made out. In many 
 cases the surface of the enlarged portion will tend to protrude 
 at the bottom of the wound. That part of the peritoneal 
 cavity which is in the neighbourhood of the liver is next 
 carefully packed with flat aseptic sponges (which are counted 
 and a record of their number kept), so that any fluid 
 which may escape from the liver during the later stages 
 of the operation may be prevented from passing into the 
 general peritoneal cavity to become a cause of peritonitis. 
 After the sponges have been introduced, pressure is applied to 
 the external surface of the abdomen, by the hands of an 
 assistant, so as to keep the abdominal parietes in close apposition 
 with the sponges, thereby preventing the passage of any 
 extraneous matter into the peritoneum. In the case of an 
 abscess, an exploring syringe with a long needle of moderate calibre 
 is pushed into the liver substance, and the locality of the pus 
 is sought for. When this has been found, an incision is made 
 into the liver tissue about one and a half or two inches long, 
 parallel to the margins of the abdominal wound. This is 
 deepened until the abscess is reached. If there are any bleed- 
 ing points in the hepatic substance, they are picked up with 
 artery forceps and ligatured with fine silk. The aperture which 
 is made into the abscess is kept open by the introduction of a 
 pair of dressing-forceps (the blades being separated), and the 
 purulent contents allowed to exude. If any difficulty is ex- 
 perienced owing to the liver showing a tendency to recede, the 
 forefinger may be passed into the cavity of the abscess, and 
 the liver hooked forwards by exerting traction with the bent 
 finger. If the forefinger is not used in this way, two strong 
 silk sutures may be passed through the margins of the hepatic 
 wound, and given to an assistant to hold. By exerting traction 
 upon these, the margins of the wound in the liver may be kept 
 in close apposition to the abdominal walls. In this manner 
 the abscess can in most cases be readily evacuated ; but if the 
 pus exudes slowly, a large rubber tube may be passed into the 
 abscess cavity, and the outer end pinched and depressed so as to 
 make it act as a syphon, or a glass syringe may be fixed to the 
 outer end of the tube, and the pus withdrawn into the syringe. 
 After the cavity has been emptied in this manner, the interior 
 is examined, as described above, and if any other abscesses are 
 present they are made to communicate with the one which has 
 
HEPATOTOMY. 311 
 
 been first opened. When the evacuation is complete, the cavity 
 is irrigated, and the aperture of the wound in the liver is 
 temporarily closed by the insertion of a sponge, which acts as 
 a plug. All traces of pus and debris are now removed from 
 the tract of the incision and from the exposed surface of the 
 liver, by irrigation and sponging, and then the sponges which 
 have been placed in the peritoneum for packing are removed 
 and counted. If there has been any escape or soaking of pus 
 into the peritoneal cavity, the soiled area is thoroughly irrigated 
 with warm sterilised water or some antiseptic solution. The 
 margins of the hepatic incision are now united to those of the 
 incision in the abdominal parietes. Silk sutures are used, which 
 are introduced by a modification of Hagedorn's needle, which 
 in shape is fully curved and the point flattened (Fig. 49). 
 Each suture is first introduced at the deeper part of the hepatic 
 incision, and then is carried through the liver tissue, and the 
 point of the needle made to emerge upon the surface of the 
 gland, about one-third or one-half of an inch from the margin 
 of the wound ; and then the same suture is carried through the 
 abdominal wall and made to emerge through the skin of the 
 abdomen, about one-third of an inch from the margin of the 
 parietal wound. The sutures are introduced at intervals of one- 
 third of an inch for the entire length of the hepatic incision, all 
 sutures being introduced before any are tied. At the upper 
 and lower extremities of the hepatic incision, a suture is passed 
 through the abdominal wall on one side of the wound, then 
 through the liver tissue just beyond the angle of the wound, 
 and finally through the abdominal wall upon the other side. 
 The portion of the abdominal incision which lies above and 
 below these sutures, is closed by the approximation and fixation 
 of its margins in the usual fashion. After all the sutures have 
 been introduced they are tied, those which pass from one side 
 to the other being tied last of all. When all the sutures have 
 been tied and their ends cut short, the sponge is removed from 
 the cavity of the abscess, and a large drainage-tube inserted, and 
 fixed so as to prevent it slipping into the cavity of the 
 abscess. Care should be taken that the drainage-tube is not 
 too long, as, if this is the case, the pressure necessary to fix 
 the dressings may drive it into the substance of the liver, 
 and give rise to severe haemorrhage. Thick absorbent aseptic 
 dressings are applied after the drainage-tube has been inserted. 
 
312 OPERATIONS UPON THE LIVER. 
 
 Fontiin ^ recommends that the walls of the hepatic abscess should 
 be well curetted whilst the irrigation is being carried out. 
 
 When this form of operation is carried out for the treatment 
 of hydatid, the parasitic cyst usually protrudes into the wound 
 after the abdominal cavity has been opened, and an incision can 
 be at once made into the liver substance without first using 
 an exploring needle in order to find out the locality of the 
 disease, since in most cases these cysts can be seen projecting 
 from the surface of the liver. 
 
 (c) Incision in two stages {ct deux temjjs). — The early stages of 
 this operation are exactly the same as those in the preceding one, 
 until the peritoneal cavity has been opened and the surface of 
 the liver exposed. When this has been done, an area of the 
 liver, about one and a half or two inches long and half an inch 
 wide, is selected (for the site of the future incision), and with a 
 fully curved Hagedorn's needle a series of interrupted silk 
 sutures is introduced, each suture entering the liver substance 
 at the margin of the selected area, passing through the hepatic 
 tissue for a short distance, and then emerging about one-third of 
 an inch outside its point of introduction, and finally being made 
 to pierce the abdominal wall, as in the last operation. When all 
 the sutures have been introduced, they are tied, and the remaining 
 portions of the abdominal incision closed with silk sutures above 
 and below the selected hepatic area. Moderately severe bleeding 
 may occur from the liver at the site of the needle punctures, but 
 this soon ceases spontaneously. By this means a portion of the 
 peritoneum which covers the liver is closely approximated to the 
 parietal layer which lines the posterior aspect of the anterior 
 abdominal wall. The margins of the wound are kept apart by 
 packing the incision with aseptic gauze, and then a dressing is 
 firmly applied. This completes the first stage of the operation. 
 After the expiration of three or four days the dressing is removed, 
 and it will then be found that adhesions have been formed 
 between the visceral and parietal layers of peritoneum, and that 
 the general peritoneal cavity has been cut off from the wound. 
 The exposed area of the liver is now incised until the cavity of 
 the abscess or cyst is reached. In order to facilitate the per- 
 formance of this stage of the operation, it is advisable, at the 
 termination of the first stage, to introduce a silk suture at the 
 upper and lower limits of the exposed area of the liver, and to 
 
 1 Fontiin, Semccine vied., Paris, 1895, No. 43. 
 
HE PA TO TOM Y. 313 
 
 leave the ends of these sutures long, so that when the incision 
 into the liver is made they may be lifted and the cut with the 
 scalpel made to extend between them. If a case of hepatic 
 abscess is being treated, it is evacuated, irrigated, and treated in 
 a manner similar to that which has been described in the last 
 operation. It is not absolutely requisite to give an ansesthetic 
 for the second stage of the operation, but in most cases it will be 
 found to be advantageous to do so. Some surgeons advise that 
 instead of suturing the liver to the parietes in the first stage, 
 that the parietal peritoneum should be fixed to the skin by a 
 few points of interrupted silk suture, and that the wound should 
 then be packed with aseptic gauze, and a thick pad tightly 
 applied, so as to bring the surface of the liver and the anterior 
 abdominal wall as far as possible into apposition, in the hope 
 that they will acquire adhesions. This method, however, is much 
 more uncertain than the preceding one, and on this account it is 
 not recommended. 
 
 In the majority of cases of cysts or abscesses of the liver, 
 it is advisable to adopt the method of immediate incision and 
 drainage. Of course, if the liver has become adherent to the 
 overlying portion of the abdominal wall, direct incision will 
 be carried out. In cases of hepatic abscess it is not advisable, 
 and often not justifiable, to lose several days in waiting for 
 adhesions to form, but when the presence of pus has been 
 definitely diagnosed it ought to be evacuated at once. In those 
 cases of cystic disease of the liver in which suppuration has not 
 occurred, there is no serious objection to the latter method 
 of operation. As, however, operations can be carried out under 
 strict antiseptic precautions and conditions, there is very little 
 advantage to be gained by operating in two stages. 
 
 (d) Incision through the thoracic walls, vjhich is followed hy 
 incision of the liver and subsequent drainage. — The operation of 
 hepatotomy, when carried out through the thoracic wall, may 
 be performed in either one or two stages, as in the case of 
 operation through the abdominal wall. 
 
 Operation at one sitting. — A site is selected on that part of 
 the thoracic wall which overlies the most prominent portion 
 of the hepatic swelling, and an incision, three inches long, which 
 may be lengthened if necessary during the later stages of the 
 operation, is made parallel to a rib. The rib is exposed, the 
 structures which are attached to it separated, and then a portion 
 
314 OPERATIONS UPON THE LIVER. 
 
 of it is excised. The underlying costal layer of the pleura is 
 next divided and the cavity of the pleura opened, when the air 
 rushes inwards and the lung of the corresponding side becomes 
 collapsed. The layer of pleura which covers the adjacent portion 
 of the diaphragm is now sought for and brought as far as possible 
 into the wound, and an incision an inch or more in length is 
 made into it. The margins of the wounds in the two layers of 
 the pleura (the costal and the diaphragmatic) are closely 
 approximated, and united with numerous fine silk sutures. At 
 this stage of the operation it may in some cases be found neces- 
 sary to aspirate the hepatic swelling and remove a portion of the 
 fluid contents, so as to relax the diaphragm and the pleura. The 
 diaphragm in the bottom of the wound is next incised, and 
 sutures are passed through it so as to fix it to the margins of 
 the wound in the thoracic wall. By these means the pleural 
 cavity of the affected side (the right) is completely shut off from 
 communication with the external atmosphere, and also from the 
 swelling which is about to be incised. An incision is now made 
 through the hepatic tissue where it is exposed at the bottom of 
 the wound, and is deepened until the cavity of the abscess or 
 hydatid cyst is reached. When this has been done, the abscess 
 or cyst is evacuated and treated in a manner similar to that 
 which has been described when the abdominal operation was 
 under consideration. The extremities of the incision in the 
 thoracic wall may be closed with sutures, if it is thought advis- 
 able. In order to obtain complete closure of the pleural sac, 
 it has been recommended to apply a continuous suture to the 
 two layers of pleura. 
 
 Operation a deux temjjs. — In this operation the early stages 
 are similar to the preceding. When the layers of the costal and 
 diaphragmatic pleurse have been incised and united with sutures, 
 the wound is plugged with aseptic gauze, and left for several 
 days. After the expiration of three to five days, an incision is 
 made into the liver, and the abscess or cyst opened and treated 
 in a manner similar to the above. In most cases it will be 
 found advisable to complete the operation at one sitting, since 
 the parts become coated with layers of lymph, and it becomes 
 very difficult to recognise the different anatomical structures as 
 they lie in the bottom of the wound. 
 
 Heixdcctomy. — It is only during recent years that surgeons 
 have successfully removed portions of the liver by operation. 
 
HE PA TE CTOMY. 3 1 5 
 
 The operation has been called " resection of the liver," or 
 hepatectomy. In those cases in which portions of the liver 
 have been removed a fair amount of success has been met with, 
 and it is to be hoped, by the introduction of improved details 
 of technique, that this operation may become a recognised 
 and justifiable one, since there are many affections of the liver 
 which only admit of a cure being obtained by a complete and 
 radical removal of the diseased tissue. All operations of this 
 nature which involve the liver are limited to the removal 
 of a portion of the organ, since it is not possible for a 
 person or mammal to live when the entire organ has been 
 taken away, even if this operation were possible from a 
 merely operative point of view. The removal of portions of 
 the liver can be effected according to one of the following 
 methods, each of which has been used and recommended by 
 surgeons of repute. 
 
 {a) Fixation of the diseased portion of the liver in a7i 
 abdominal wound and ajiplication of an elastic ligature to its hase, 
 so as to cause sloughing of the parts distal to the ligature. — When 
 the abdominal walls have been prepared for the performance of 
 an aseptic operation, and the patient has been anaesthetised, an 
 incision, from four to six inches long, is made through that 
 portion of the abdominal wall which overlies the affected 
 portion of the liver, commencing above at the costal margin 
 and extending downwards in a vertical direction. This incision 
 is deepened until the parietal peritoneum is reached, when it is 
 divided for the entire length of the wound. All haemorrhage 
 from blood vessels in the - incised abdominal walls is arrested, 
 and then that portion of the liver which it is wished to remove 
 is brought well into the wound, and made to protrude externally, 
 so that the base of the diseased part can be brought into good 
 apposition with the margins of the wound in the abdominal 
 parietes. A series of silk sutures is next passed through the 
 liver substance, well beyond the diseased area, and then through 
 the abdominal wall a short distance from the margins of the 
 incision, so that when these are tied the liver is firmly fixed to 
 the abdominal wall, and the diseased portion protrudes externally. 
 That portion of the abdominal wound which lies below the pro- 
 truded part of the liver is closed in the ordinary manner with 
 silk sutures. An elastic ligature is placed around the base of 
 the protruded piece of liver, but distal to the ring of sutures 
 
3i6 OPERATIONS UPON THE LIVER. 
 
 which fix the organ to the anterior abdominal wall. This 
 ligature is allowed to remain in position for three or four days, 
 the area of the operation being protected by the application of 
 aseptic dressings. About the third day the elastic ligature is 
 replaced by a second one, which is more tightly applied, and, if 
 requisite, this in its turn is also replaced by a still tighter one. 
 By these means the portion of the liver which lies beyond the 
 elastic ligature is made to undergo a necrotic change, and in 
 a short time it becomes separated as a slough or mass of 
 gangrenous tissue. When the constricted portion has separated 
 from its connection with the remainder of the liver, the base of 
 the protruded portion will cicatrise and heal. The separation of 
 the protruded portion may be hastened by the use of the actual 
 cautery, on the tenth or twelfth day after the application of the 
 elastic ligature. If the gangrenous portion remains too long in 
 connection with the liver, putrefactive changes are very liable to 
 become established, and the abdominal wound, or the liver itself, 
 may become the seat of suppuration. Llicke ^ has removed a 
 cancerous mass from the left lobe of the liver by this method, 
 and the patient recovered, whilst a similar result followed in 
 a case of multilocular hydatid cysts, which was operated upon 
 by Terrillon.- Bastianelli,^ Hochenegg,* and Schmidt ^ have also 
 operated upon the liver in this manner. 
 
 (&) 'Fixation of the, diseased portion of the liver in an 
 abdominal ivo7ind, and removal of the affected part after the liver 
 has hecome adherent to the margins of the incision (ojjcration a 
 deux tempis). — The early stage of this operation is exactly similar 
 to that of the preceding. The portion of the liver which it is 
 desu^ed to remove is fixed by its base to the margins of a wound 
 in the anterior abdominal wall, where it is left for several days 
 or more. When the liver has formed adhesions to the margins 
 of the abdominal wound, the second stage of the operation is 
 performed. The portion of the liver which protrudes is detached 
 from the remainder of the gland, either by cutting it away with 
 a knife or with a Paquelin's cautery. As the piece of liver is 
 
 1 Liicke, " Entfernuiig des liukyukrebsigen Leberlappeu," Centralbl. f. Chir., 
 Leipzig, 1891, s. 118. 
 
 ' Terrillon, " Chirurgie du foie," Bull. Soc. de chir. de Paris, 1890, p. 855. 
 
 ' Bastianelli, op. cit. 
 
 •« Hochenegg, " Eiii Beitrag zur Leberchinirgie." Wii^n. klin. Wchnschr., 1890, 
 ss. 223 aud 1008. 
 
 ^ Schmidt, " Ueber LeberresL-ctioii," Deutsche mcd. Wchnschr., Leipzig, 1893, No. 8, 
 s. 175. 
 
HEPATECTOMY. 317 
 
 removed the cut surface should be covered with a sponge, and 
 pressure applied so as to arrest temporarily any htomorrhage 
 which may occur, and to prevent the possibility of entrance of 
 air into the open mouths of the intra-hepatic veins, and thereby 
 to avoid air embolism. When the portion of the liver has been 
 detached the sponge pressure is relaxed, and all bleeding points 
 upon the cut surface are ligated with silk. After haemorrhage 
 has been arrested in this manner, the cut surface of the organ is 
 irrigated so as to remove all traces of blood and debris, and then 
 an aseptic dressing is applied and is firmly fixed in position by 
 strapping and a bandage. Miiller, Tillmans,^ and Tricomi ^ have 
 resected portions of the liver by this method, and they speak well 
 of the operation. In order to avoid the exposure of large cut 
 surfaces of the liver after the resected portion has been taken 
 away, it appears to me that in the second stage of the operation 
 it would be preferable to resect the part of the liver which is to 
 be removed, by the employment of a wedge-shaped incision, such 
 as is described later. If this form of incision in the liver were 
 adopted, it would be possible to bring together the margins of 
 the hepatic wound, and fix them in apposition by the insertion of 
 sutures. All fear of the occurrence of h£emorrhage and air- 
 embolism may thus be avoided. In all cases of exposure of a 
 cut area of the liver, great care must be taken to prevent the 
 entrance of air into the hepatic veins, since in these structures the 
 venous blood pressure may be negative, and air tend to be drawn 
 inwards by suction. Some authors have recommended that, 
 after the portion of liver has been detached with the knife, the 
 actual cautery should be applied to the cut surface, so as to 
 arrest haemorrhage and prevent the occurrence of air embolism. 
 If it is wished to make use of the cautery, it appears to me to be 
 preferable to remove the piece of the liver with the knife of 
 a Paquelin's cautery, and so arrest all hccmorrhage as the 
 operation proceeds. The objection to the use of the cautery in 
 these cases is the necessary necrosis of charred tissue which must 
 follow, and the liability to suppuration as the dead tissue is being 
 separated or absorbed. A number of cases have been recorded 
 in which a portion of the liver has been protruded externally 
 through a penetrating wound of the abdominal wall, and this 
 protruded part has been removed, either by encircling its base 
 
 1 Tillmaus, Ber. u. d. Verhandl. d. deutsch. Gesellsch. f. Chir., Leipzig, 21 Coug. s. 73. 
 
 2 Tricomi, iJev. de chir.. Paris, 1894, p. 433. 
 
3i8 OPERATIONS UPON THE LIVER. 
 
 with an elastic ligature and causing it to slough, or with the knife, 
 after which the base has been cauterised to prevent hemorrhage, 
 (c) Removal of tumours and cysts from the liver hy dissection, 
 and subsequent closure of the wound in the liver iy sutures, 
 together with simultaneous clos7ire of the ahclominal incision. — 
 Tumours of the liver which are completely encapsuled, or 
 hydatid and other forms of cysts which are embedded in the 
 gland, may be removed by dissection. After the surface of that 
 portion of the liver which contains the tumour or cyst has been 
 exposed by an incision in the abdominal wall, the surrounding 
 portion of the peritoneal cavity is packed with aseptic sponges, 
 so as to avoid contamination of the peritoneum with blood or 
 foreign material, or injury to the intestines, and then an incision 
 is made into the hepatic substance until the superficial portion 
 of the tumour is exposed. The tumour or cyst is then separated 
 from the normal hepatic tissue by a process of careful dissection, 
 and all bleeding vessels clamped and tied as the operation pro- 
 ceeds, so as to avoid, as far as possible, any severe loss of 
 blood. When the tumour has been removed in this manner, and 
 all haemorrhage arrested, the surfaces of the wound in the liver 
 are brought into apposition and fixed by the insertion of sutures. 
 If the cavity extends for some distance into the substance of the 
 gland, it is advisable that its deep parts should be approximated 
 by the insertion of one or more tiers of buried sutures, and 
 finally the margins of the wound on the surface of the liver are 
 fixed in accurate apposition by the insertion of a row of fine 
 sutures, which should not be more than one-third of an inch 
 apart. When the incision in the liver has been treated in this 
 manner, the organ is dropped back into the abdominal cavity, 
 and after all sponges, blood, and other material have been 
 removed from the peritoneum, the abdominal wound is closed in 
 the usual manner. Great care must be taken in. the perform- 
 ance of this operation, not to include the portal vein, or one of 
 its large branches, within any of the ligatures or sutures. I have 
 seen one case in which this accident happened, and the patient 
 died a few hours afterwards from abdominal haemorrhage and 
 arrest of the circulation of the blood through the portal vein, 
 Tansini^ has recorded a case of hydatid cyst of the liver which 
 he treated in this manner, and the patient rapidly recovered. 
 
 1 Fogliani, "Estirpazione totale di cisti di echinococco," etc., Gaz. d. Os])., Napoli, 
 Jan. 21, 1891, p. 45. 
 
HEPATECTOMY. 319 
 
 Bergmann,^ Ktister, and Eiselberg ^ have removed portions of 
 the liver containing cysts and tumours in a manner resembling 
 the above, and they recommend that a small portion of the 
 abdominal incision should be left open, and that the cavity in 
 the liver should be packed with a long strip or tampon of 
 aseptic gauze, the end of which is made to pass out through the 
 open angle of the abdominal wound. After one or two days it 
 is removed, and the abdominal wound is allowed to close. It is 
 thought that this precaution diminishes the liability of the 
 occurrence of haemorrhage from the injured area of the liver. 
 
 {d) Excision of a 'portion of the, liver ly the employment of a 
 loed'je-sha'ped ineidon. — The author has performed this opera- 
 tion a number of times with success in a series of investigations 
 upon the " surgery of the liver and biliary passages," which have 
 been carried out at the laboratories of the Eoyal Colleges of 
 Physicians and Surgeons. In most cases the animals used for 
 the experiments were cats. From the success which was met 
 with in these experiments, and the comparative ease with which 
 the removal of portions of the liver was effected, it seems 
 possible that a similar operation may, in suitable cases, be made 
 use of in man when it is necessary to remove portions of the 
 liver. The operation is performed in the following manner : — 
 The abdominal walls are cleansed and rendered aseptic in 
 the ordinary manner, and then a vertical incision, 4 to 6 in. 
 long, is made through the abdominal walls, commencing above at 
 the costal margin and situated over that portion of the liver 
 which it is wished to remove. In most cases it will be found 
 that the incision can be made in either the linea alba or in the 
 right or left linea semilunaris. The peritoneal cavity is opened 
 for the entire length of the incision, and then the affected 
 portion of the liver is brought out into the abdominal wound, 
 and its base surrounded with an elastic ligature, which is applied 
 sufficiently tightly to control the circulation of the blood in the 
 part of the liver beyond its line of application. A piece of 
 moderately stout red indiarubber tubing will be found to be the 
 most suitable material for the purpose. The surrounding area of 
 the peritoneal cavity is packed with large flat sponges, and care 
 is taken not to include a coil of intestine or a piece of the 
 
 1 Bergmanu, "Zur Casuistik der Leber-Chirurgie," Arch. f. klin. Chir., Berlin, Bd. 
 xlvi. s. 394. 
 
 - Eiselberg, " Cavernom der Leber," Wien. klin. Wchnschr., 1893, No. 1. 
 
OPERATIONS UPON THE LIVER. 
 
 omentum within the elastic ligature. 
 
 The liver is now incised, 
 the line of the incision 
 being elliptical in shape 
 and surrounding the 
 tumour or cyst which it 
 is wished to remove. 
 The incision is deepened 
 in such a manner that 
 the two sides of the 
 incision tend to meet one 
 another in the substance 
 of the liver beyond the 
 deep limits of the tumour. 
 The piece of liver and the 
 contained tumour when 
 removed in this manner 
 have the form and shape 
 of a blunt wedge, and 
 the wound which is left 
 after the removal of the 
 diseased portion presents 
 two surfaces which can 
 easily be brought into 
 
 apposition in a manner similar to that in which the two flaps of 
 
 an amputation are ap- 
 proximated. The lines 
 
 of the incisions, after the 
 
 wedge - shaped portion 
 
 has been removed, are 
 
 shown in Figs. 45 and 
 
 47. The larger branches 
 
 of the portal vein and 
 
 the hepatic artery which 
 
 have been divided will 
 
 usually be found to lie 
 
 in the region of the angle 
 
 at the bottom of the 
 
 incision, and there they 
 
 can be picked up with 
 
 fine artery forceps, and 
 
 tied with fine silk. It 
 
 Fig. 45. — Resection of liver. Method of inserting 
 sutures into the liver after a "wedge-shaped" 
 portion has been removed. This diagram shows 
 all the sutures in position loefore any have been 
 tied. In this case the portion of the gland which 
 has been resected has been from the antero- 
 inferior margin, and the adjacent parts of the 
 inferior and anterior surfaces of the left lobe. 
 
 Fk;. 46. — Resection of liver. Same as Fig. 45, but 
 with all the sutures tied and the ends cut short. 
 
HEPATECTOMY. 
 
 321 
 
 will be necessary, in order to secure all the bleeding points, for 
 
 the assistant who has charge of the elastic ligature to relax it 
 
 slightly, so as to allow 
 
 the smaller vessels to 
 
 bleed, for they can 
 
 then be recognised 
 
 and tied. In the case 
 
 of the larger vessels, 
 
 however, they will be 
 
 readily seen on the 
 
 cut surface of the 
 
 liver, and can be 
 
 tied without relaxing 
 
 the encircling rubber 
 
 tubes. All ligatures 
 
 which are applied 
 
 for the arrest of 
 
 haemorrhage are cut 
 
 short, and then the 
 
 two flaps of the liver 
 
 are brought into 
 
 exact apposition, and 
 
 are fixed in this 
 
 position by the insertion of a row of silk sutures, which are about 
 
 one-third of an inch 
 apart. If the wound 
 in the liver is a deep 
 one, it may be re- 
 quisite to unite its 
 deeper parts with 
 buried sutures, but 
 in most cases this 
 will not be neces- 
 sary. Each suture 
 passes through both 
 flaps, and the method 
 of insertion is illus- 
 trated in Fiss. 45 
 and 47. Eor the 
 needle of the shape 
 
 shown in Fig. 49 is the best. The portion of the needle near 
 
 Fig. 47.— Resection of liver. Method of inserting sutures 
 after a "wedge-shaped" portion of the liver has been 
 resected from the surface of the gland. This illustra- 
 tion shows all the sutures in position before any have 
 been tied. 
 
 Fig. 48. — Resection of liver. Same as Fig. 47, but with all 
 the sutures tied and the ends cut short. 
 
 introduction of the sutures a large curved 
 
32 2 OPERATIONS UPON THE LIVER. 
 
 the point is flattened, so that its long edge is parallel with the 
 margin of the wound. The sutures are not so liable to cut out 
 as when they have been introduced with an ordinary Hagedorn's 
 
 needle. When the entire row of 
 
 ^ n sutures has been introduced, the 
 
 \ / sutures are tied, and their ends cut 
 
 ^^ y short. Each suture is only tied tight 
 
 ^^s^=— ggss*^ enough to hold the surfaces of the 
 
 Fig. 49.— Needle for introduction jiyer flaps in approximation, and if 
 
 of sutures into liver tissue. , ^ p • t ■ j_ ■ 
 
 too much rorce is used m tymg 
 them, it will be found that they cut through the edges of 
 the flaps, an accident which must be avoided if possible. 
 At the points of entrance and exit of the suture needle, 
 there is in most cases rather brisk hemorrhage at first, but 
 this soon ceases spontaneously. When all sutures have been 
 introduced, tied, and the ends cut short, the stump of liver is 
 dropped back into the abdominal cavity. The exposed part of 
 the peritoneal cavity is well sponged, so as to remove any debris, 
 and the wound in the abdominal parietes is then closed. In those 
 cases in which a large portion of hepatic tissue has been removed, 
 or if there is a tendency to haemorrhage from the incised portion 
 of the liver, it will be advisable to pack the hepatic wound with 
 a long strip of aseptic gauze, the end of which is allowed to 
 remain protruding from an unclosed portion of the parietal 
 wound. This strip of gauze or tampon is removed at the 
 expiration of one or two days, and the wound in the abdominal 
 wall is allowed to close, or it may be closed by the insertion of 
 one or two points of silk suture. If on the removal of the strip 
 of gauze there are signs of haemorrhage or of the development of 
 peritonitis, the wound should be again packed with a strip of 
 gauze, so that drainage may take place, and the appearance of 
 any further symptoms or complications recognised. It has been 
 recommended by some surgeons that a glass or rubber drainage- 
 tube should be passed down to the region of the wound in the 
 liver, and left in for a few days. The employment of a long 
 strip of absorbent aseptic gauze appears to serve all the purposes 
 of a drainage-tube, whilst it does not possess its disadvantages. 
 
 Ilepatojiexy or HeiJatorrhcqihy. — The operation of hepatopexy 
 or hepatorrhaphy has for its object the fixation of an abnormally 
 movable liver to the abdominal or thoracic parietes. The 
 entire liver, or only one portion of it, may be movable and 
 
HEPATOPEXY AND HEPATOSTOMY. 323 
 
 require fixation. In most cases it has been found that it is 
 the right lobe which requires to be anchored to the thoracic 
 wall. In those cases in which only one lobe needs fixation the 
 operation is called partial hepatopexy, whilst if the entire organ 
 requires anchorage it is called complete hepatopexy. On account 
 of the extreme difficulty which is met with in making a diagnosis 
 of the presence of a movable liver, it will be found necessary in 
 nearly all cases to perform an exploratory laparatomy in order to 
 confirm the diagnosis. When the diagnosis of the condition 
 of movable liver has been confirmed, an incision is made through 
 the anterior abdominal wall over the movable portion of the 
 organ, and immediately below and parallel with the costal 
 margin. The liver is then replaced in its normal position in the 
 upper portion of the abdomen, and a number of stout silk 
 sutures are passed deeply into its substance, and then through 
 the posterior aspect of the overlying portion of the anterior 
 abdominal wall. When these sutures have been introduced they 
 are tied, and by this means an attempt is made to fix the liver in 
 its normal position. The ends of the sutures are cut short and 
 the incision in the abdominal parietes closed in the usual manner. 
 The patient is kept at rest in bed, lying in the dorsal position 
 for several weeks, after the operation. In one case of this kind, 
 which was operated upon by Langenbuch, the patient could walk 
 about six weeks after the operation. In a second case, which 
 also was operated upon by Langenbuch, a nephrorrhaphy for 
 a floating kidney was also performed at the same time. In 
 both these cases the liver was only partially movable. Gerard 
 Marchant,^ using silk sutures, has successfully fixed a liver which 
 was completely displaced, to the costal cartilages and the 
 anterior abdominal wall. This is the only case of complete 
 hepatopexy which has been described in the records of surgery, 
 according to my knowledge. The operation was completely 
 successful. 
 
 Hepatostomy. — This operation has for its object the creation 
 of a cutaneous biliary fistula, the deep extremity of which com- 
 municates with the lumen of one or more of the intra-hepatic 
 bile ducts. It was performed by Knowsley Thornton ^ on a 
 patient who suffered from a large accumulation of biliary calculi 
 within the intra-hepatic bile ducts. It is carried out through an 
 
 1 Gerard Marchaut, " Hepatopexie," Bull. Acad, de med., Paris, Aug. 11, 1891. 
 
 2 Thornton, Brit. Med. Journ., Loudon, 1887. 
 
324 OPERATIONS UPON THE LIVER. 
 
 abdominal incision made over that portion of the liver in which 
 the dilated and calculus-containing bile ducts are situated. 
 When the surface of the liver is exposed, an incision is made 
 through the hepatic tissue, and deepened until the dilated bile 
 duct is opened. The contained calculi are removed, and then the 
 margins of the wound in the liver and the dilated intra-hepatic 
 bile ducts are united to those of the incision in the abdominal 
 parietes, the remaining portion of the external wound being 
 closed in the usual manner. During the performance of the 
 operation the peritoneal cavity is packed with flat sponges, to 
 prevent the possibility of any septic contamination, owing to the 
 entrance of any of the material which is removed from the 
 interior of the dilated bile ducts. Before the peritoneal cavity is 
 closed it is advisable to examine the course of the extra-hepatic 
 bile ducts, to ascertain if calculi are arrested in any portion 
 of them. If any are found they should be removed, according 
 to the methods which have already been discussed. The patient 
 who was operated upon by Thornton recovered after more than 
 four hundred calculi had been extracted. 
 
 Baudouin ^ has recently described this operation under the 
 name of " Cholangiostomie." 
 
 1 Baudouin, Progres med., Paris, April 25, 1896. 
 
CHAPTER XXV. 
 
 OPERATIONS UPON THE GALL BLADDER. 
 
 Tapping and Aspiration. — The operation of tapping or aspiration 
 of the gall bladder has been performed both as a diagnostic 
 measure and as a form of treatment. It can be done either 
 with a trocar and cannula, or with the needle of some form of 
 aspirator or exploring syringe. In most cases it will be found 
 convenient and advisable to use the form of aspirator which 
 is known as Potain's. In aspirating a swelling which is situated 
 in the hepatic area or connected with the liver, the most 
 prominent portion of the tumour is selected, and the skin over it 
 rendered as aseptic as possible, by washing first with soap and 
 water, then with ether, and finally with a solution of corrosive 
 sublimate (1—500). The needle of the aspirator is pushed 
 inwards through the abdominal wall until it enters the interior 
 of the swelling. Care must be taken not to force the point 
 of the needle beyond the swelling which is the subject of 
 examination, otherwise important anatomical structures in the 
 immediate neighbourhood of the gall bladder and liver may 
 be injured. When the point of the needle has been felt to 
 enter the interior of the tumour or swelKng, it is connected with 
 the pump of the aspirator, and a sufficient quantity of the 
 contents are withdrawn to allow of an examination of the 
 substance or fluid being made. In those cases in which aspira- 
 tion is carried out as a form of treatment, the amount of fluid 
 which is to be withdrawn depends upon the object of the 
 operation and the pathological condition for which it is done. 
 Thus, in cases of hydatid disease of the liver, it may be desired 
 to withdraw only a few drachms of the fluid contents, or it may 
 be wished to empty the cystic swelling completely. After this 
 operation has been performed for the purposes of diagnosis, the 
 fluid contents of the enlarged gall bladder or other form of 
 tumour which is being examined, are very liable to leak and 
 
326 OPERATIONS UPON THE GALL BLADDER. 
 
 escape through the tract of the pvincture into the peritoneal 
 cavity, and give rise to acute peritonitis. 
 
 In those cases in which the gall bladder is the seat of an 
 inflammatory or septic process, septic peritonitis is very liable to 
 develop after the aspiration has been carried out. Many cases 
 have been recorded in which fatal results have followed a simple 
 exploratory puncture with the needle of an aspirator or a small 
 trocar. On account of the frequency of fatal results from this 
 method of procedure, it is very undesirable that aspiration of a 
 tumour or swelling of the gall bladder should become a routine 
 method of diagnosis in obscure cases ; and it is recommended that 
 it should only be performed exceptionally, and in those cases in 
 which permission is given to perform any further operation 
 which may prove to be requisite after the examination has been 
 made. When it is impossible to establish a diagnosis without 
 examining the contents of the tumour, it is safer for the patient 
 to submit to an exploratory laparotomy, so that the exact nature 
 of the swelling can be made out, and if it is necessary to 
 perform an operation for the relief of the abnormal condition, 
 this can be carried out through the same incision in the ab- 
 dominal wall, the wound being lengthened if requisite. The 
 trocar and cannula, or the aspirator, is often found to be of 
 considerable use in drawing off the contents of a distended gall 
 bladder or of a cyst, after an incision has been made through the 
 abdominal wall, and the surface of the swelling has been 
 exposed, since evacuation of the contents facilitates the free 
 exposure of the gall bladder, and enables the surgeon to draw 
 the distended viscus into the wound. 
 
 Sounding for gall stones. — A method of examination of 
 patients who are supposed to be the subjects of gall stones, 
 which has been advocated by Harley and other observers, has 
 been called " sounding for gall stones." This procedure is carried 
 out by introducing a long needle through the anterior abdominal 
 wall in the immediate neighbourhood of the swelling supposed 
 to be a gall bladder or bile duct containing a calculus, and feel- 
 ing with the point of the instrument for any hard solid body 
 which may be a gall stone. Instead of plunging the sounding 
 needle directly through the abdominal wall, a trocar and cannula 
 may first be pushed into the swelling. After withdrawal of the 
 trocar, a needle is passed through the cannula, and the area of the 
 swelling is then examined. This appears to me to be a most 
 
CHOLECYSTOTOMY. 327 
 
 dangerous method of examination, since the results which may- 
 follow its employment are very uncertain, and injuries of the 
 liver, gall bladder, great blood vessels, and other adjacent viscera, 
 may very easily and unknowingly be inflicted, and give rise to 
 a fatal termination. A fatal result followed in one case which 
 was examined in this manner by Harley. In those cases in 
 which it is not an easy matter to make an exact diagnosis, it 
 is far safer and much more satisfactory to make a small incision 
 through the abdominal wall over the prominent portion of the 
 swelling, and to examine with the fingers the relations and con- 
 nections of the abnormal swelling, and its position with regard 
 to the different parts of the biliary system. Even if no further 
 operative measures can be employed for the alleviation of the 
 disease, no ill results are likely to follow an examination of this 
 kind, if it is carried out under strict aseptic precautions. 
 
 Cholecystotomy. — By this term we understand the performance 
 of an operation which involves making an incision in the wall of 
 the gall bladder through a wound in the overlying portion of the 
 abdominal wall, and fixing the margins of the incision in the gall 
 bladder to the lips of the parietal wound. This operation is 
 apparently a comparatively modern one, and Bobbs of Indiano- 
 polis appeared to have performed it successfully for the first 
 time in 1867, whilst Marion Sims in 1878 described in detail 
 the method of performance of the operation. There are several 
 varieties of this operation, the distinctions between them depend- 
 ing upon whether the operation is performed in one stage or two, 
 and whether or not the gall bladder is fixed to the margins 
 of the incision in the abdominal wall, before its interior is 
 examined through an incision in its walls ; and also upon the 
 method of after-treatment, when the cavity of the viscus has 
 been examined and any stones which may have been present 
 removed. The form of operation which will be found of the 
 most use, and applicable in the majority of cases of gall stones, 
 is the following : — 
 
 Operation. — The patient is placed in the dorsal position, and 
 the abdominal walls are rendered thoroughly aseptic in the usual 
 manner. An incision is then made through the abdominal 
 parietes over the most prominent portion of the tumour. In 
 most cases it will be found convenient to make this incision in 
 a vertical direction, commencing above immediately below the 
 costal margin, and, if possible, in the right linea semilunaris or 
 
528 OPERATIONS UPON THE GALL BLADDER. 
 
 in the linea alba. In those cases of supposed gall stones in 
 which no tumour can be felt it is usually advisable to make the 
 incision in the right linea semilunaris, commencing above at the 
 ninth costal cartilage. The incision in the abdominal parietes is 
 at first made about three inches in length, but it can be made 
 longer if the nature of the case requires it. The incision is 
 deepened until the peritoneum has been divided for the entire 
 length of the wound, all bleeding points in the tissues of the 
 abdominal wall being ligatured before the peritoneal cavity is 
 
 opened. The gall bladder is 
 sought for and brought into 
 the wound, if it does not at 
 once protrude. In many cases 
 of gall stones it will be found 
 to have acquired fibrous ad- 
 hesions to the adjacent viscera, 
 and in order to bring it to the 
 surface these adhesions may 
 require to be separated and 
 ligatured. If the gall bladder 
 is distended, and fills up that 
 portion of the abdomen in the 
 region of the wound, it may be 
 difficult at first to ascertain 
 the exact nature of the con- 
 ditions which are presented. 
 In these cases it is better to 
 pack the region of the dis- 
 tended gall bladder with flat 
 sponges, in order to protect 
 the intestines and other viscera 
 from injury or contamination, and then to evacuate the 
 fluid contents of the swelling with a trocar and cannula 
 or an aspirator. Care must be taken, especially in those 
 cases in which the gall bladder is the seat of an inflammatory 
 condition, not to allow the peritoneum to become contaminated 
 with the material which is removed from the cavity of the in- 
 flamed viscus. When the gall bladder has been emptied in this 
 manner, the walls become flaccid, and it can readily be drawn 
 into the parietal wound. A vertical incision, about one inch in 
 length, is then made in the fundus of the gall bladder, and its 
 
 Fig. 50. — Incision in right linea semilunaris 
 for cholecystotomy. 
 
CHOLE C YSTO TOM V. 
 
 329 
 
 margins are held apart with forceps. As the wall of the gall 
 bladder is divided, a strong silk ligature is passed through each 
 margin of the wound, and the ends are given to assistants to 
 hold. These ligatures serve to hold the gall bladder well up in 
 
 Fig. 51. — Cholecystotomy forceps (Tait's pattern). 
 
 the wound, and to approximate its walls to the margins of the 
 incision in the abdominal parietes, and so avoid or minimise the 
 possibility of the entrance of extraneous matter into the peri- 
 toneal cavity. The cavity of the organ is now thoroughly 
 
 Fig. .52. — Cholecystotomy forceps (Anderson's pattern 
 
 examined with the finger, and all calculi are removed either 
 with the finger or with long and fine lithotomy forceps. Some- 
 times a gall stone is found embedded in or grasped by the neck 
 of the gall bladder and the commencement of the cystic duct, 
 
 Fig. 53. — Cholecystotomy. Scoop for removing gall stones from gall 
 bladder or cystic duct (Tait's pattern). 
 
 in which case it is seized with the forceps and carefully extracted. 
 If it is firmly fixed, its removal may be facilitated and rendered 
 possible by passing the finger into the peritoneal cavity in the 
 region of the cystic duct, and manipulating the stone from the 
 external aspect of the neck of the gall bladder and the cystic 
 
330 OPERATIONS UPON THE GALL BLADDER. 
 
 duct. By the adoption of this method of manipulation, calculi 
 in this position can, in nearly every case, be dislodged and 
 removed. After the gall bladder has been evacuated in this 
 manner, its interior is irrigated with a dilute antiseptic solution, 
 and is then packed temporarily with a sponge, to which a silk 
 thread is attached. The sponges or pads of gauze which were 
 used to protect the peritoneum are now removed, and a complete 
 and systematic examination of the course of the extra-hepatic 
 bile ducts made, in order to ascertain if there are any calculi or 
 other forms of obstruction present. The course of the cystic 
 duct should be examined first, and afterwards that of the common 
 bile duct, both as it passes through the gastro-hepatic omentum, 
 and also as it lies behind the first part of the duodenum and in 
 relation with the head of the pancreas. In order to carry out 
 this examination, it is necessary to have the coils of intestine 
 well retracted towards the left by the fingers of an assistant. 
 If any pathological condition, such as tho impaction of a calculus, 
 is found in the cystic, hepatic, or common bile ducts, it is dealt 
 with according to the methods which are described later when 
 the operations upon these ducts are under consideration. These 
 measures having been carried out, if it is decided that they are 
 requisite, the peritoneum is rendered free from all blood and 
 other foreign matter, and then the margins of the incision in 
 the gall bladder are joined to those of the parietal wound by the 
 insertion of a number of interrupted silk sutures, which are 
 introduced at intervals of one-third of an inch. Each suture 
 passes through the wall of the gall bladder and through the 
 abdominal wall, the entire row being introduced before any are 
 tied. The uppermost and the lowermost of the sutures which 
 pass through the wall of the gall bladder are made to pass from 
 one side of the wound in the parietes to the other, and to pick 
 up the muscular and serous coats of the gall bladder just beyond 
 the angles of the incision. By this means the angles of the 
 wound in the gall bladder are lifted well into the abdominal 
 wound, and any escape of fluid at these spots is avoided. The 
 portion of the wound in the abdominal wall which lies above 
 and below the opening in the gall bladder is carefully closed 
 with silk sutures in the ordinary manner, and all possibility of 
 infection of the peritoneum avoided, as far as possible. When 
 the gall bladder has been fixed to the abdominal wall, and the 
 remainder of the parietal incision closed, a guarded red rubber 
 
CHOLE CYSTOTOMY. 33 1 
 
 drainage-tube is passed into its cavity so as to allow of free 
 drainage, and then aseptic absorbent dressings are applied. In 
 some cases the anterior surface of the fundus of the distended 
 gall bladder is found to be adherent to the posterior aspect of 
 the anterior abdominal wall, and when this condition is met 
 with an incision can at once be made into the cavity of the gall 
 bladder, and its contents evacuated. When this has been 
 done, the interior is washed out ; the after-treatment is similar 
 to that mentioned above. If the operation has been successful 
 as regards the removal of all causes of obstructioil, the biliary 
 fistula which results from the fixation of the aperture in the 
 gall bladder to the abdominal wall will usually close within a 
 few weeks from the time of the operation ; but if it does not 
 close spontaneously, it is necessary to deal with the fistula 
 according to the methods which are considered in Chapter XXII. 
 This is the best variety of the operation of cholecystotomy, since 
 it allows the surgeon to make a complete examination of the 
 entire course of the biliary ducts ; and on this account it is 
 recommended. The operation itself has been called " cholecyst- 
 otomy with primary incision of the gall bladder and secondary 
 fixation to the abdominal wall," in contradistinction to another 
 variety in which the gall bladder is first fixed to the margins of 
 the abdominal wound by sutures, and its wall subsequently 
 incised, its interior examined, and its contents evacuated. The 
 advantage of this operation is that the peritoneum is less likely 
 to become contaminated, but this is much outweighed by the dis- 
 advantage of not being able to examine the course of the bile 
 ducts ; and, moreover, in the first-described operation, if care is 
 taken to protect the peritoneum, no contamination need result. 
 On this account the performance of the operation with primary 
 incision of the gall bladder and secondary fixation to the abdominal 
 wall is strongly recommended, in all cases in which it is necessary to 
 examine the interior of the gall bladder and to remove pathological 
 collections from its cavity. When the operation is performed 
 in two stages, it has been called " cholecystotomy a deux tem^js." 
 In the first stage the abdominal wall is incised and the fundus 
 of the gall bladder is fixed in the incision and left for three to 
 five days, when an incision is made through the exposed area, 
 the interior of the organ examined, and any purulent collections 
 or calculi removed. This form of operation is not recommended, 
 since it does not allow the operator to make an examination of 
 
332 OPERATIONS UPON THE GALL BLADDER. 
 
 those parts of the bile ducts which lie beyond the gall bladder 
 or the commencement of the cystic duct. 
 
 The performance of the operation of cholecystotomy is 
 indicated in the following clinical and pathological conditions : — 
 
 (a) In cases of empyema of the gall bladder. In this con- 
 dition the gall bladder is filled with purulent fluid, which may 
 contain a number of calculi. Empyema of the gall bladder may 
 occur in connection with gall stones, inflammatory affections of 
 the bile ducts owing to extension from the duodenum, the passage 
 of an ascaris into the gall bladder, in typhoid fever, in tubercular 
 disease of the gall bladder, and in connection with primary new 
 growths which involve the mucous membrane. 
 
 (&) In cases in which it is desirable to establish a temporary 
 biliary fistula. 
 
 (c) In cases of distension of the gall bladder with mucus, 
 owing to the impaction of a calculus in the cystic duct. 
 
 id) In all cases of gall stones which are situated within the 
 gall bladder and are associated with an inflammatory condition 
 of the walls of the viscus. 
 
 (e) In cases of rupture of the gall bladder, in which the 
 rupture is large and is situated in the region of the fundus. 
 
 (/) In those cases of gall stones in which the calculus is 
 impacted in the cystic duct, and it appears probable that it can 
 be extracted through the gall bladder, or in which it can be 
 manipulated backwards into the cavity of this organ. 
 
 Terrier of Paris has recently advocated the performance of 
 cholecystotomy in certain inflammatory affections of the bile 
 ducts, and also in cases of hypertrophic cirrhosis of the liver. 
 In the former class of cases he appears to have met with a fair 
 amount of success, but in the latter, there is not, as yet, sufficient 
 evidence to show that the performance of the operation has been 
 of permanent value. 
 
 According to the statistics of Courvoisier ^ and Martig,^ the 
 following results have been met with in 161 cases of ordinary 
 cholecystotomy ; that is to say, cases in which the operation has 
 been performed at one sitting, and the gall bladder has been 
 opened before it has been sutured to the margins of the parietal 
 incision. In forty-six cases the result was a complete cure, in 
 forty-eight it was doubtful, in thirty-five a fistula remained (in 
 four cases the discharge was pus and in the remainder bile), and 
 
 1 Courvoisier, op. cit. 2 Martig, " Beitr. z. Chirurgie d. Gallenwege," Basel, 1893. 
 
IDEAL CHOLECYSTOTOMY. 333 
 
 in thirty-two cases a fatal termination followed, in fifteen of 
 which death was said to be directly due to the operation and 
 in seventeen indirectly. The results of cholecystotomy in which 
 the gall bladder was sutured to the abdominal wall before being 
 opened, according to the same authors, are as follows : — Out of 
 thirty cases eleven resulted in a complete cure, two remained 
 uncured, four had fistuke left, and thirteen died (six directly from 
 the operation and seven from causes not directly connected 
 with the operation). In sixty-six cases, in which the operation 
 was performed in two stages, forty-two were definitely cured, 
 three were not benefited, one was improved, four had a perman- 
 ent biliary fistula, seven had a mucous fistula, in one the result 
 was doubtful, and eight died (six directly from the operation and 
 two from causes not immediately dependent upon the operation; 
 The percentage of complete cures appears to have been 
 greatest when the operation was performed in two stages, but 
 this is probably due to the fact that the cases in which this 
 method can be adopted are much more favourable than those in 
 which the procedure is carried out at one sitting. Eiedel 
 of Jena,^ has obtained the best results from the operation in two 
 stages, and strongly recommends its adoption. Hans Kehr - 
 has recently collected and published all cases of cholelithiasis 
 which had been operated upon by him during the years 1890- 
 1895. In ninety-six cases he performed cholecystotomy in one 
 stage, and in three cases in two stages, with no fatal result. 
 
 Cholecystenclysis or Ideal Cholecystotomy. — In the performance 
 of this operation the incision in the abdominal parietes is similar 
 to that which is made use of in cholecystotomy. When the 
 peritoneal cavity has been opened, and the gall bladder exposed, 
 it is drawn into the wound and a small incision made through its 
 wall in the region of the fundus. This incision must be large 
 enough to allow of the easy removal of the contained calculus. 
 In those cases in which the organ has been perforated by some 
 traumatic agent, or the wall has been ruptured owing to external 
 violence or by ulceration, the portion of the gall bladder in which 
 the aperture is situated is drawn into the wound and the injured 
 area is fully exposed. The margins of the rupture are then 
 thoroughly cleansed and united according to the method of 
 suture which is described later. In cases of calculi the gall 
 
 ^ Riedel, op. cit. 
 
 2 Kehr, " Die Chirurgische Behandlung der Gallensteinkranklieit," 1896. 
 
334 OPERATIONS UPON THE GALL BLADDER. 
 
 bladder is completely evacuated by removing its contents 
 through the opening which has been made. When the calculi 
 are large, it is better to make an attempt to break them up into 
 several fragments, by crushing with a form of straight lithotrite 
 or forceps, before removing them, in order to avoid the necessity 
 of enlarging the aperture in the wall of the organ. Care must 
 be taken, when removing calculi in this manner, not to lacerate 
 the walls of the gall bladder, or damage them by tearing the 
 mucous membrane in the region of the incision. When the wall 
 of the gall bladder is ulcerated or perforated by gall stones, it is 
 advisable to trim up the edges of the rupture with a pair of 
 scissors before sutures are inserted. Under these circumstances, 
 however, this form of operation should be only exceptionally 
 made use of. The margins of the incision or rupture are united 
 by the introduction of two or three tiers of fine sutures. The 
 first tier unites the mucous membrane alone, and for this purpose 
 a continuous suture oE fine silk or aseptic catgut should be used ; 
 the second tier approximates, if possible, the edges of the 
 muscular coat, and should consist of interrupted sutures of fine 
 silk, inserted about one-fourth or one-third of an inch apart ; 
 whilst the third or most superficial tier unites the serous or 
 peritoneal coat, and consists of fine silk sutures, introduced after 
 the method of Lembert. The ends of all the sutures are cut 
 short, and then the area of the wound in the gall bladder and the 
 surrounding parts are well sponged and cleaned, and the gall 
 bladder dropped back into the peritoneal cavity. The region of 
 the operation is irrigated with sterilised water, if there has been 
 any escape (into the peritoneum) of blood, fluid from the gall 
 bladder, or calculi, and then the external wound in the abdominal 
 parietes is closed in the usual manner. Some surgeons advise 
 that a small part of the abdominal wound should be left open, 
 through which a small drainage-tube or a strip of aseptic gauze 
 should be inserted, and the lower extremity passed into the 
 region of the rupture or incision in the gall bladder, so that 
 if any escape or leakage of bile occurs it may at once be 
 detected. 
 
 The performance of the operation of cholecystendysis, or 
 ideal cholecystotomy, appears to be indicated in the following 
 conditions, namely : — 
 
 1. In those cases in which there is a small wound in the 
 gall bladder in the region of the fundus, which has been caused 
 
MODIFICATION OF CHOIEC YSTEND YSIS. 335 
 
 by a sharp instrument, and in which no signs of peritonitis have 
 developed ; 
 
 2. When the gall bladder contains one or more small 
 calculi and the walls of the organ are in a perfectly healthy 
 condition ; 
 
 3. In cases of rupture of the gall bladder from external 
 violence, when the aperture is situated in the neighbourhood of 
 the fundus, is small, and there is no accompanying peritonitis. 
 
 Cholecystendysis is contraindicated — {a) in all cases of large 
 calculi in the gall bladder ; (&) in every case in which inflam- 
 matory conditions involve the gall bladder or the structures in 
 its immediate neighbourhood ; (c) in nearly all cases of perfora- 
 tion of the walls of the gall bladder as the result of ulceration ; 
 {d) in cases of rupture and perforation of the gall bladder when 
 the injuries are situated in the region of the neck of the organ, 
 and cannot easily be manipulated ; (e) in all cases in which there 
 is a simultaneous obstruction in the common bile duct. 
 
 Zielewicz recommends that in all cases in which cholecyst- 
 endysis has been performed, the cystic duct should be closed 
 by the application of an absorbable ligature before the operation 
 is completed, so as to prevent for a time the passage of bile into 
 the gall bladder. If a catgut ligature be employed for this 
 purpose, it is possible that, in a short time after its intro- 
 duction, it will be absorbed, and then bile will again pass into 
 the gall bladder ; and if this can be relied upon, time will 
 be allowed for the wound in the wall of the gall bladder to 
 become closed by the exudation of lymph and union of the 
 divided surfaces, before the organ is dilated with bile. This 
 modification does not appear to have been made use of in a 
 sufficient number of cases to enable an opinion upon its value to 
 be formed. If a ligature is applied in this manner, care must be 
 taken not to tie it too tightly, otherwise ulceration of the mucous 
 membrane of the cystic duct may be induced, and be followed 
 later by the development of a fibrous stricture. 
 
 Czernys modification of cholecystendysis. — Czerny has advised 
 that in those cases in which it is unnecessary to establish a 
 fistulous communication with the surface, the margins of the 
 wound in the gall bladder should be closed and fixed to the 
 parietal peritoneum in the abdominal wound, and after this has 
 been accomplished the margins of the parietal incision are 
 approximated in the usual manner. He says that when this has 
 
336 OPERATIONS UPON THE GALL BLADDER. 
 
 been done the fluid or exudation from the gall bladder will pass 
 out through the external wound, and hence become apparent. 
 It is probable, however, that if the external wound is completely 
 closed in this manner, the superficial layers of the abdominal 
 wound will unite quickly and not allow the passage of any fluid, 
 and on this account the contents of the gall bladder may pass 
 into the peritoneal cavity and be a source of danger. It is 
 probable, however, that this method of operation is somewhat 
 safer than ordinary cholecystendysis. 
 
 Martig ^ has collected the statistics of fifty-seven cases of 
 cholecystendysis (eighteen from Courvoisier), and of these forty- 
 three recovered ; in four there was a recurrence, in one a fistula 
 remained, three died directly from the operation, and six from 
 causes only indirectly connected with the operation. It appears 
 from these figures that the operation has resulted in cure in 
 about 84 per cent, of cases. 
 
 Hans Kehr 2 has recently reported two successful cases of 
 cholecystendysis ; in one, a large calculus was removed, and in 
 the other Loreta's divulsion of the pylorus was also performed. 
 
 Cholecystectomy. — The operation which comprises a removal 
 of the gall bladder is known as cholecystectomy. It was first 
 proposed and performed by Langenbuch.^ The operation is 
 performed in the following manner : — An incision 3 to 5 in. 
 long is made in the right linea semilunaris, commencing above 
 at the costal margin and extending through the abdominal 
 parietes until the peritoneal cavity has been opened. The gall 
 bladder is drawn into the wound, and the adjacent part of the 
 peritoneum is packed with sponges, so as to keep the intestines 
 free from injury, and to avoid the entrance of blood or any of the 
 contents of the gall bladder. The gall bladder is evacuated 
 either by incision or aspiration, if it is distended with fluid. Two 
 parallel incisions are next made through the peritoneum, one on 
 each side of the gall bladder as it lies in its fossa upon the 
 inferior aspect of the liver, which divide the peritoneum, and 
 another incision is made which joins the anterior extremities of 
 the two first along the antero-inferior border of the liver. The 
 gall bladder can now be easily separated from its connection with 
 the inferior surface of the liver by means of the fingers, or the 
 handle of the scalpel, or a blunt director. This separation is 
 carried backwards until the neck of the organ and the cystic 
 
 1 Martig, op. cit. - Kehr, op. cit. ^ Laugenbuch, op. cit. 
 
CHOLECYSTECTOMY. 337 
 
 duct are reached, when it will be seen that the gall bladder only- 
 remains attached by the duct. The cystic duct is surrounded 
 with two ligatures about half an inch apart, which are tied, and 
 then the intervening portion is divided with the knife, and the 
 gall bladder removed. In order to facilitate this part of the 
 operation, it is advisable to direct an assistant to hook the 
 antero-inferior border of the liver upwards and forwards with his 
 bent fingers or a large retractor. The haemorrhage which follows 
 the separation of the gall bladder from the liver varies in 
 amount ; in some cases it is almost absent, whilst in others it is 
 very profuse, and the actual cautery may have to be called into 
 requisition in order to arrest it ; but usually hot-sponge pressure, 
 and the application of a few fine silk ligatures to any definite 
 bleeding points, prove sufficient. After the gall bladder has been 
 removed, and the resulting hemorrhage arrested, the margins of 
 the divided peritoneum upon the inferior aspect of the liver are 
 brought together and fixed in apposition with sutures. The free 
 end of the cystic duct may be cauterised with the needle of a 
 Paquelin's cautery, and, if possible, the mucous lining of the 
 ligatured portion of the duct should be removed, either by 
 scraping with a sharp spoon or with the cautery. The sponges 
 are now removed from the peritoneum, and the region of the 
 operation irrigated so as to remove all traces of blood and other 
 debris. The wound in the parietes is then closed. In those 
 cases in which all the haemorrhage has been arrested and there 
 are no signs of recurrence, the entire wound is closed, but when 
 there has been much bleeding during the operation, and oozing of 
 blood from the area of the gall bladder cannot be completely 
 arrested, it is advisable to pack the part with a long strip of 
 aseptic gauze, the end of which is brought out through an angle 
 of the parietal wound, which is left open for the purpose. This 
 can be removed in one or two days' time, and if there are signs 
 of the recurrence of hcemorrhage at the time of removal another 
 strip can be inserted. 
 
 Calot ^ has made statistics comprising records of seventy-eight 
 cases ; of these 17"9 per cent, terminated fatally, but in seven he 
 considers that death was due to causes independent of the opera- 
 tion upon the gall bladder ; hence he places the mortality of 
 cases in cholecystectomy at 8'9 per cent. Sprengel- has 
 
 1 Calot, "De la Cholecystectoraie. " These de Paris, 1891. 
 - Sprengel, Deutsche med. Wchnschr., Leipzig, 1891, s. 1061. 
 22 
 
338 OPERATIONS UPON THE GALL BLADDER. 
 
 recorded a case in which the gall bladder was removed, and at 
 the same time the common bile duct was found to be dilated and 
 blocked with a calculus, and on this account a choledocho-duo- 
 denostomy was performed. The patient recovered. Broca re- 
 commends that the stump of the cystic duct should be drained 
 after the gall bladder has been removed ; he has performed the 
 operation successfully in three cases. Hermann ^ has recently 
 published five cases, of which four recovered and one died on 
 account of haemorrhage from the area of the operation. The 
 patient was jaundiced, and the hgemorrhage was said to be 
 " cholaemic " in character. Beckmann has recorded a fatal case, 
 in which the patient died on the fourth day after the operation, 
 from peritonitis and bleeding from the liver. In this patient a 
 calculus was discovered at the post-mortem to be impacted in 
 the common duct. In one of Terrier's cases, in which the gall 
 bladder was removed on account of calculi and ulceration of its 
 walls, a biliary fistula developed on the eleventh day after the 
 operation, and from this, at intervals, several small calculi were 
 discharged, the fistula closing on the fiftieth day. These cases of 
 Beckmann and Terrier emphasise the importance of making a 
 complete examination of the entire course of the biliary ducts at 
 the time of the operation, so as to exclude as far as can be done 
 the possibility of leaving a calculus undetected in the common bile 
 duct or in the hepatic ducts. When the calculi are intra-hepatic, 
 it is not possible to detect them under ordinary conditions. 
 
 Before removal of the gall bladder on account of carcinoma, 
 a careful examination of the adjacent part of the liver, the 
 lymphatic glands in the region of the portal fissure, and the 
 course of the bile ducts, should be made, in order to ascertain if 
 any secondary growths are present, or if the ducts are affected 
 by a direct extension of the disease. Hans Kehr has recorded a 
 case in which a biliary fistula developed after removal of the gall 
 bladder, and on performing a second operation the common bile 
 duct was found to be involved in a carcinomatous lymphatic 
 gland the size of a walnut. No radical measure was possible, and 
 the patient died ten days after the second operation. Kehr has 
 removed the gall bladder nineteen times, with only one fatal result. 
 
 The performance of the operation of cholecystectomy is 
 indicated in the following pathological conditions, viz. : — 
 
 1 Merniann, " Beitr. z. Cliir. der Gallemvege," Beitr. z. klin. Chir., Tiibiugeu 
 Bd. xiii. s. 319-389. 
 
CHOLECYSTENTEROSTOMY. 339 
 
 ia) In those cases of carcinoma of the gall bladder in which 
 the growth is strictly limited and secondary deposits have not 
 developed in other viscera. 
 
 (&) In cases of ulceration of the gall bladder in which 
 several perforations of its walls have occurred, or in which the 
 walls have become gangrenous. 
 
 (c) In some cases of contracted gall bladder which are 
 dependent upon old chronic inflammation. 
 
 (c?) In cases of rupture of the gall bladder, owing to external 
 violence, in which the ruptures are extensive, or situated in the 
 region of the neck, and in perforating wounds which are very 
 large or near the neck of the organ. 
 
 {e) In all cases of distension of the gall bladder with pus or 
 mucus (empyema or hydrops), which are associated with complete 
 closure of the cystic duct by chronic inflammatory processes. 
 
 Eemoval of the gall bladder must never be performed when 
 the common bile duct is permanently closed or obstructed, either 
 by a new growth or a fibrous tissue stricture, or when the organ 
 has acquired very extensive adhesions to the adjacent viscera. 
 Out of eighty-seven cases of cholecystectomy which have been 
 collected by Martig, seventy-two recovered and fifteen died, 
 twelve directly from the operation, and three from indirect 
 causes. 
 
 Cholecystenterostomy. — In the performance of this operation 
 a fistulous canal is established between the cavity of the gall 
 bladder and the lumen of some portion of the alimentary canal, 
 usually the duodenum or some other part of the small intestine, 
 and only in rare cases the transverse colon. A considerable 
 number of varieties of this operation have been described and 
 adopted by different surgeons, and they can be classified according 
 to the number of stages into which the procedure has been 
 divided. There are operations in one stage, in two stages, and 
 in three stages. 
 
 Operations in one stage. — (1) By sutures: a parietal incision 
 is made in the upper part of the right linea semilunaris, 3 to 4 
 in. long, by which the peritoneal cavity is opened. The gall 
 bladder, which is usually distended in cases requiring this opera- 
 tion, is sought for and brought into the wound, the surrounding 
 part of the peritoneum packed with sponges, and then the dis- 
 tended viscus punctured with a trocar and cannula, by which 
 means its fluid contents are evacuated. An incision is made in 
 
340 OPERATIONS UPON THE GALL BLADDER. 
 
 the wall of the gall bladder passmg through the point of entrance 
 of the trocar, through which the entire contents of the organ are 
 removed, its interior well irrigated with a dilute aseptic solution, 
 and its cavity temporarily packed with a small sponge, and then 
 the viscus is replaced within the abdomen. A loop of the small 
 intestine, preferably the duodenum or the upper portion of the 
 jejunum, in most cases the latter, is brought out through the 
 abdominal wound, and its interior emptied of its contents by 
 forcing them onwards with the fingers. At each extremity of 
 the loop a strong silk ligature is passed, with an aneurism needle, 
 through the mesentery near its attachment to the bowel. These 
 silk ligatures are given to assistants to hold, and they serve first 
 to occlude the lumen of the gut after it has been emptied of its 
 contents, and, secondly, to hold the loop steady in the parietal 
 wound. An incision similar in length to that which has been made 
 in the gall bladder, from \ %q \ in., is now made on the convexity 
 of the intestinal loop, opposite the attachment of the mesentery, 
 and parallel with the long axis of the bowel. The gall bladder 
 is then brought into the abdominal wound again, the sponge is 
 removed from its interior, and the incision in the bowel is ap- 
 proximated to that in the gall bladder, their margins being fixed 
 in apposition by the insertion of a double row of interrupted 
 sutures of fine silk. The first row of sutures aims at uniting the 
 mucous membrane at the lips of the apertures closely together. 
 The second row of sutures unites the serous and muscular coats of 
 the gall bladder and intestine. When all the sutures have been 
 introduced, tied, and the ends cut short, the structures which have 
 been exposed during the operation, and the adjacent part of the 
 peritoneum, are thoroughly cleansed and freed from blood and 
 debris by irrigation with sterilised water, or a dilute antiseptic 
 solution. The silk sutures are then removed from the mesentery, 
 the apertures through which they passed being closed with fine 
 sutures, if it is thought advisable. The gall bladder and the 
 intestine are replaced within the abdomen, and the parietal 
 incision closed with sutures in the usual manner. 
 
 (2) By the use of " Murphy's button." A small variety of 
 anastomosis button is made use of in this operation, which is 
 performed in the following manner : — An incision is made from 
 the edge of the ribs, 2 in. to the right of, and parallel to, 
 the median line, extending downwards for 3 in. The gall 
 bladder and the duodenum are drawn into the wound ; a needle, 
 
OPERATIONS IN ONE STAGE. 
 
 341 
 
 threaded with 15 in. of silk, is inserted into the duodenum, 
 directly opposite the attachment of the mesentery, and at a 
 point near the head of the pancreas ; a stitch is taken through 
 the entire bowel, one-third of the length of the incision to be made; 
 the needle is again inserted one-third the length of the incision 
 from its outlet, in a line with the first, and emljracing the same 
 amount of tissue as the first. A loop 3 in. long is held 
 here, and the needle is inserted in a similar manner, making two 
 stitches parallel to the first in the reverse direction, and one- 
 fourth of an inch from it. coming out at 
 a point near the insertion of the needle. 
 This forms a running thread, which, when 
 tightened, draws the incised edge of the 
 bowel within the cup of the button. A 
 similar running thread is inserted in the 
 gall bladder. An incision is now made 
 in the intestine, which is two-thirds of 
 the diameter of the button to be used, 
 care bemg taken to avoid cutting the 
 running thread when making the in- 
 cision ; the male half of the " button " 
 is slipped in, the running thread tied 
 firmly around the central cylinder, and 
 then the button is given to an assistant 
 to hold with forceps, so as to prevent it 
 slipping into the cavity of the bowel 
 An incision is now made in the gall 
 bladder, the same length as the one in 
 the intestine, between the two rows of 
 suture. The gall stones and fluid con- 
 tents of the gall bladder are removed ; 
 the female half of the " button " inserted, 
 and the running thread tied. The forceps are then removed, 
 the two halves of the " button " are held between the fingers 
 and slowly pressed together, A sufficient degree of pressure 
 must be used to bring the serous surfaces of the gall bladder 
 and intestine firmly in apposition and compress the tissues. 
 The elastic pressure of the spring cup of the " button " 
 produces a pressure atrophy of the tissues embraced by it, 
 and leaves an opening which is larger than the " button." 
 When the latter is liberated, it passes on through the bowel. 
 
 Fig 54. — Method of inserting 
 ' ' purse-string suture " into 
 intestine in the operation 
 of cholecystenterostomy. 
 
342 OPERATIONS UPON THE GALL BLADDER. 
 
 and is voided per aniim from eight to fourteen days after the 
 operation. The advantages which have been claimed for this 
 method of operation, and the use of " anastomosis buttons," are 
 the following : — («) The use of sutures is dispensed with ; (&) 
 invagmation is not required ; (c) non-apposition is impossible, 
 and there is no danger of sloughing through of discs, or too rapid 
 
 Fig. 55. — Cholecystenterostomy. Method of holdiug male half of 
 anastomosis button for insertion. 
 
 digestion of catgut ; {6i) there are no difficulties of technique ; and 
 (c)''^prolonged exposure of the abdominal contents and protracted 
 aneesthesia are avoided. There appears to be no doubt that, 
 by the use of this contrivance, the margins of the apertures can 
 easily be brought into exact apposition, and retained in that 
 position until the " button " becomes separated ; but it seems 
 possible that in certain cases, where the walls of the viscera are 
 
 Fig. 56. — Cholecystenterostomy. Method of liolding female portion of 
 anastomosis button for insertion. 
 
 thin, the " button " will separate before firm adhesions have been 
 formed ; and on this account I think that, after the " button " has 
 been inserted, it is advisable to further fix the gall bladder and the 
 duodenum by inserting a row of interrupted sutures of fine silk 
 immediately outside the edge of the " button." In a case of 
 cholecystenterostomy which I operated upon by this method, 
 without using sutures, the button separated on the fifth day, a 
 
OPERATIONS IN TWO STAGES. 
 
 343 
 
 considerable amount of haemorrhage followed, the line of union of 
 the gall bladder and the duodenum gave way, and the contents 
 of the bowel passed into the peritoneal cavity, causing fatal 
 peritonitis. 
 
 Operations in tivo stages. — Winiwarter of Luttich has been 
 the chief supporter of this form of cholecystenterostomy. The 
 early stages of the operation are similar to those of the opera- 
 tion in one stage. After the abdominal cavity has been opened, 
 the gall bladder and a loop of small intestine are drawn into 
 the wound, and an area upon the convex surface of the gall 
 
 Fig. 57. — Cholecystenterostomy. Gall bladder and duodenum, showing two 
 halves of anastomosis button, introduced with the "purse-string" sutures 
 tied, and ready for fixing together. 
 
 bladder, about one inch long and half an inch wide, is selected 
 and approximated to a similar area upon the convexity of the 
 selected loop of small intestine ; these two areas are fixed in 
 apposition by a number of sutures introduced through the 
 serous and muscular coats of both viscera, at the margins of 
 the selected areas. These are tied, and the loop of bowel is 
 fixed into the bottom of the abdominal wound by means of a 
 few silk sutures. The external wound is packed with an 
 aseptic dressing, and four or six days afterwards the intestinal 
 loop is again drawn out into the parietal wound, and a vertical 
 
344 OPERATIONS UPON THE GALL BLADDER. 
 
 incision made into its convexity a short distance below the 
 area where the gall bladder and intestine have been fixed in 
 apposition. With the knife of a thermocautery, the cavities 
 of the gall bladder and intestine are made to communicate by 
 destroying their walls w^here they lie in contact. The mucous 
 membrane of the gall bladder is then fixed to that of the 
 intestine at the margins of the aperture by the insertion of a 
 few fine silk sutures ; and, finally, the incision in the intestine 
 lower down is closed with sutures. The intestine and gall 
 bladder are dropped back into the peritoneal cavity, the parts 
 in the region of the operation thoroughly washed and irrigated, 
 and then the wound in the abdominal parietes closed in the 
 usual manner. 
 
 Operations in three stages. — In the first stage the abdomen 
 is opened by an incision in the right linea semilunaris, and 
 an oval area upon the lower surface of the gall bladder 
 approximated and fixed to a loop of the small intestine, in a 
 manner similar to that described in the operation " in two 
 stages." When this has been done, the gall bladder is drawn 
 into the parietal wound, an incision made into it, and its con- 
 tents evacuated. The margins of the incision in the gall bladder 
 are united to those of the parietal incision, and the remainder 
 of the abdominal wound is closed. By this means a biliary 
 fistula is established. Aseptic dressings are applied and changed, 
 as occasion demands. At the expiration of eight or ten days 
 the second stage is carried out. The partition between the 
 gall bladder and the adherent loop of intestine is divided with 
 a scalpel, care being taken not to divide the tissues beyond 
 the adherent area. This procedure may be rendered easy by 
 introducing during the first stage of the operation two silk 
 ligatures, the ends of which are left long, through the mucous 
 membrane of the gall bladder, one at the upper limit and the 
 other at the lower limit of the approximated area, so that, when 
 the division of the partition is made, the incision may extend 
 through the tissue between the points of attachment of these 
 two silk loops. After the partition has been divided, and a 
 communication between the cavity of the gall bladder and the 
 lumen of the gut established, the mucous membrane of the 
 gall bladder is united to that of the intestine along the margins 
 of the fistulous aperture. This completes the second stage of 
 the operation. At the expiration of two or three weeks after 
 
OPERATIONS IN THREE STAGES. 345 
 
 the completion of the second stage, the wound in the abdominal 
 wall is closed by a plastic operation, and this constitutes the 
 third and final stage. Each method of cholecystenterostomy 
 has its advocates, but when the ease and rapidity with which 
 the operation can be performed when an " anastomosis button " 
 is made use of, are taken into consideration, and also the 
 greater percentage of recoveries which have followed the use 
 of this contrivance, it appears that this is the best operation 
 to adopt in order to produce a fistulous communication between 
 the gall bladder and the intestine. In order to avoid the 
 misfortunes which may follow the too early separation of the 
 " button," it appears to me that its use ought to be supplemented 
 by a row of sutures inserted immediately outside the external 
 margin, uniting the serous and muscular coats of the gall 
 bladder and intestine. A row of sutures of this kind can 
 be very quickly inserted after the viscera have been fixed in 
 apposition with the " button," as this body acts as a kind of 
 splint. 
 
 The operation of cholecystenterostomy appears to be indicated 
 in the following conditions : — 
 
 (a) In all cases where the common bile duct is permanently 
 obstructed or occluded, by adhesions, inflammatory processes, 
 or malignant growths, the cystic duct remaining patent. The 
 forms of new growth include those which are primary in the 
 common bile duct and those which commence in the head of 
 the pancreas and spread to it by direct extension. In cases 
 where the common bile duct is occluded, as the result of 
 secondary malignant growths, it is not advisable to perform the 
 operation. 
 
 (6) In all cases of complete division of the common bile 
 duet as the result of injury or operative measures. 
 
 (c) In cases of chronic biliary fistulse which cannot be 
 cured by the performance of a plastic operation, or in which 
 the fistulse are due to obstruction of the common bile duct 
 which is not amenable to direct surgical interference. 
 
 idC) In all cases of perforation of the common bile duct 
 which result from an ulcerative process. 
 
 (e) In cases of kinking of the common bile duct which are 
 due to the presence of fibrous adhesions and cannot be remedied 
 by operation. 
 
 Cholecystenterostomy is contraindicated in cases of well- 
 
346 OPERATIONS UPON THE GALL BLADDER. 
 
 established cholsemia, where the patient is suffering from 
 exhaustion. 
 
 In the first list of cases of cholecystenterostomy (compris- 
 ing records of seventeen patients) which Murphy published, no 
 fatal terminations were reported, but in a later communication 
 he gave an account of fatal results having been met with when 
 the operation had been done in certain cases of malignant 
 disease. Martig -^ has collected details of twenty-four cases 
 which had been reported up to 1893, and of these fifteen were 
 successful, six died directly from the operation, and three after 
 the operation from indirect causes. 
 
 Cholecysto-lWiotrijjsy. — This operation consists in opening the 
 abdomen, exposing the gall bladder and bringing it into the 
 abdominal wound, and crushing or breaking up into fragments 
 any calculi which may happen to be in its interior, by applying 
 pressure through the wall of the gall bladder. The calculi 
 may either be crushed between the fingers or with forceps, the 
 blades of which have been covered with tubes of indiarubber. 
 When the calculi have been broken up in this manner, they 
 are forced into the cystic duct, whence they pass along the 
 biliary canal into the intestine. In this operation no incision 
 is made in the walls of the gall bladder. Two cases treated 
 by this method have been reported by Mayo Eobson, and in 
 both success followed. It seems to be probable that a con- 
 siderable risk is run of causing such local injury to the wall of 
 the gall bladder during the crushing, especially in the case of 
 hard calculi, that ulceration and localised gangrene may result, 
 and therefore it is questionable whether this method of 
 treatment can be safely recommended. In cases where the 
 calculi are small and of soft consistency, it may be justifiable 
 to attempt their removal in this way. Further details of 
 results of this method of treatment of gall stones situated 
 within the gall bladder, are required before a definite opinion 
 can be formed as to the exact value of the operation. 
 
 1 Martig, oj). cit. 
 
CHAPTER XXVI. 
 
 OPERATIONS UPON THE BILIAEY DUCTS. 
 
 Choledocho-litliotomy — choledochotomy. — This operation has for 
 its object the removal of one or more calculi from the interior of 
 the common bile duct, in cases in which an obstruction to the 
 flow of bile along this canal has been established, or in which 
 severe symptoms result from the impaction. In performing the 
 operation the abdominal cavity is opened by an incision which 
 is made either in the linea alba, commencing above immediately 
 below the ensiform cartilage, or in the right linea semilunaris, 
 commencing just below the costal margin. It is not always 
 possible to make an exact diagnosis as regards the seat of the 
 impacted calculi, and when this is the case it is better to make 
 the incision in the linea semilunaris. When the abdominal 
 cavity has been opened, the course of the biliary tract is 
 examined with the finger ; the gall bladder should be examined 
 first, then the cystic duct, and then the common bile duct, both 
 as it lies in the gastro-hepatic omentum and in its course behind 
 the first part of the duodenum, and where it lies between and 
 behind the head of the pancreas and the left aspect of the second 
 portion of the duodenum. In many cases, placing the examining 
 finger in the foramen of Winslow will be found to be of diag- 
 nostic value, since in this position a considerable extent of the 
 common bile duct can be palpated, and if there is a calculus in 
 its interior its position can be at once made out. When a stone 
 is discovered in the common bile duct, the gastro-hepatic omentum 
 and the common bile duct are drawn into the abdominal wound. 
 The peritoneal cavity around these structures is packed with 
 sponges, and an incision is made in the common bile duct over 
 the calculus, this incision being parallel to the long axis of the 
 duct. Through this incision the impacted calculus is extracted, 
 care being taken to damage the walls of the duct as little as 
 possible. In order to facilitate the removal of the calculus, it is 
 
348 OPERATIONS UPON THE BILIARY DUCTS. 
 
 found in some cases to be advantageous to break up the stone 
 with crushing forceps and to extract it in several fragments. 
 When the stone has been removed, the area of the operation is 
 thoroughly ii'rigated, and the margins of the incision in the 
 common bile duct are then approximated and fixed in apposition 
 by the insertion of two tiers of fine silk sutures. The first 
 unites the mucous membrane, and the second the muscular and 
 serous coats. If the peritoneum which forms the anterior layer 
 of the gastro-hepatic omentum has been dissected from the bile 
 
 duct, it may be united separ- 
 ately from the muscular walls 
 of the common duct, in which 
 case three tiers of sutures will 
 be requisite. The sponges are 
 now removed from the peri- 
 toneum, and after further irri- 
 gation the abdominal incision 
 is closed. In many cases of 
 this operation it will be found 
 advisable to pack the region of 
 the incision in the common 
 duct with a strip of aseptic 
 gauze, and to bring out the 
 end of this strip through an 
 angle of the abdominal wound, 
 which is left open for the pur- 
 pose. This strip is removed 
 after one or two days, and if 
 
 Fig. f.8.-Incisiou in upper portion of linea t^^ere is UO sigU of leakage 
 
 alba for exposure of common bile duct from the duct, the abdominal 
 
 by a median incision, and for exposure ^^^^^ -^ entirely closed. The 
 
 01 the liver. '' 
 
 strip of gauze is replaced by a 
 similar one when any small quantity of fluid escapes. Michaux 
 advises that, if the gall bladder is very dilated at the time of the 
 operation, it should be incised and its contents evacuated, and that 
 if it is filled with small calculi it should be removed. He advocates 
 the closure of the wound in the common bile duct with sutures, 
 after the removal of the calculus, and packing with a tampon 
 of iodoform gauze. He records two cases, one being successful. 
 In one case which has been operated upon by Frank, the wound 
 in the duct was left open and a drain inserted ; the operation 
 
CHOLEDOCHO-LITHOTOMY. 349 
 
 was successful. Quenu also recommends that the wound in the 
 duct should not be sutured. It is sometimes found that the 
 impacted calculus lies behind the duodenum, and then it is 
 necessary to lift up this structure and open the common bile duct, 
 as it lies behind it. If the calculus is a small one, or the common 
 bile duct is considerably dilated, an attempt may be made to 
 manipulate the calculus into the duodenum, by forcing it along 
 the duct and through the orifice on the biliary papilla. 
 
 The indications for the operation of choledocho-lithotomy or 
 choledochotomy are as follows : — 
 
 (a) When the cystic duct is closed and obliterated, and there 
 is a simultaneous obstruction of the common bile duct, owing to 
 the impaction of a calculus. 
 
 (6) In cases of perforation of the walls of the common bile 
 duct by a calculus, when the walls of the duct are in a comparat- 
 ively healthy condition ; that is to say, when there are no signs 
 of a septic inflammation. 
 
 (c) In cases of impaction of a calculus in the common duct, 
 and the presence of the calculus is causing attacks of biliary 
 colic and ague-like fever. 
 
 In twenty-seven cases of choledocho-lithotomy which have 
 been collected by Martig, twenty-one recovered, five died from 
 the operation, and in one the result was uncertain. Terrier has 
 performed the operation many times, and says that the percentage 
 of mortality is about 1 7 per cent. Hermann ^ has recently pub- 
 lished records of four cases, three being successful and one fatal 
 from cholaemia. Hans Kehr has performed the operation of 
 choledochotomy upon twenty- eight patients, with two fatal 
 results. One of these patients died from acute dilatation of the 
 stomach following a kinking of the duodenum, owing to the 
 presence of adhesions between it and the gall bladder ; and the 
 other from acute septic peritonitis, which was induced by the 
 occurrence of a perforation of the wall of the fistula between the 
 gall bladder and the colon during an attack of vomiting. A 
 successful case has also been recently recorded by Mr. Anderson. 
 Jourdan ^ has recently collected the records and results of 
 seventy-two cases of choledochotomy which had been published 
 up to 1895, Fifty cases recovered and twenty-two terminated 
 fatally. 
 
 1 Mermann, op cit. 
 
 2 Jourdan, " De la Choledochotomie, " Paris, 1895. 
 
350 OPERATIONS UPON THE BILIARY DUCTS. 
 
 Choledochostomy. — Choledochostomy implies the creation of a 
 cutaneous fistula which communicates with the lumen of the 
 common bile duct. The operation has only been performed a 
 few times, and in each case it was for an abdominal tumour, 
 situated immediately below the liver, which was due to an 
 enormous dilatation of the common bile duct. In most cases 
 the abdomen has been opened before the nature of the swelling 
 became apparent. Winiwarter operated upon a case in which 
 the condition of dilated common bile duct was recognised before 
 the operation. The operation is similar to that of cholecystotomy, 
 and consists in opening the abdomen by an incision in the right 
 linea semilunaris, incising the dilated common bile duct, and 
 stitching the margins of the incision to those of the parietal 
 wound. All the patients who have been operated upon in this 
 manner have died, and, owing to the rarity of the condition, it is 
 difficult to formulate any rules for the diagnosis of the dilated 
 bile duct and its treatment by operation. If, however, when the 
 abdomen has been opened, and this condition is discovered, 
 evacuation of the contents of the dilated duct through an incision 
 in its walls appears to be the only rational method of treatment. 
 If in a case of this kind the communication between the common 
 bile duct and the duodenum has become obliterated, and the con- 
 nection between the gall bladder and the hepatic duct is not 
 interfered with, the performance of a cholecystenterostomy seems 
 to be indicated. 
 
 Gholecloclio-enter ostomy. — This operation consists in the 
 establishment of a fistulous communication between the cavity 
 of a dilated common bile duct and the lumen of the alimentary 
 canal, usually the duodenum. Sprengel performed the operation 
 on a patient in whom the common bile duct was considerably 
 dilated on account of a large calculus. The details of the 
 method of performance of the operation are similar to those 
 which were described in connection with cholecystenterostomy. 
 
 Choledocho-lithotrity or choledocho-lithotrijysy. — By this term is 
 understood the crushing of a calculus which is impacted in the 
 common bile duct, by the application of padded forceps to the 
 exterior, and without any incision of the walls of the duct. 
 The operation is similar to that of cholecysto-lithotripsy, and 
 was first performed by Langenbuch in 1886. It appears probable 
 that when this operation has been performed, ulceration and 
 gangrene of the mucous membrane of the bile duct may result 
 
CHOLEDOCHECTOMY. 35 1 
 
 owing to the injuries which have been inflicted upon it during 
 the process of crushing, or that all the fragments of calculus 
 will not pass into the duodenum, but some of them remain and 
 become the nuclei of other large calculi. In those cases in 
 which a calculus has been exposed in the common bile duct 
 by an incision, it is occasionally useful to break it into several 
 fragments by crushing before attempting its removal, but in 
 these cases the forceps are applied directly to the calculus as it 
 lies embedded in the duct. This operation appears to have been 
 performed eleven times ; eight were successful. 
 
 Choledochedomy, or excision of a portion of the common Hie 
 duct. — The early stages of the operation are the same as those in 
 choledocho-lithotomy, and when the gastro-hepatic omentum 
 with the common bile duct have been exposed, the duct is 
 separated from its surroundings above and below the portion 
 which it is proposed to excise, and then silk ligatures are 
 applied to the duct proximally and distally to the diseased 
 portion. The duct is then divided transversely above and below 
 the portion which it is proposed to excise, and the separated 
 part removed. The mucous membrane of the two ends of the 
 divided duct should then be cauterised with the needle of a 
 Paquelin's cautery, or thoroughly scraped with a small sharp 
 spoon. The peritoneum is then stitched over the space formerly 
 occupied by the excised part of the duct, and a cholecyst- 
 enterostomy is performed, so as to allow the bile to pass from the 
 liver into the intestine. 
 
 This operation appears to be indicated in the following 
 pathological conditions : — 
 
 {a) In cases of localised malignant growths of the common 
 bile duct which are not associated with the presence of secondary 
 deposits in other viscera, and which do not involve the portal 
 vein and the hepatic artery, or extend to the cystic duct or 
 the hepatic ducts. 
 
 (&) In a few cases of impacted calculi in the common bile 
 duct which have caused extensive ulceration and inflammation. 
 
 (c) In papillomata of the common bile duct which involve a 
 considerable area of mucous membrane. 
 
 Owing to the difficulty of the diagnosis of the conditions 
 which have been enumerated as indicating the performance of 
 this operation, it will be rarely found possible to make use of 
 this procedure. Experimentally, I have removed a small part 
 
352 OPERATIONS UPON THE BILIARY DUCTS. 
 
 of the common bile duct in a dog, and at the same time per- 
 formed a cholecystenterostomy, and the operation was followed 
 by recovery of the animal. 
 
 Choledochotomy (by a lumhar incision). — Terrier has pro- 
 posed, in cases in which a gall stone has become impacted in the 
 lower portion of the common bile duct — that is to say, in the 
 ampulla of Vater — that an incision should be made in the 
 right lumbar region parallel to and immediately below the 
 lower border of the last rib. This is deepened until the 
 kidney is exposed, when this organ is pulled downwards, and the 
 dissection is prolonged upwards and inwards, until the common 
 bile duct is exposed as it lies behind the duodenum and the 
 head of the pancreas. If it is found to contain a stone, this 
 is removed either through an incision in the wall of the duct, or 
 it is manipulated with the fingers into the duodenum. Terrier 
 has performed this operation on the dead body, and he thinks it 
 is a method of procedure which may be introduced with advantage 
 into modern surgery. The difficulties which may be met with 
 during the process of dissection, the great depth of the 
 common bile duct from the surface in persons who are inclined 
 to be stout, and the immediate proximity of the inferior vena 
 cava and other large blood vessels, appear to militate very 
 strongly against the introduction of this operation as a form 
 of treatment for impacted gall stones. 
 
 Internal choledocho-duodenostomy. — Kocher has performed an 
 operation upon a patient who was suffering from chronic 
 jaundice with symptoms of gall stones, which he has called 
 by the above name. The abdominal cavity was opened and the 
 gall bladder and bile ducts examined. The gall bladder was 
 small, and contained only a moderate amount of bile, whilst 
 in the common bile duct, in that portion which lies behind 
 the duodenum, a calculus the size of a pigeon's egg was found. 
 Attempts were made to crush it with forceps, but unsuccessfully. 
 A transverse incision was then made in the anterior wall of 
 the second portion of the duodenum, and the calculus was 
 separated from its connections by incising the posterior wall 
 of the duodenum and the part of the common bile duct which 
 enclosed the calculus. After the gall stone had been removed, 
 the margins of the wound in the common bile duct were sutured 
 to those of the wound in the posterior part of the duodenum, 
 and the incision in the anterior wall of the gut was then 
 
INTERNAL CHOLEDOCHO-DUODENOSTOMY. 353 
 
 closed with sutures. The wound in the abdominal wall was 
 closed except at one point, which was left open for a drainage- 
 tube which had been passed down to the region of the incisions 
 in the duodenum and common bile duct. During the course 
 of the operation haemorrhage from the pancreas was encountered 
 but this was arrested by the application of gauze pads. 
 M'Burney of New York has described a similar case in which he 
 incised the anterior wall of the second portion of the duodenum 
 and then dilated the orifice of the common bile duct, and 
 removed through the dilated aperture a gall stone which had 
 been impacted in the lower part of the common bile duct. In 
 those cases in which the impacted calculus is large, dilatation 
 of the biliary orifice in the duodenum is not sufficient, and it 
 is necessary to incise the duct. The performance of the opera- 
 tion of internal choledocho-duodenostomy is indicated when a 
 calculus is impacted in the ampulla of Vater, and cannot be 
 dislodged by other and less severe measures. 
 
 Gystico-litliotomy. — It is requisite in some cases of cholelithiasis, 
 in which a calculus has become arrested in the cystic duct, and 
 has withstood all attempts to remove it, either by an operation 
 carried out from the interior of the gall bladder, or by manipulation 
 from the exterior of the duct itself, to incise the wall of the 
 cystic duct so as to enable the surgeon to extract the calculus. 
 The early stages of the operation are like those of choledocho- 
 lithotomy, and the incision of the cystic duct is made in a 
 manner similar to that which is employed in incision of the 
 common bile duct; after the calculus has been removed the 
 margins of the incision are united in a like manner with sutures. 
 In the majority of cases of gall stones impacted in the cystic 
 duct, which cannot be removed through the gall bladder, it 
 will be found advisable to remove the gall bladder and that 
 portion of the cystic duct which encloses the calculus, since the 
 inflammation which results from the presence of the impacted 
 stone often terminates in the obliteration of the lumen of the 
 cystic canal by a fibrous constriction ; and the establishment of 
 this condition is in most cases subsequently followed by a 
 distension of the gall bladder with a quantity of mucus secreted 
 by the mucous glands in its walls. If, however, the walls of the 
 cystic duct are in a moderately healthy state and not the seat of 
 extensive inflammation and ulceration, the stone may be removed 
 and the margins of the incision in the walls of the duct closed. 
 23 
 
354 OPERATIONS UPON THE BILIARY DUCTS. 
 
 Before incising the cystic duct, an attempt should always be 
 made to manipulate the calculus backwards into the cavity of the 
 gall bladder. Digital manipulation from without and dilatation 
 of the cystic duct from within the gall bladder often succeed 
 in bringing about the extraction of the calculus. 
 
 The common hepatic duct has been incised in a manner 
 similar to that which has been described for the common bile 
 duct and the cystic duct, and the margins of the incision stitched 
 to the lips of the abdominal wall. This operation has been per- 
 formed unsuccessfully by Kocher. The operation has been called 
 " hepaticostomy." 
 
 Catheterism of the hiliary 'passcujes. — It is occasionally necessary 
 to examine the course of the bile ducts with a catheter or sound. 
 The operation may be performed either through a biliary fistula 
 which opens upon the surface of the abdomen, or during the 
 course of an operation when some portion of the bile canal has 
 been incised. For the purpose of sounding or passing a catheter 
 along the bile canal, a soft olive-headed bougie is the best instru- 
 ment to use. Solid metal instruments are very prone to be the 
 cause of the establishment of false passages or to cause a rupture 
 of the canal. This procedure has been made use of both as a 
 means of diagnosis and as a form of treatment. It cannot be 
 said, however, that good results have followed its employment. 
 In certain cases it is possible to locate a stone or the situation of 
 a stricture, but the information which is obtained in this manner 
 cannot always be relied upon. 
 
BIBLIOGRAPHY. 
 
BIBLIOGRAPHY. 
 
 CHAPTER I. 
 
 Anatomy. 
 
 Berkley. — "Studies in the Histology of the Liver," Anat. Anz., Jena, 1893, 
 
 ss. 769-792. 
 CuNXiXGHAM. — " Delimitation of the Regions of the Abdomen," Journ. Anat. 
 
 and Physiol, London, 1893, jDp. 257-273. 
 DoYOX. — " Etude analytique des organes moteurs des voies biliaires," These 
 
 de Paris, 1893. 
 Faure. — " LAppareil suspenseur du foie," These de Paris, 1892. 
 Faure. — " Quelques points sur I'anatomie du canal cystique," Bull. Soc. 
 
 anat. de Paris, 1892, p. 511. 
 Hamilton. — "The Normal Position of the Gall Bladder in Males," Journ. 
 
 Am. Med. Assoc, 1895, p. 551. 
 Hartmann. — "Quelques points sur I'anatomie et la chirurgie des voies 
 
 biliaires," Bull. Soc. anat. de Paris, 1891, pp. 481-500. 
 Hochstetter. — " Anormalien der Pfortader, etc.," Arch.f. Anat. u. Physiol., 
 
 Leipzig, 1886, s. 369. 
 KoROLKow. — " Ueber die Nervenendigungen in der Leber," Anat. Anz., Jena, 
 
 1893, s. 751. 
 McCallum. — " The Terminations of the Nerves in the Liver," Quart. Journ. 
 
 Micr. Sc, London, 1887, vol. xxiv. p. 439. 
 Minot.—" Human Embryology," 1893. 
 Pfluger. — Arch.f. Physiol., Leipzig, 1869, Hefte 9, 10. 
 Purser.— "Double Gall Bladder," Trans. Acad. Med. Ireland, Dublin, 1887, 
 
 vol. V. p. 243. 
 QuAiN. — " Elements of Anatomy," 10th edition, vol. iii. pt. 4. 
 QuENU. — " Sur I'anatomie du choledoque a un point de vue chirurg.," Rev. de 
 
 chir., Paris, 1895, No. 7. 
 Reid. — " Researches in Anatomy and Physiology," 1848, p. 386. 
 RoLLESTON. — "Abnormal Vascular Supply of the Liver," Journ. Anat. and 
 
 Physiol., London, 1889, vol. xxiv. p. 132. 
 Sappey.— " Traite d'anatomie," 1877. 
 SiRAUD. — "Sur I'anatomie de la vesicule biliaire," Lyo7i mM., 1895, Nos. 
 
 20 and 21, pp. 72, 111. 
 Symington. — " On Certain Physiological Variations in the Shape and Position 
 
 of the Liver, Edi7i. Med. Journ., Feb. 1888. 
 Testut. — " Traite d'anatomie," 2nd edition, 1896, tome iii. 
 
 CHAPTER IIL 
 
 Jaundice. 
 
 Chaufpard. — " Contrib. a I'etude de I'ictere catarrhale," Rev. de me'd., Paris, 
 1885, p. 9. 
 
358 BIBLIOGRAPHY. 
 
 DuscH, Von. — " Untersucli. u. Experimente zur Pathogenesis d. Icterus," 
 
 Leipzig, 1854. 
 Fleischl. — " Von der Lymplie und den Lymphgefassen der Leber," Arh. a. d. 
 
 pMjsiol. Anst. zu. Leipzig, 1874, s. 22-27. 
 Frerichs. — " Diseases of the Liver," New Syd. Soc. Trans., 1861. 
 Gerhardt. — " Ueber Icterus gastro-duodenalis," Samml. hlin. Vortr., Leipzig, 
 
 1871, No. 17. 
 Halter und Lauterbacher. — " Beitr. zur Lebre von Icterus," Beitr. z. path. 
 
 Anat. u.z. allg. Path., Jena, Bd. x. s. 311-319. 
 Hanot et Gombault. — In Hanot, " Contribution a I'etude de Tacliolie," 
 
 Arch. g^n. de med, Paris, 1885, p. 12. 
 Harlet (Vaughan). — " Leber " imd Galle wahrend dauernden Verschlusses 
 
 von Gallen-und Brustgang, Arch.f. Anat. u. Physiol, Leipzig, 1893, s. 291. 
 Heitler. — " Zur Klinik des Icterus katarrb.," TFieji. med. Wchnschr., 1887, 
 
 Nos. 29, 30, and 31. 
 Hennig. — "Ueber epidemischen Icterus," Samml. Min. Vortr., LeijDzig, 1890, 
 
 No. 8. 
 Hoppe-Seyler. — "Handbucb der Physiol. Chem.," 1883. 
 Kelsch. — "De la nature de I'ictere catarrh.," Rev. de me'd., Paris, 1886, 
 
 p. 657. 
 Kupferath. — " Ueber die Abwesenheit der Gallensauren ini Blute nach dem 
 
 Verschlusse des Gallen-und Milchbrustgangs," Arch. f. Anat. u. Physiol., 
 
 Leipzig, 1880, s. 92. 
 Kuhne. — " Beit. z. Lehre vom Icterus," Virchoid's Archiv, Bd. xiv. s. 310. 
 KuNKEL. — " Ueber das Verhaltniss, etc." Arh. a. d. physiol. Anst. zu Leipzig, 
 
 1875, s. 112. 
 Legendre ET Raoult. — " Ictere par obstruction et infection secondaire par 
 
 la coli-bacille," Semaine me'd., Paris, 1892, No. 15. 
 Legg (Wickham). — "Bile, Jaundice, and Biliary Diseases," 1880. 
 Leyden. — " Beitr. z. Pathologie vom Icterus," Berlin, 1886. 
 Liebermeister. — "Zur Pathogenese des Icterus," Deutsche med. Wchnschr., 
 
 Leipzig, 1887, s 365. 
 Lowit. — Ibid., Beitr. z. path. anat. u. z. allg. Path., Jena, Bd. xiv. s. 310. 
 Mackay. — "Beitr. z. Lehre vom Icterus," Arch.f. exper. Path. u. Pharmakol., 
 
 Leipzig, 1885, Bd. xix. s. 269. 
 Minkowski und Naunyn. — " Ueber den Icterus durch Polycholia," Arch. f. 
 
 exper. Path. u. Pharmakol., Leipzig, 1886, s. 1—33. 
 Murchison. — Article "Jaundice," "Quain's Diet, of Medicine"; "Lectures 
 
 iipon Diseases of the Liver," 3rd edition, 1885. 
 Naunyn. — "Beitr. z. Lehre von Icterus," Arch.f. Anat. u. Physiol., Leipzig, 
 
 1886, s. 401-440. 
 Quincke. — Beitr. z. Lehre vom Icterus, Virchow's Archiv, Bd. xcv. s. 125-140. 
 Nothnagel. — " Ueber Icterus catarrhalis," JVien. med. Wchnschr., 1891, 
 
 Nos. 1, 3, and 4. 
 Otto. — "Ueber syphilitischen Icterus," Inaug. Diss., Kiel, 1894. 
 Potain. — "Emotional Jaundice," Ifcd. Week, 1894, p. 469. 
 Riedel. — " Erfahrungen liber die Gallensteinkrankheit, mit und ohne 
 
 Icterus," 1892. 
 Stern. — "Beitr. z. Pathologie der Leber und des Icterus," Arch.f. exper. 
 
 Path. u. Pharmakol., Leipzig, 1885, s. 39-59. 
 Thummel. — "Icterus in der Friihpei-iode der Syphilis," Inaug. Diss., 
 
 Berlin, 1894. 
 AVertheimer et Meyer. — " De quelqiies faits nouveaux relatifs au passage 
 
 de la matiere colorante du sang dans la bile," Arch, de physiol. norm, 
 et path., Paris, 1890, p. 425. 
 Ziegler. — " Lehrbuch der pathologischen Anatomie," Aufl. 8, 1895. 
 
BIBLIO GRAPHY. 3 5 9 
 
 CHAPTER IV. 
 Diagnosis. 
 
 BoHNSTEDT. — " Die DifFerentialdiagnose zwisclieii dem durcli Gallenstein 
 und dem durcli Tumor bedingten Verschluss des Ductus Clioledoclius," 
 Inaug. Diss., Halle, 1893. 
 
 Bright. — " Clinical Memoirs on Abdominal Tumours," Neio Syd. Soc, 
 1860. 
 
 Brockbank. — " Gallstones," 1896. 
 
 BuDD. — " Diseases of the Liver," 1844. 
 
 Chauffard. — In " Traite de med. Charcot.," etc., Paris, 1893. 
 
 Dequerat. — " Relations pathologiques du foie et de I'estomac," Paris, 1894. 
 
 Fagge.— " Text-Book of Medicine," 3rd edition, 1895. 
 
 Gallez. — "Diagnostic des tumeurs du ventre," 1890. 
 
 Gumprecht. — " Neuere Fortschritte in der Kenntniss der Cholelithiasis," 
 Deutsche med. Wchnschr., Leipzig, 1895, Nos. 14, 15, 17, and 20. 
 
 GuTTMANN. — "Physical Diagnosis," iVety Hyd. Soc. Trans., 1879. 
 
 Hanot. — " Du diagnostic ditterentielle entre la vesicule biliaire et I'hydrone- 
 phrose droit," Bull. Acad, de meU,, Paris, Feb. 13, 1895. 
 
 Harley. — " Diseases of the Liver," 1883. 
 
 Jaksch (von). — "Clinical Diagnosis," Eng. trans., 2nd edition, 1895. 
 
 Kehr. — " Gallensteinkrankheiten," 1896. 
 
 Langenbuch. — " Die Chirurgie der Leber und Gallenblase," 1894. 
 
 Legg (Wickham). — "Bile, Jaundice, and Biliary Diseases," 1880. 
 
 Leichtenstern. — In "Penzoldt and Stintzing's Handbuch," 1896, Bd. iv. 
 
 Leube. — "Specielle Diagnose der Inneren Krankheiten," 1895, Bd. i. 
 
 LiONNAis. — "Tumeurs de I'hypochondre droit," These de Paris, 1896. 
 
 KoHLER. — "Zur Diagnostik der Abdominaltumoren," Inaug. Diss., Frei- 
 burg, 1896. 
 
 Minkowski. — " Zur Diagnostik der Abdominaltumoren," Berl. klin. TFchnschr., 
 1888, No. 31. 
 
 MuRCHisoN. — "Diseases of the Liver," 3rd edition, 1885. 
 
 MussER.— " Medical Diagnosis," 1894. 
 
 Naunyn.— " Klinik der Cholelithiasis," 1892. 
 
 Ortner. — "Klinik der Cholelithiasis und der Gallenwege Infectionen," 1894. 
 
 OsLER. — "Lectures on the Diagnosis of Abdominal Tumours," 1895. 
 
 Robson (Mayo). — " Gallstones and their Treatment," 1892. 
 
 RiEDEL. — "Erfahrungen liber die Gallensteinkrankheit mit und ohne Icterus," 
 1892. 
 
 RuND. — "Febris hejDatica," Inaug. Diss., Berlin, 1891. 
 
 ScHtJPPEL. — In Ziemmssen's " Handbuch," vol. ix., Eng. trans. 
 
 . CHAPTER V. 
 
 Malformations. 
 
 Anderson. — " On Hsemorrhage from the Umbilicus after Sej)arating of the 
 
 Funis," Boston Med. and S. Journ., Jan. 2, 1850. 
 BiNZ. — "Zur Kenntniss des todlichen Icterus der Neugeborenen aus 
 
 Obliteration der Gallengange," Virchoiv^s Archiv, Bd. xxxv. s. 470. 
 Cnopf. — " Ueber Icterus Neonatorum," Miinchen. med. Wchnsclir., 1891, Nos. 
 
 16, 17. 
 
36o BIBLIOGRAPHY. 
 
 Freund. — " Ein Fall von congenitaler interstitieller Hepatitis mit Anomalie 
 der Gallenaujifiilirungsgange," Jahrb. f. Kindcrh., Leipzig, 1876, Bd. ix. 
 s. 178. 
 Gessxer. — "Ueber congenit. YerscHuss der Gallenausfulirungsgange," 
 
 Halle, 1886. 
 GiESE. — " Ueber Defect und congenitaler Obliteration der Gallenausfiilirungs- 
 
 gSnge," Jahrb. f. Kinderh., Leijizig, 1896, Heft 2. 
 Glaister. — "Icterus Neonatorum," Lancet, London, 1879, vol. i. p. 293. 
 Gould, — "Cases of Congenital Iclithvosis and Umbilical Hcemorrhage," 
 
 Boston Med. and S. Joiirn., 1855, p. 109. 
 Harley.— " Diseases of tlie Livei'," 1883, p. 299. 
 Hawkins. — "Congenital Obliteration of the Ductus Communis Clioledoclius," 
 
 Tra ns. Path. Soc. London, 1 895, j). 76. 
 Hennig. — " Sclirumpfung und Verschluss der Gallenwege," Jahrb. f. Kinderh., 
 
 LeijJzig, Bd. ix. s. 406. 
 Hexoch. — " Diseases of Children," vol. i. -p. 28. 
 Heschl. — " VoUstandiger Defect der Gallenwege," Wien. med. TVchnschr., 
 
 1865, s. 493. 
 Jacquemet. — "Anomalies du foie et des voies biliaires," These de Lj^on, 
 
 1896. 
 Kynoch. — " Fatal Jaundice from Congenital Obliteration of the Bile Ducts," 
 
 Ed.in. Med. Journ., Julv 1896. 
 Legg (Wickham).— " Bile Jaundice, etc.," 1880, p. 641. 
 Lomer. — " Ueber einer Fall von congenitaler partieller Obliteration der 
 
 Gallengange," Virchotvs Archiv, Bd. xcix. s. 130. 
 Lotze. — "Fall von todlichen Icterus in Folge congenitaler Defecte der 
 
 Gallenausfiihrungsgange," Berl. hlin. JVchnschr., 1876, s. 438. 
 Meyer. — " Ein Beitr. zur Diagnose der Hepatitis interstitiel. syphilitica bei 
 
 Neugeborenen," -fc'erZ. klin. JVchnschr., 1886, Nos. 16, 17. 
 Morgan. — "Case of Congenital Malformation of the Ductus Communis 
 
 Choledochus," Trans. Path. Soc. London, vol. xxix. p. 137. 
 MuRCHisoN. — " Diseases of the Liver," 3rd edition, p. 422. 
 NuNXELEi". — "Congenital Obliteration of the Hepatic Ducts," Trans. Path. 
 
 Soc. London, vol. xxiii. p. 152. 
 OxLEY. — " Congenital Atresia of the Duodenal Opening of the Common Bile 
 
 Duct," Lancet, London, 1883, vol. ii. p. 988. 
 HoTH. — " Beobachtungen ueber congenitaler Defecte der grossen Gallengange," 
 
 Virchow's Archiv, Bd. xliii. s. 296. 
 ScHUPPEL. — " Ueber Peripj'lephlebitis syjshilitica bei Neugeborenen," Arch. 
 
 d. Heilk., Leipzig, Bd. xi. s. 78. 
 Simpson. — "Congenital Absence of the Gall Bladder," Edin. Med. Journ., 
 
 1860-1861, p. 1045. 
 Smith. — "Diseases of Children," 3rd edition, p. 718. 
 Steven. — "Congenital Obliteration of the Bile Ducts," ^?Y/i. Pediat., N. Y., 
 
 1896, pp. 733-736. 
 Thomas. — " Icterus Neonatorum occurring in Five Successive Births," New 
 
 Zealand Med. Journ., 1891, p. 161. 
 Thomson. — " Congenital Obliteration of the Bile Ducts," Edin. Med. Journ., 
 
 vol. xxxvi. p. 523 et seq. 
 West. — " Diseases of Children," 8th edition, p. 649. 
 
 White. — " Icterus Infantum, from Congenital Deficiency of Ductus Com- 
 munis Choledochus," Am. Journ. Ohst., N. Y., 1888, p. 48. 
 WiLKs. — " Obliteration of the Biliary Ducts in an Infant," Trans. Path. Soc. 
 
 London, vol. xiii. p. 119. 
 WiTTiG. — " Ueber einen Fall von Hepatoniphalos," Inaug. Diss., Konigs- 
 berg, ] 888. 
 
BIBLIO GRAPH Y. 361 
 
 CHAPTER VI. 
 
 Abscess of the Liver, 
 
 AiTKEN.—" Chronic Hepatic Fistula," Edin. Med. Journ., 1870, p. 992. 
 Annesley. — " Researches upon the more Prevalent Diseases of India," 
 
 London, 1841. 
 Babes. — " Ueber Entero-hepatitis suppurativa endeniica," Centralhl. f. 
 
 Balderiol. u. Parasitenk, Jena, 1894, s. 952. 
 Barensprung. — "Beitr. z. Path. u. Diag. der Lebererkrankungen," Berlin, 
 
 1891. 
 Barker. — "On Two Cases of Hepatic Abscess," Lancet, London, 1882, 
 
 . vol. ii. 
 ■ Bernhard. — " Leberabscesse im Kindesalter," Strassburg, 1886. 
 Bertrand. — "Origine et nature des microbiennes non-spec-d'hepat. supp., 
 
 Gaz. hebd. d. sc. med. de Bordeaux, 1891, Nos. 4-6. 
 Bertrand and Fontan. — "Traite medico-chirurgicale de I'hepatite sup- 
 puree," Paris, 1895. 
 Bramwell and Stiles. — "Deep-seated Tropical Abscess of the Liver, 
 
 successfully treated by Trans-thoracic Method," Lancet, London, 1896, 
 
 p. 742. 
 Buckling. — " 36 Falle von Leberabscess," Inaug. Diss., Berlin, 1868. 
 Cambray, — "Traite de dysenterie des pays chauds," Paris, 1847. 
 Castro. — "Les abces du foie," Paris, 1870. 
 Cayley. — " Tropical Diseases of the Liver," in Davidson's "Diseases of Warm 
 
 Climates," 1893. 
 CoRRE. — " Traite clinique des maladies des pays chauds," 1887. 
 Councilman. — "Dysentery,' Johns Hopkins Hosp. Rep., Baltimore, 1891, 
 
 p. 2. 
 CuRNOw. — "Hepatic Abscess followed by Amoebic Dvsenterj^," Lancet, 
 
 London, 1895, p. 1109. 
 Cyr. — '• Traite pratique des maladies du foie," Paris, 1887. 
 Davaine. — " Traite des entozoaires," Paris, 1877. 
 DiEULAFOY.— " Du diagnostic et du traitement des kystes hydatique et des 
 
 abces du foie," Gaz. d. hop., Paris, 1872, Nos. 74 et seq. 
 Dmochowski und Jankowski. — " Bacilli in Multiple Liver Abscesses," 
 
 Centralhl. f. Bakteriol. u. Parasitenk., Jena, 1894, Bd. xvi. s. 130. 
 DuTROULAU. — •" Traite des maladies des Europ. dans les pays chauds," 1868. 
 Fascieu. — " De la frequence de I'hepatite suppuree in Cochinchina," Arch. 
 
 de m^d. nav., Paris, June 1894. 
 Fayrer. — In Davidson's " Hygiene and Diseases of Warm Climates," 1893. 
 Flugge.— " Bakteriologie," 3rd edition, 1896. 
 Fontan. — "Sur I'ouverture des grands abces du foie," Bull, et mem. Soc. 
 
 de chir. de Paris, tome xvii. p. 778. 
 Frankel. — " Leberabscesse," Deutsche med. Wchnschr., Leipzig, 1891, No. 48. 
 Frerichs.— " Diseases of the Liver," New Syd. Soc. Trails., 1861. 
 Friedmann. — "Ueber Leberabscesse," Inaug. Diss., Freiburg, 1896. 
 Galliard.— " Therap. des maladies du foie," Paris, 1894. 
 Galloupe.— " A Case of Hepatic Abscess," Boston Med. and S. Journ., 1883, 
 
 p. 271. 
 Godlee. — " Abscess of the Liver," Brit. Med. Journ., London, Jan. 11, 1890 ; 
 
 " Two Cases of Abscess of the Liver," Trans. Clin. Soc. London, 1896, 
 
 p. 160. 
 Grimm. — " Ueber einen Leberabscess mit Protozoa," ^j-c/t./. klin. Chir., Berlin, 
 
 Bd. xlviii. s. 478. 
 Harley. — " Hepatic Abscess from a Fall," Trans. Clin. Soc. London, vol. xiv. 
 
 p. 13 ; "Diseases of the Liver," etc., London, 1883. 
 
362 BIBLIOGRAPHY. 
 
 Harley (Vaughan). — "Abscess of the Liver," Brit. Med. Journ., London, 
 
 Nov. 23, 1889. 
 Haspel. — In Henoch's " Unterleibskrankheiten," 1864. 
 Helm. — " Pimctionsdrainage in Leberchirurgie," Deutsche med. Wchnschr., 
 
 1891, No. 36. 
 Hexgesbach. — ■" Ueber Leberabscess," Inaug. Diss., Berlin, 1894. 
 HiRSCH.— " Handbook of Geographical Pathology," 1886, vol. iii. 
 Hulke. — "Bursting of a Large Hepatic Abscess into the Peritoneum," 
 
 Med.-Chir. Trans., London, 1894, p. 81. 
 Kartulis. — " Zur ^Etiologie der Leberabscesse," Centralbl. f. Bakteriol. m. 
 
 Parasitenk., Jena, 1887, No. 25 ; and Virchoio's Archiv, Bd. cxviii. s. 97. 
 Kelsch et Kiexer. — " Traite des maladies des j)ays chauds," 1889. 
 Korte. — "Ueber die chirurgische Behandlung des Leberabscesses," Berl. 
 
 klin. Wdmschr., 1892, No. 32. 
 Zruse und Pasquale. — "Dvsenterie und Leberabscess," Deutsche med. 
 
 Wchnschr., Leipzig, 1893, Nos. 15, 16. 
 Langenbuch. — "Chirurgie der Leber und Gallenblase," "Deutsche Chir.," 
 
 Leipzig, 1894. 
 Leahy. — " Eelation between Dysentery and Abscess of the Liver," Lancet, 
 
 London, 1895, p. 926. 
 Lebloxd. — " Diagnosis et traitement des abces du foie," These de Paris, 
 
 1893. 
 Leyden. — "Multiple Leberabscesse in Folge von Gallensteinen," Berlin, 
 
 1886. 
 Louis. — "Eecher. anatom. sur le fievre typhoide," 2nd edition, vol. i. p. 118. 
 MACLEOD. — " Dysentery and Hepatic Abscess," Lancet, London, 1895, p. 1037. 
 Maxsox. — " Amoebic Abscess of the Liver," Lancet, London, 1894, p. 678 ; 
 
 "Abscess of the Liver," Quain's "Diet. Med.," 2nd edition, 1894. 
 Marshall.—" Notes on Topography (Medical) of Ceylon," 1821. 
 Meyer.—" Die Wunden der Leber und Gallenblase," 1872. 
 MoREHEAD. — " Clinical Researches on Diseases of India," 1856. 
 MoRTOX. — "Abscess of the Liver and its Treatment," ia?icef, London, May 
 
 22, 1894. 
 MoSLER. — " Ueber traumatischen Dojjpelabscess der Leber," Inaug. Diss., 
 
 Berlin, 1883. 
 Nasse. — "Amceben bei Leberabscessen," Arh. a. d. chir. Klin., d. k. Univ. 
 
 Berlin, Bd. v. 
 OsLER. — " Ueber die in Dysenterie und dysenterischen Leberabscessen 
 
 vorhand. Amoaba," Centralbl. f. Bakteriol. u^ Parasitenk., Jena, 1890, s. 736. 
 Otis. — " Stab of Liver followed by Abscess of Liver," " Med. and Surg. Hist., 
 
 War of Rebel.," Surg. Vol., p. 129. 
 Paxtalexi. — " Contrib. a I'etude de la chir. du foie," Arch. prov. de chir., 
 
 Paris, 1892 and 1894. 
 Pel. — "Ueber die Diagnose der Leberabscesse," jBerL klin. Wchnschr., 1890, 
 
 No. 34. 
 Peyrot. — "Le sterilite du pus des abces du foie, etc.," Bull, et mem. Soc. 
 
 de chir. de Paris, tome xvii. p. 39. 
 Peyrot et Roger.— " Abces dysenterique ne contenant que des amides," 
 
 Bull. Acad, de m^d., Paris, 1896, tome xxxv. p. 388. 
 Pimser. — " Hepatitis suppurativa nach Dvsenterie," Wie7i. med. Wchnschr., 
 
 1883, s. 1244. 
 Podwyssozki.— " Coccidia, etc.," Centralbl. f. klin. Med., Bonn, 1890, No. 48. 
 Rexnie.—" Large Hepatic Abscess," Brit. Med. Journ., London, 1896, p. 83. 
 RiEUX. — " De la j'leurisie sereuse driot. consec. aux abces du foie," These de 
 
 Lyon, 1896. 
 Romberg. — " Beobachtungen ueber Leberabscesse beim Typhus abdominalis," 
 
 Berl. klin. Wchnschr., 1890, No. 9. 
 Scheube. — " Die Krankheiten der warmen Lander," 1896. 
 
BIBLIOGRAPHY. 363 
 
 Tait (Lawson).— " Surgery of the Liver," Edin. Med. Journ., 1889. 
 Waring. — " An Inquiry into the Statistics of Diseases of the Liver," 1854. 
 Zancarol.— " Traitemenfc chirurgical des abces du foie des pays cliauds," 
 
 Paris, 1893 ; " Dysenterie et abces du foie," Frogres me'd., Paris, 1895, 
 
 No. 24. 
 
 CHAPTER VIL 
 
 Tubercular Abscess of the Liver. 
 
 Arnold. — " Ueber Lebertuberculose," Virchow's Archiv, Bd. Ixxxii. s. 377. 
 Cadet de Gassicourt. — " Peritonite sus-hepatique suppuree prise pour 
 
 une collection purulente du foie," Bull, et mem. Soc. mM. d. hop. de Paris, 
 
 1886, p. 481. 
 Deschamps. — " De la peritonite peri-hepatique enkyste," These de Paris, 
 
 1885. 
 Frankel. — " Klin. Mittheilungen ueber Lebertuberculose," Berlin, 1882. 
 GoMBAULT et Breda. — " Abces areolaire tuberculeux du foie," Bull. Soc. 
 
 anat. de Paris, 1887, p. 737. 
 Lannelongue. — "Sur les abces tuberculeux peri-hepatique," Bull. Acad. 
 
 de me'd., Paris, 1887, p. 432 ; " Tuberculose hepatique et peri- 
 hepatique," Mem. de Congrh frangais pour Vetude de tuberculose, 1889, 
 
 p. 204. 
 Lauth. — " Essai sur la cirrhose tuberculeuse," These de Paris, 1888. 
 Orth. — " Ueber localisirte Tuberculose der Leber/' Virchow's Archiv, 
 
 Bd. Ixvi. s. 113. 
 PiLLiET. — " Etude d'histologie pathologique sur la tuberculose exper. et 
 
 spont. du foie," These de Paris, 1891. 
 RoBSON (Mayo). — " Tubercular Abscess of the Liver," Lancet, London, Jan. 19, 
 
 1896. 
 Sabourin. — "Le foie des tuberculeux," Paris, 1884. 
 SiMMONDS. — " Ueber chronische interstitielle Entziindung der Leber," 
 
 Deutsches Arch.f. hlin. Med., Leipzig, 1880, Bd. xxvii. s. 73. 
 Wagner. — "Die Tuberculose der Leber," Arch. d. Eeilh., Leipzig, 1861, 
 
 Abth. 2. 
 WiLHELMY. — "Zur Lebertuberculose," Inaug. Diss., Wiirzburg, 1876. 
 
 CHAPTER VII L 
 
 Actinomycosis of the Liver. 
 
 Bostroem. — "Die Aktinomycose des Menschen," Beitr. z. path. Anat. u. z. allg. 
 
 Path., Jena, 1890, Bd. ix. s. 1-248. 
 Eve. — " Actinomycosis of the Liver," Brit. Med. Journ., London, 1889, vol. i. 
 
 p. 584. 
 Harley. — " A Case of so-called Actinomycosis of the Liver," London, 1886. 
 Illich. — "Beitr. z. klin. d. Aktinomycose," Wien, 1862. 
 Israel. — "Klin. Beitr. z. Kenntniss d. Aktinomycose des Menchen," 
 
 Berlin, 1885. 
 Leith. — " Actinomvcosis of the Liver, Colon, and Lung," Edin. Hosp. Rep., 
 
 1894, voL ii. pp. 121-191. 
 
364 BIBLIOGRAPHY. 
 
 PoNFiCK. — " Zur Gescliiclite der Aktinomycose," Virchoiv's Archiv, 1881, 
 
 ss. 541-561. 
 Shattuck. — " Two Cases of Actinomycosis in Man," Trans. Path. Soc. London, 
 
 yol. xxxyi. pp. 254-261. 
 Stewart axd Muir. — " Notes on a Case of Actinomycosis of Ovaries and 
 
 Liver," Edin. Hosp. Rep., 1893, vol. i. pp. 96-1 1:^. 
 Waring. — "Actinomycosis hominis," St. Barth. Hosp. Rep., 1891, pp. 173-175. 
 
 CHAPTER IX. 
 
 Syphilis op the Liver. 
 
 Barensprung. — " Die liereditaire Syphilis," Berlin, 1864. 
 
 Baumler. — Article " Syphilis " in Ziemmssen's " CycloiDsedia," vol. iii. 
 
 Bourel. — " De la Syphilis hepatique," 1884. 
 
 Frerichs. — " Diseases of the Liver," Nev: Syd. Soc. Trans., vol. ii. 
 
 Labadie-Lagrave. — " Traite des maladies du foie," 1892. 
 
 Lancereaux. — " Traite de la syphilis," New Syd. Soc. Trans. 
 
 MoxoN. — " Syphilitic Disease of the Liver," Trans. Path. Soc. London, vol. 
 
 xxiii. p. 153. 
 Payne. — " Three Cases of Syphilitic Growths in the Liver," Trans. Path. Soc. 
 
 London, vol. xxi. p. 207. 
 Peiser. — " Beitr. z. Kenntniss der Lebersyphilis," Inaug. Diss., Erlangen, 
 
 1886. 
 Thummel. — " Ueber Icterus in der Friihperiode der Syphilis," Inaug. Diss., 
 
 Berlin, 1894. 
 WiLKS. — " Syphilitic Affections of Internal Organs," Guy^s Hosp. Rep., 
 
 London," 1863. 
 
 CHAPTER X. 
 
 Hydatid Cysts of the Liver. 
 
 Alison.—" Traitd des maladies du foie," Paris, 1887. 
 
 Bahrt. — " Spontanheilung bei Leberechinococcus durch Brucli in den 
 
 Magendarmkanal," Arch. d. Heilk, Leipzig, 1882, Hefte 4-5. 
 Bechert. — " Zur Behandlung des Leberechinococcus," Inaug. Diss., Konigs- 
 
 berg, 1894. 
 Bobrow. — " Ueber die Behandlung des Echinococcus," Ref. in Centralbl. f. 
 
 CJhir., Leipzig, 1894, s. 779. 
 Braine. — " Traitement chir. des kystes hydatique du foie," Paris, 1886. 
 BuDD.— " Diseases of Liver," 1842.' 
 Cadet.— "Recher. sur la rupture des kystes hydat. du foie," Th^se de Paris, 
 
 1865. 
 Churton AND RoBSON. — "Large Hydatid Tumour of the Liver," Lancet, 
 
 London, 1888, vol. i. p. 573. 
 Davaine.—" Traite des Entozoaires," Paris, 1877. 
 Delbet. — " Kyst hydatique du foie commuuifjuant avec leg voies biliaires, 
 
 guere par le capitonnage sans drainage," Bull. Acad, de rn^d., Paris, 
 
 1896, p. 577. 
 
BIBLIOGRAPHY. 365 
 
 DoLLiNGER. — "Ein Fall von Durchbrucli des Leberecliinococcus in die 
 grossen Gefasse," Pe.si. med.-chir. Presse, Buda-pest, 1876, No. 40. 
 
 Fagge and Durham. — "Electrolysis in Treatment of Hydatid Tumours of 
 the Liver," Med.-Chir. Tram., London, vol. liv. pp. 1-46. 
 
 Frerichs. — " Diseases of the Liver," 1861. 
 
 Graham.—" Hydatid Disease," 1891. 
 
 Habershon. — " Ruj^ture of a Hydatid into the Lung ; Death from Htemor- 
 rhage," G2iy's Hosij. R&p., London, 1863, p. 174. 
 
 Hanot. — "Trois kystes hydatique du foie gueris par la ponction avec injec- 
 tion de liqueur de van Swieten," Arch. gen. de mM., Paris, 1891, 
 p. 738. 
 
 Harley. — " Diseases of the Liver," 1883 ; "Treatment of the Hydatid Disease 
 of the Liver," St. Thomas's Hasp. Rej}., London, 1877. 
 
 Helm. — " Functions-drainage in der Leberchirurgie," Deutsche med. Wchnschr., 
 Leipzig, 1891, s. 1052. 
 
 Israel. — " Ein Beitr. zur Leberchirurgie," Deutsche vied. Wchnschr., Leipzig, 
 1890, s. 40. 
 
 JoNASSEN. — "Rupture of a Hydatid Cyst of the Liver into the Urinary 
 Bladder " (quoted by Langenbuch), ([.v. 
 
 Keith. — "Abdominal Surgery," 1895. 
 
 Lachmann. — " Ueber op. Behandlung des Echinococcus der Bauchorgane," 
 Inaug. Diss., Breslau, 1896. 
 
 Landau. — "Zur Operation d. Echinococcen der Bauchhohle," Berl. Iclin. 
 Wchnschr., 1880, Nos. 7 and 8 ; " Surgical Treatment of Sub- 
 diaphragmatic Hydatid Tumours," Ref., Semaine med., Paris, 1886, pp. 
 558 and 511. 
 
 Langenbuch. — " Die Chirurgie der Leber und Gallenblase," 1894 ; " Der 
 Leberechinococcus und seine Chirurgie," 1891. 
 
 Leuckart. — " The Parasites of Man," Eng. Trans., 1886. 
 
 Lezin. — "Echinococcus of Liver treated by ' Lindemann-Landau ' Method," 
 Vrach, St. Petersburg, 1894, s. 907. 
 
 Lindmann. — Ref. in Kirschner, " Inaug. Diss.," Berlin, 1879. 
 
 Madelung. — "Beitr. z. Lehre d. Echinococcuskrankheit," 1885. 
 
 Mauny. — " Etude sur les ruptures intra-peritoneales des kystes hydatiques 
 du foie," Paris, 1891. 
 
 Murchison. — " Diseases of the Liver," 1885. 
 
 Neisser. — "Die Echinococcuskrankheit," 1877. 
 
 NuTZENADET (Riedel). — " Ueber die Schwierigkeit der Leberechinococcus- 
 diagnose," Inaug. Diss., Jena, 1889. 
 
 Paget. — " Two Cases of Hydatid Disease of the Liver drained through the 
 Chest Wall," Brit. Med. Journ., London, 1894, p. 1095. 
 
 PoTHERAT. — " Kystes hydatique du foie," These de Paris, 1889. 
 
 Recamier. — " Observation d'Hepatite," Eev. de mecL, Paris, 1825, tome iv. 
 p. 26. 
 
 Recklinghausen (von). — " Chem. Untersuch. einer Echinococcusfliissigheit," 
 Virchoiv's Archiv, Bd. xiv. s. 481. 
 
 Reuberling. — " Ueber Spontanheilung von Leberechinococcus," Inaug. 
 Diss., Marburg, 1894. 
 
 Rudall. — " Surgical Treatment of Hydatid Tumours," Austral. Med. Journ., 
 1895, No. 1. 
 
 Scheussler. — " Das neue Billrothische Verfahren z\ir Behandlung intra- 
 peritoneal. Echinococcus," 1892, Beitr. z. Chir. Festschr. . . . Th. Billroth 
 . . . Stuttgart, 1892. 
 
 Smith (Greig). — "Abdominal Surgery," 1896, vol. ii. 
 
 Tait (Lawson). — " Hydatids of the Liver treated by Abdominal Section and 
 Drainage," Zancei, London, 1880, vol. ii. p. 976. 
 
 Thomas.— " Hydatid Disease," 1894. 
 
366 BIBLIOGRAPHY. 
 
 Thornton. — " Two Cases of Hepatotomy for Hydatids," Med. Times and Gaz., 
 
 London, 1883, vol. i. p. 89. 
 Weber. — " Beitr. z. die statis. Echinococcuskrankheit," Inaug. Diss., Kiel, 
 
 1892. 
 
 CHAPTER XL 
 
 MULTILOCULAR ECHINOCOCCUS OP THE LiVER. 
 
 Brunner. — "Ein Beitrag zur Beliandlung des Echinococcus alveolaris 
 
 hepatis," Miinchen. vied. Wchnschr.^ 1891, s. 509. 
 Brinsteiner. — " Zv;r vergleichenden Pathologie des Alveolarechinococcus der 
 
 Leber," Inaug. Diss., Miinclien, 1884. 
 Bruns. — " Leber-resection bei multilocularen Ecbinococcus," Beitr. z. hlin. 
 
 Chir., Tlibingen, 1896, Bd. xvii. s. 120. 
 Carriere. — " De la tumeur hydatique alveolar," These de Paris, 1868. 
 Frerichs. — Diseases of the Liver," New Syd. Soc. Trans., 1861. 
 Gallez. — " Tumenrs du ventre," Paris, 1890. 
 Langenbuoh. — "Chirurgie der Leber imd Gallenblase," "Deutsche Chirurgie," 
 
 Leipzig, 1894. 
 Lehhann. — " Zur Casuistik des Multilocularen Echinococcus der Leber," 
 
 Inaug. Diss., Miinchen, 1889. 
 Leuckart. — " The Parasites of Man," Eng. trans, 1886. 
 Nahm. — " Ueber den Multilocularen Echinococcus der Leber, etc.," Miinchen. 
 
 med. TFchnschr., 1887, Nos. 35 and 36. 
 Strathausen. — "Ein Fall von Echinococcus multilocularis," Inaug. Diss., 
 
 Munchen, 1889. 
 Terrillon. — " Ablation d'un mor9eau du foie renipli de petits kystes 
 
 hydatiqiies par la ligature elastique," Bidl. Acad, de me'd., Paris, 1891, 
 
 p. 75. 
 ViERORDT. — "Abhandlung ueber den multilocularen Echinococcus," Inaug. 
 
 Diss., Freiburg, 1886 ; " Der multiloculare Echinococcus der Leber," 
 
 Berl. Klinik, 1890, No. 28. 
 ViRCHOW. — Verhandl. d. fliys.-med. Gesellsch. zu JVilrzburg., 1856. 
 Zeller. — " Das AlveolarcoUoid der Leber," Tiibingen, 1854. 
 
 CHAPTER XI L 
 
 Cysts of the Liver. 
 
 Bayer (Carl.) — " Uel)er eine durch Operation geheilte, ungewohnliche grosse 
 
 Leberkyste," Prag. med. Wchnschr., 1892, No. 52. 
 Bristowe. — Trans. Path. Soc. London, vol. vii. p. 229, and vol. ix. p. 174. 
 Cameron. — " A Case of Cystic Degeneration of tlie Liver," Glasgow Med. 
 
 Journ., 1894, p. 205. 
 Claude. — " La maladie polykystique du foie," Bull. Soc. anat. de Paris, 1896, 
 
 p. 109. 
 CoMBis. — "Contribution I'dtiide des kystes du foie et reins," Paris, 1877. 
 Cousins.— " Large Simple Cyst of the Liver," Brit. Med. Journ., London, 
 
 1874, p. 700. 
 Demantke. — Bull. Soc. anat. de Paris, 1893-94-95. 
 
BIBLIOGRAPHY. 367 
 
 Dmochowski und Janowski. — " Totale cystische Entartung der Leber," 
 
 Beitr. %. path. Anat. u. z. alhj. Path., Jena, 1894, Bd. xvi. s. 166. 
 Frerichs. — "Diseases of the Liver," 1861. 
 
 Hawkins. — "Cysts of Liver," Med.-Chir. Trans., London, vol. xviii. 
 HiPPEL. — " Cystadenom der Gallengiinge," Virchovfs Archiv, Bd. xxiii. 
 
 s. 473. 
 HuLKE. — " Dermoid Cyst attached to Liver," Trans. Path. Soc. London, 
 
 vol. xxiv. p. 157. 
 Juhel-Renoy. — " Degenerescence kystique du foie et des veins," Rev. de mM., 
 
 Paris, 1881, p. 929 et seq. 
 Kahlden. — " Genese der Cystenleber," Beitr. z. path. Anat. u. z. allg. Path., 
 
 Jena, 1893, Bd. xiii. s. 291. 
 Lejars. — These de Paris, 1888. 
 North.— "A Case of Cystic Disease of the Liver," Med. Rec, N. Y.. 1882, 
 
 p. 344. 
 Pye-Smith. — " Cystic Disease of Liver and both Kidneys," Trans. Path. Soc. 
 
 London, vol. xxxii. p. 112. 
 Sabourin. — Rev. de me'd., Paris, May 1883. 
 Sharkey. — "Simple Cyst in connection with Liver," Trans. Path. Soc. 
 
 London, vol. xxxiii. p. 168. 
 SlEGMUND. — "Cvstadenom des Gallenganges," Virchonfs Archiv, Bd. cxv. 
 
 s. 155. 
 Simon. — Article " Foie," " Xouveau Diet, de med. et de chir. pratique." 
 Terburgh. — "Ueber Leber und Nierenkysten," Inaug. Diss., Freiburg, 1893. 
 White. — " Cystic Degeneration of Liver," Lancet, London, 1884, vol. i. p. 663. 
 WiTZEL. — " Hemicephalus mit Leberkvsten," Gentralhl. f. GynciJc, Leij)zig, 
 
 1880, No. 24. 
 
 CHAPTER XIII 
 
 Movable Liver. 
 
 Blet. — " Etude sur le foie mobile," These de Paris, 1876. 
 
 Cantani. — " Caso di fegato ambulante," Ann. univ. di med. e chir., Milano, 
 
 1866, p. 373. 
 Cardarelli. — " Un novo caso di fegato &mh^Aa,■n.t&," Riforma med., Roma, 1893. 
 Faure.— These de Paris, 1892. 
 Gerard-Marchant. — " Hepatopexie," Bull. Acad, de me'd., Paris, Aoftt 11, 
 
 1891. 
 GoDART. — " Observations de quelques cas d'hepatoptose," Journ. de me'd., chir. 
 
 et pharmac, Bruxelles, 1894, page 1-8. 
 Hertz. — " Abnorm. Bauchorgan," Berlin, 1894. 
 Jacquemet. — " Anomal. du foie," These de Lyon, 1896. 
 Landau. — " Ueber Dislocation der Leber," Deutsche med. Wchnschr., Leipzig, 
 
 1885, s. 754 ; " Die Wanderleber und der Hangebauch der Frauen," 
 
 1885. 
 Langenbuch. — Berl. hlin. Wchnschr., 1891, s. 68. (Two cases operated upon.) 
 Legg (Wickham). — " Moveable and Displaced Liver," St. Barth. Hosp. Rep., 
 
 London, 1877. 
 Leube. — "Zur Genese der Wanderleber." Sitzungsb. d. phxjs.-med. Gesellsch. 
 
 zu Wilrzburg, 1893, No. 7 ; " Innere Krankheiten," Bd. i. s. 204. 
 Letienne. — "Sur la mobilite du foie," Me'd. mod., Paris, Dec. 1892. 
 LoNGUET. — "Anomal. du foie," Bi'.ll. Soc. anat. de Paris, 1874, p. 186. 
 Mann. — " Hepatoptose," Ann. d. mal. d. org. ge'nito-uriii., Paris, Dec. 1891. 
 Mathieu. — " Un cas de foie mobile," Btdl. et me'm. Soc. mM. d. h6p. de Paris, 
 
 Oct. 1893. 
 
368 BIBLIOGRAPHY. 
 
 MUller. — " Ueber eiuen Fall von Wanderleber," Berl. Min. TFchnschi:, 1892, 
 
 No. 15 ; " Zur Diagnose von Wanderleber," Deutsches Arch.f. Min. Med., 
 
 Leipzig, Bd. xiv. s. 146. 
 Patry. — " Hepatocele operee," Eei\ me'd. de la Suisse Rom., Geneve, 1896, p. 354. 
 RiCHELOT. — " Fixation d'un foie deplace," Union me'd., Paris, Ao<\t 5, 1893. 
 RiEDEL. — "Ueber den zungenformigen Fortsatz des rechten Leberlappens, 
 
 etc.," Berl. Min. JFchnschr., 1888, Nos. 29 and 30. 
 Sangline. — " L'Heimtoptose," These de Paris, 1896. 
 Segond. — " Traite de Chir. Duplay et Reclus," tome vii. 
 Snowman. — "Displacement of the Liver," Lancet, London, May 9, 1896. 
 Symington. — "Variations in Shape and Size of the Liver," Edin. Med. Jonrn., 
 
 1887-88, p. 724. 
 WiCKHAM. — "Anormal. du lig. suspen. du foie," Bull. Soc. anat. de Paris, 
 
 1846, p. 25. 
 
 CHAPTER XIV. 
 Traumatic Affections of the Liver. 
 
 Beck. — " Stichverletzungen Leber und Magen," Deutsche med. JFchischr., 
 
 Leipzig, 1894, s. 758. 
 Bergasse. — " Blessure mortelle du foie," Arch, de me'd. mil., Bruxelles, Feb. 
 
 1896. 
 Bremer. — "Ein Fall von Leberverletzung," Dettfsc/i-e med. JFchnschr., 1894, 
 
 No. 7. 
 Broca. — "Deux laparotomies pour plaies du foie," Mercredi me'd., Paris, 
 
 1891, tome ii. p. 361. 
 Bryant — " Rupture of the Liver," Lancet, London, Nov. 9, 1895. 
 Burchardt. — " Beitr. z. Behandlung der Leberverletzungen," Centralbl. f. 
 
 Chir., Leipzig, 1889, s. 361. 
 Dalton. — " Stab Wound of Liver, Laparotomy," Trans. Med. Ass. Missouri, 
 
 August 1890; "Rupture of Liver and Kidney," JFeeMy Med. Rev., 1890, 
 
 p. 261 ; " Cases of Penetrating Stab Wounds of Abdomen,'' Journ. Am. 
 
 Med. Ass., Chicago, 1890, p. 708. 
 Dalziel.— "Foreign Body in the Liver." Glasrjow Med. Journ., 1894, p. 457. 
 Edler. — " Die traumatische Verletzungden der parenchymatiisen L^nters- 
 
 leibsorgane," Arch.f. Min. Chir., Berlin, 1887, Bd. xxxiv. s. 173. 
 Faure. — " Decollement de ]a vesicule biliaire et hsemorrhage du foie," Bull. 
 
 et m^m. d. Soc. de Chir., Paris, 1896, p. 620. 
 FiALLA. — "Injuries of the Liver," Eif or ma oned., Roma, 1894. 
 Flamerdhinghe.^ — " Revolverschuss in die Leber," Deutsche med. JFchnschr., 
 
 Leipzig, 1890, s. 867. 
 Gage. — " Secondary Laparotomy for Pistol Wound of the Liver," Boston Med. 
 
 and S. Journ., vol. cxxvi. p. 417. 
 Gangolphe. — " Piaie du foie j)ar coup de revolver," Lyon mM., Nov. 24, 1895. 
 Hamilton. — " Fat Embolism after Rujsture of the Liver," Brit. Med. Journ., 
 
 London, Oct. 7, 1877. 
 Heath. — " Two Cases of Traumatic Ruiiture of the Liver," Brit. Med. Journ., 
 
 London, May 25, 1889. 
 Hess. — " Beitr. zur Lehre von den traum. Leber-rupturen," Virchovjs 
 
 Archiv, Bd. cxxi. s. 151. 
 Horwitz. — " Rupture of the Liver," Theraf. Ga:L, Detroit, July 1896. 
 Jelks. — "Gunshot Wound of Liver and Stomach," Journ. Am. Med. Ass., 
 
 Chicago, 1892, p. 64. 
 
BIBLIOGRAPHY. 369 
 
 Jones. — ^" Penetrating Wound of Liver," Lancet., London, 1894, voL i. 
 
 p. 1132. 
 Klob. — " Ueber die Rupturen der Leber," Wim. vied. BL, 1878, Nos. 13-18. 
 KoRTE. — " Ueber die Chirurgie der Leber und Gallenblase," Samml. klin. 
 
 Vortr., Leipzig, 1892, No. 40. 
 Kronlein. — Quoted by " Schlatter," q.v. 
 Lambotte et Hermann. — Ann. Soc de me'd. d'Anvers, 1895. 
 Langenbuch. — " Chirurgie der Leber und Gallenblase," 1894, Abt. 1. 
 Lupo. — " Ferita del fegato, laparotomia, etc.," Riforma vied., Roma, 1893, 
 
 tome iv. j). 503 ; and 1895, tome ii. p. 350. 
 McMillan. — " Rupture of the Liver ; Operation and Cure," Lancet, London, 
 
 1860, vol. ii. p. 431. 
 Marshall. — " Complete Rupture of the Liver," ibid., Feb. 7, 1874. 
 Mayer. — " Die Wunden der Leber und Gallenblase," Munich, 1872. 
 M:6gewand. — " Dechirures du foie par traumatisme," Rev. vied, de la 
 
 Suisse Rom., Geneve, 1890, No. 6. 
 Meyer. — "Wunden der Leber," 1878. 
 Otis. — " Med. and Surg. Historj', War of Rebellion," pt. ii. vol. ii. pp. 16 
 
 and 129. 
 Pag-e. — " Peritonitis from Hsemorrhage after Ruptured Liver," Trans. Clin. 
 
 80c. London, vol. xxv. pp. 172-177. 
 NussBAUM. — " Die Verletzungen des Untersleibs," " Deutsche Chirurgie," 
 
 Leipzig, 1880. 
 PosTEMSKi. — " Les plaies du foie et leur traitement par suture," Trans. 
 
 Internat. Med. Congress, 1890, Bd. iii. s. 190. 
 Schlatter.— " Die Behandlung der traumatischen Leberverletzungen," Beitr. 
 
 z. klin. Ghir., Tiibingen, Bd. xv. s. 531-562. 
 Segond. — Article " Foie," " Traite de Chir.," Duplay et Reclus, 1892, vol. vii. 
 Smits.— "Ein Fall von Leberverletzung," Gentralhl. f. Ghir., Leipzig, 1893, s. 
 
 622. 
 Terrier et Auvray. — ^" Les Traumatismes du foie," Rev. de chir., Paris, 
 
 1896, No. 10, pp. 717-776. 
 Terrillon. — " Chirurgie du foie," Bull, et mem. Soc. de Ghir. de Paris, 1890, 
 
 p. 835. 
 Vanverts. — " Des ruptures du foie et de leur traitement," Arch. gen. de me'd., 
 
 Paris, 1897, pp. 44-78. 
 Wherry. — " Rupture of the Liver," Glin. Sketches, London, July 1893. 
 Zeidler. — " Drei Falle traumatischer Leberverletzung," Deutsche med. 
 
 JVchnschr., Leipzig, 1894, No. 37. 
 Zoledziow^ski. — " Fin Beitr. zur Kasuistik der traumatischen Ruptur der 
 
 Leber," Gentralhl. f. Ghir., Leipzig, 1894, s. 1213. 
 
 CHAPTER XV. 
 
 Tumours op the Liver. 
 
 Ahlenstiel. — "Die Lebergeschwiilste und ihre Behandlung, Arch. f. klin. 
 
 Ghir., Berlin, Bd. Iii. s. 906. 
 Bastianelli. — "La diagnosi e la terapia chir. de fegato cordato," Policlin., 
 
 Roma, 1895, tome 2. 
 Bergmann. — •" Extirpation einer Geschwulst der Leber," Gentralhl. f. Ghir., 
 
 Leipzig, 1893, s. 65 ; "Zur Kasuistik der Leberchirurgie," Arch. f. klin. 
 
 Ghir., Berlin, Bd. xlvi. s. 393. 
 EiSELBERG. — " Abtragung eines Cavernoms der Leber," Wien.hlin. Wchnschr., 
 
 1893, No. 1. 
 
 24 
 
370 BIBLIOGRAPHY. 
 
 Garre. — "Eeitr. z. Leber-cliirurgie," Beiir. z. Chir. Festschrift . . . Th. 
 
 Billroth . . . Stuttgart, 1892, s. 181. 
 Gluck. — "Ueber Extirpationeai von Organen," ^?r/i./. Jdin. Chir., Berlin, Bd. 
 
 XXX. Heft 3 ; "Ueber die Bedeutungder phy.-cliir. Exper. an der Leber," 
 
 ibid., Bd. xxix. Heft 1. 
 Groube. — Quoted by " Kousnetzoff et Pensky," q.v. 
 HoCHENEGG. — " Ein Beitr. zur Leber-chirurgie," Wien. Idin. Wchnschr., 
 
 1890, SS.223 und 1008. 
 Israel. — "Ein Beitr. zur Leber-cliirurgie," Deutsche med. Wchnschr., Leipzig, 
 
 1894, No. 34. 
 Keen. — " On Resection of the Liver, especially for Hepatic Tumours," Boston 
 
 Med. and 8. Journ., 1892, No. 17. 
 Koexig. — " Lehrbucli der speciellen Cliirurgie," 1889, s. 223. 
 Kousnetzoff et Pensky. — " Sur la resection partielle du foie," Bev. de chir., 
 
 Paris, 1896, Nos. 7, 12. 
 Langenbuch. — "Ein Fall von Resection eines linksseitigen Sdmiirlappen 
 
 der Leber," Berl. Idin. Wchnschr., 1888, s. 37. 
 LoRETA. — "Resection der Leber," Wien. klin. Wchnschr., 1888, s. 154. 
 LtiCKE. — " Entfernung des linken krebsigen Leberlappen," Centrcdhl. f. Chir., 
 
 Leipzig, 1891, s. 115. 
 Pantaloni. — " Resection partielle du foie," Arch. prov. de chir., Paris, 1895, 
 
 No. 6. 
 Peabody.—" Excision of a Portion of the Liver," Med. Rec, N. Y., Feb. 1896. 
 PoDVisoTZKY. — Vrach, St. Petersburg, 1892, s. 469. 
 PoNFiCK. — " Ueber Leber-resection und Leber-creation," Virchoic's Archiv, 
 
 Bde. cxviii. and cxix. 
 RoBSON. — " Excision of a Portion of Liver for Tumour," Med.-Chir. Trans., 
 
 London, 1896, p. 159. 
 RoMME. — Tribune med., Paris, 5th July 1894. 
 Rosenthal. — "Angioma fibromatodes der Leber," Gaz. ZeA;., Warszawa, 1894, 
 
 No. 45. 
 ScHiiiDT. — " Ueber Leber-resection," Deidsche med. Wchnschr., Leipzig, 1893, 
 
 s. 175. 
 Sklifassowsky. — A Case of " Fibromyoma - lii^omatodes sarcomatodes," 
 
 Vrach, St. Petersburg, 1890, No. 27. 
 Tillmanns. — " Exj)er. und anat. Untersuchungen ueber Wunden der Leber," 
 
 Ber. it. d. Verhandl. d. deutsch. Gesellsch. f. Chir., Leipzig, Bd. xxi. 
 
 s. 73. 
 Wagner. — " Syphiloma der Leber, Entfernung," ibid., Bd. xix. s. 96. 
 
 CHAPTERS XVI. and XVIL 
 
 Injuries and Ruptures of Gall Bladder and Bile Ducts. 
 
 AuRiGNAN. — " Des traumatismes du foie et des voies biliaires," These de Paris, 
 
 1876. 
 Cami'aignac. — " Plaies des voies biliaires," Juurn. held, de med., Paris, 1829, 
 
 tome ii. p. 204. 
 CuRETON. — "Rupture of the Gall Bladder," Lancet, London, 1888, vol. ii. ji. 
 
 186G. 
 Dixon. — "Rupture of tlie Gall Bladder," Ann. Surg., St. Louis, Ajiril 1887. 
 Freeland. — "Rupture of the Hepatic Duct," Lancet, London, 1882, vol. i. 
 
 p. 731. 
 Haslam.—" Rupture of tlie Gall Bladder," ibid., 1889, vol. ii. p. 1060. 
 
BIBLIO GRAPH Y. 3 7 1 
 
 Hermes. — "Ein Fall von Verletzung der Gallenwege,'' Deutsche med. 
 
 JVchnschr., Leipzig, 1892, s. 643. 
 Hess. — (Case of Czerny), "Beitr. z. Lelire von den traum. Leber-rupturen," 
 
 Virchow's Archiv, Bd. cxxi. s. 154. 
 HuNERHOFF. — " Ueber Perforation der Gallenblase in Folge von Cholelith- 
 iasis," Inaug. Diss., GiJttingen, 1893. 
 Kehr. — "Ueber einen durch 'ideale Cholecystotomie ' geheilten Fall von 
 
 Schussverletzung der Gallenblase," Centralbl. f. Ghir., Leipzig, 1892, b. 
 
 645. 
 KuLENKAMPFF. — " Traumatische Zerreissung der grossen Gallenwege," ibid., 
 
 1885, s. 757. 
 Labrousse. — " Essai sur les plaies de la face inferieur du foie," These de 
 
 Paris, 1880. 
 Lane. — " Rupture of the Gall Bladder ; Operation and Recovery," Lancet, 
 
 London, 1891, vol. i. p. 1091. 
 Martel. — " Ruj)ture de la vesicule biliaire," Bull, et mdm. Soc. de chir. de 
 
 Paris, 1882, tome xix. p. 469. 
 Hermann. — " Beitr. z. Chir. der Gallenwege," Beitr. z. Idin. Ghir., Tiibingen, 
 
 Bd. xiii. s. 319-389. 
 Meyer. — " Wunden der Leber und Gallenblase," Munich, 1872. 
 MiCHAUX. — " Rujjture des voies biliaires," Bull, et me'm. Soc. de Ghir. de Paris, 
 
 tome xix. p. 243. 
 Morton. — " Primary Perforation of the Gall Bladder," Lancet, London, 18th 
 
 March 1893. 
 NussBAUM. — " Wounds of Liver and Gall Bladder," in " Die Verletzungen 
 
 des Untersleibs," " Deutsche Chirurgie," 1880. 
 RouTiER. — " De la rupture des voies biliaires," Bull, et me'm. Soc. de Ghir. de 
 
 Paris, 1892, p. 773. 
 Roux. — "Ruptures des voies biliaires par contusion grave de I'abdomen," 
 
 Gaz. d. hSp., Paris, July 18, 1895. 
 Sheild and Monier-Williams. — " Perforation of Gall Bladder after Typhoid 
 
 Fever," Lancet, London, March 2, 1895. 
 SiREDAY. — "Perforation of Gall Bladder, Suture of Rupture, Recovery," 
 
 Semaine me'd., Paris, 1896, No. 56. 
 Terrier et Auvray. — " Les Traumatismes des voies biliaires," Bev. de chir., 
 
 Paris, 1897, p. 36. 
 
 CHAPTER XVIIL 
 
 Cholelithiasis. 
 
 Abbe.—" Surgery of Gall Stone Obstruction," Med. Rec, N. Y., 1893, p. 548. 
 
 Arndt. — "Blutungen bei Cholelithisis," Inaug. Diss., 1895. 
 
 Aubert. — " De I'endocardite ulcereuse vegetante dans les infections biliaires," 
 These de Paris, 1891. 
 
 Banks. — " Surgerv of the Gall Bladder," Liverpool Med.-Ghir. Journ., 1893, 
 p. 305. 
 
 Bastianelli. — "Bacter. Befund bei Angiocholitis suppur. Steinkranker," 
 Centralbl. f. allg. Path. u. path. Anat., Jena, 1892. 
 
 Bristowe. — " Cholesterin in Walls of Gall Bladder," Lancet, London, Feb. 
 19, 1887. 
 
 Brockbank. — '■'■ On Gall Stones," London, 1896. 
 
 Burrows. — "Vomiting of a Gall Stone," Brit. Med. Journ., London, 1885, p. 
 843. 
 
 CouRVOisiER. — " Casuistisch-statistische, Beitr. z. path. u. Chir. d. Gallen- 
 wege," Leipzig, 1890. 
 
372 BIBLIOGRAPHY. 
 
 Delbecq. — " Des Lesions de la vesicule biliaire dans la Lithiasis." These de 
 
 Paris, 1892. 
 DoMiNici. — " Des angiocliolites et cholecystites supp.," Paris, 1894. 
 EcKLiN. — "Ueber das Verlialten der Gallenblase bei dauernden VerscHuss 
 
 des Ductus Clioledoclius," Inaug. Diss., Basel, 1896. 
 FouRXiER, " Origine microbienne de la litMasis biliaire," These de Paris, 
 
 1896. 
 FuRBRixGER. — "Die Gallensteinkrankheiten," Wiesbaden, 1891. 
 Gallez. — "Tumeurs du ventre,''' Paris, 1890. 
 Gilbert et Girodb. — " Contrib. a I'etude bacter. des voies biliaires," Compt. 
 
 rend. Soc. de bioL, Paris, 1890, p. 739. 
 GuMPRECHT. — " Neure Fortscliritte in der Kentniss der Cholelithiasis," 
 
 Deutsche med. JFclmschr., Leipzig, 1895, Nos. 14, 15, 17, 20. 
 GuTERBOCH. — Gallensteinconcreniente in der Harublase," Virdioio's Archiv, 
 
 Bd. Ixvi. s. 273. 
 Harley. — "Diseases of the Liver," London, 1883. 
 Herz. — "Wie lange kann ein Mensch leben bei volligen Verschluss der 
 
 Gallenwege, Bed. hlin. Wclinschr., 1877. 
 Jaxkowski. — " Veranderungen in der Gallenblase beim Vorhandensein von 
 
 Gallensteinen," Beitr. z. imth. Anat. m. z. allg. Path., Jena, 1891, 
 
 Bd. X. s. 449. 
 Kehr. — Die chirurgische Behandlung der Gallensteinkrankheit," Berlin, 
 
 1896. 
 Korte. — " Ueber die Chirurgie der Gallenblase und der Leber," Sainml. klin. 
 
 Vortr., Leipzig, 1892, No. 40. 
 Kratjs. — "Gallstones," London, 1896, English trans. 
 
 Leyden. — "Ein Fall von multiplen LelDerabscessen in Folge von Gallen- 
 steinen," Charite'-Ann., Berlin, 1886. 
 Lionnais. — "Tumeurs de I'Hypochondre droit formees par la vesicule 
 
 biliaire," These de Paris, 1896. 
 Loxguet. — "Traitement chirur. de I'angiocholites non-cal.," These de Paris, 
 
 1896. 
 MiGNOT. — " Recherclies exper. et anat. sur les Cholecystites," These de Paris, 
 
 1896. 
 MuRCHisoN. — " Diseases of the Liver," 3rd edition, London, 1888. 
 Musser axd Keen. — " Cholecystotomy," Am. Journ. Med. Sc, Phila., 1884, 
 
 pp. 333-367. 
 Naunyn.— " Klinik der Cholelithiasis," 1892, English trans., 1896. 
 Netter et Martha. — " De I'Endocardite dans les Affect, des voies Biliaires," 
 
 Arch, de physiol. norm, et path., Paris, 1886. 
 Ortner. — "Zur Klinik der Cholelithiasis und der Gallenwegeinfectionen," 
 
 Wien, 1894. 
 Parker. — "Complications of Cholelithiasis," Ann. Surg., St. Louis, 1893, 
 
 No. 6. 
 Renvers. — "Zur Path, der intermit. Gallenfieber," Charite'-Ann., Berlin, 
 
 1892. 
 RiEDEL. — "Erfahrungen ueber die Gallensteinkrankheit mit und ohne 
 
 Icterus," 1892. 
 RoBSOx. — " Gall Stones and their Treatment," London, 1892. 
 Schroder. — Inaug. Diss., Strassburg, 1893. 
 Tuffier et Marchais. — " Des retrecissements du pylore d'origine hepatique," 
 
 Rev. de chir., Paris, p. 100 et seq. 
 Wade. — " Large Gall Stone passed ]3er Rectum," Brit. Med. Journ., London, 
 
 1882, vol. i. p. 703. 
 Zexker. — " Der primiire Krebs der Gallenblase und seine Beziehung zu 
 
 Gallensteinen," Deutsches Arch. f. Jdin. Med., Leipzig, Bd. xliv. Hefte 2 
 
 and 3. 
 
BIBLIOGRAPHY. 373 
 
 CHAPTER XIX. 
 
 Neoplasms op the Gall Bladder. 
 
 Albers.— "Fibroma of the Gall Bladder," "Atlas Path. Auat.," 1862, Taf. 38, 
 
 Figs. 3 and 4. 
 Bardenheuer. — " Mitth. aus dem Kciln. Biirgerhosp.," 1887. 
 Calot. — "De la Cholecystectomie," These de Paris, 1891. 
 Courvoisier.— "Kasuistisch-statistische Beitr. z. path. u. Chir. d. Gallen- 
 
 wege," Leijjzig, 1890. 
 Coyne. — " Carcinome primitive du pylore et cancer colloid primitif de la 
 
 vesicule biliaire," Journ. de med. de Bordemtx, March 1894. 
 Czerny. — "Ueber den gegenwartigen Stand der Gallenblasen-chirurgie," 
 
 Deutsche med. TFchnschr., Leipzig, 1893, No. 23. 
 Frerichs. — "Diseases of the Liver," Neiv Syd. Soc. Trans., 1861. 
 Gallez. — "Tumeurs du ventre," Paris, 1890. 
 Harley. — " Diseases of the Liver," London, 1883. 
 HEDDiEus.—" Beitr. z. path. Chir. d. Gallenblase-Geschwiilste," Inaug. Diss., 
 
 Tubingen, 1894 ; also Beitr. z. Jdin. Chir.,_ Tubingen, Bd. xii. Heft 2. 
 HocHENEGG. — " Ein Beitrag z. Leber-chirurgie," }Fie7i. klin. TFchnschr., 1890, 
 
 ss. 223, 1008. 
 Jankowski. — " Ueber Veranderungen der Gallenblase, etc.," Beitr. z. fcdh. 
 
 Anat. u. z. allg. Path., Jena, Bd. x. s. 449. 
 Martig.— " Beitr. z. Chir. der Gallenwege," Basel, 1893. 
 MussER.— " Primary Cancer of the Gall Bladder and the Bile Ducts," Bost. 
 
 Med. and S. Journ., Dec. 5, 1889. 
 Naunyn.— " Klinik der Cholelithiasis," 1892. 
 Ohloff. — " Ueber Epithelmetaplasie und Krebsbildung in der Schleimhaut 
 
 von Gallenblase," Inaug. Diss., Tiibingen, 1891. 
 EiEDEL. — "Erfahrungen ueber der Gallensteinkrankheit," Berlin, 1892. 
 EoBSON.— " Excision of a Portion of Liver for Tumour," Med.-Ghir. Trans., 
 
 London, 1896, p. 159. 
 Schmidt. — " Ueber Leber-resection," Deutsche med. TFchnschr., Leipzig, 1893, 
 
 No. 8. 
 ScHUPPEL. — Ziemmssen's " Handbuch," vol. ix. Eng. trans. 
 SlEGERT.— "Zur iEtiologie des primaren Carcinoms der Gallenblase," 
 
 Virchoiv's Archiv, Bd. cxxxii. s. 353. 
 Winiwarter.— "J ubilaumsfestschrift. gewidmet, Billroth," 1891. 
 Yamagiva. — "Primarer Gallenblasenkrebs," Virchoiv's Archiv, Bd. cxlvii. 
 
 s. 141. 
 Zenker. — " Der primare Krebs der Gallenblase," Deutsches Arch.f. Min. Med., 
 
 Leipzig, Bd. Ixiv. Hefte 2 u. 3, s. 159-184. 
 
 CHAPTER XX. 
 
 Tumours of the Bile Ducts. 
 
 BoHNSTEDT.— " Die Differentialdiagnose zwischen dem durch Gallenstein 
 und dem durch Tumor bedingten Verschlues des Ductus Choledochus," 
 Inaug. Diss., Halle, 1893. 
 
 Brunswig. — " Fall von primarem Krebs der Gallenwege," Kiel, 1893. 
 
 BussoN. — " Du cancer de I'ampoule de Vater," These de Paris, 1890. 
 
 Coats and Finlayson. — " Cancer of the Terminal Portion of the Common 
 
374 
 
 BIBLIOGRAPHY. 
 
 Bile Duct," Trans. Glasgow Path, and Clin. Soc, 1892 ; Glasgoiv Med. 
 
 Journ., 1892, No. 2. 
 CouRMONT. — " Cancer primitif de I'resophage et de I'ampoule de Vater, Lyon 
 
 me'd., June 3, 1894. 
 CouRVOisiER. — " Kasuistiscli-statistische Beitr. z. Path. u. Chir. d. Gallen- 
 
 wege," Leipzig, 1890. 
 Durand-Fardel. — " Cancer du canal clioledoque, etc.,'' Arch. gen. de. med., 
 
 Paris, 1840, tome A'iii. p. 167. 
 GooDHART. — "Atlas of Pattology," Netv Syd. Soc, Fasc. 5. 
 Hanot. — " Cancer de I'ampoule de Yater "Bull. A cad. de med., Paris, 1896, No. 28. 
 Hanot et Bard. — "Cancers de I'ampoule de Vater," ibid., 1896, No. 29. 
 Head. — " On Disturbances of Sensation in Visceral Disease," Brain, London, 
 
 1893, p. 75. 
 Hesper. — " Zwei Falle von primiirem Carcinom de Gallenausfiilirungsgange," 
 
 Bonn, 1893. 
 Jenster. — " LTeber Stauungs-Ikterus infolge primaren Krebses der Ductus 
 
 bepatici," Inaug. Diss., Breslau, 1892. 
 Martha. — " Cancer du duodenum au niveau de I'ampoule de Vater," Bull. 
 
 Soc. anat. de Paris, 1887, p. 280. 
 Morax. — " Obliteration du canal cboledoque au niveau de son embrochure 
 
 par un petit nodule epitheliomateux," ibid., 1889, p. 482. 
 Murphy.—" Operative Surgery of the Gall Tracts," Med. Rec, N. Y., 1894, 
 
 p. 35 et seq. 
 Mdsser. — " Primary Cancer of tbe Gall Bladder and the Bile Ducts," Boston 
 
 Med. and S. Journ., Dec. 5, 1889. 
 Pick. — " Zur Kenntniss der Leberveranderungen nacli Unterbindung des 
 
 Ductus clioledochus," Ztschr. f. HeilL, Berlin, 1890, Heft 2, Bd. xi. ; 
 
 " Cancer primitif du duodenum," Rev. de med., Paris, Dec. 1894 and Jan. 
 
 1895. 
 PiLLiET. — " Epitlielioma de I'ampoule de Vater," Bull. Soc. anat. de Paris, 1889, 
 
 p. 589 ; " Sur la structure de I'ampoule de Vater," Compt. rend. Soc. de 
 
 biol., Paris, 1894, p. 549. 
 Eay. — "Cancer de I'ampoule de Vater," Presse med. beige, Bruxelles, June 17, 
 
 1896. 
 Eendu. — " Epithelome de I'ampoule de Vater," Bull, et mem. Soc. me'd. d. hop. 
 
 de Paris, 1896, No. 16. 
 RoLLESTOX. — " Primary Carcinoma of tbe Larger Bile Ducts," Med. Cliron., 
 
 Manchester, Jan. 1896. 
 Schroder. — " Ueber den primaren Carcinom des Ductus choledochus," 1893. 
 Vincent-Georges. — " Etude sur le Cancer de I'ampoule de Vater," These de 
 
 Paris, 1896. 
 Whitier. — Cancer of the Duodenum," Boston Med. and S. Journ., Oct. 17, 
 
 1889. 
 WiLKS and Moxon.— " Pathological Anatomy," 1875, p. 465. 
 Yamagiva. — " Cylinderzellenkrelas des Ductus hepaticus und des Ductus 
 
 cysticus," Virclunvs Archiv, Bd. cxlvii. s. 137. 
 Zenker. — " Der primare Kreljs der Gallenblase," Deutsches Arch.f. Jclin. Med., 
 
 Leipzig, 1891, Bd. xliv. Hefte 2 and 3. 
 
 CHAPTER XXL 
 
 Subphrenic Abscess. 
 
 Affleck. — "Rupture of Kidney with resulting Subphrenic Abscess and 
 
 Urinary Fistula," Edin. Hosp. Rep., 1894, vol. ii. }). 372. 
 Barlow. — "Subijhrenic Abscess,'' Med. Times, London, 1845, vol. xii. p. 368. 
 
BIBLIOGRAPHY. 375 
 
 Brck.— "Subplirenic Abscess," Metl. Rec, N. Y., Feb. 15, 1896; "Beitr. z. 
 
 Literatur des subijhrenisclieii Abscesses," Arch.f. Idin. CIvir., Berlin, Bd. 
 
 lii. s. 516. 
 Canniot. — " De la resection du bord inferieurdu tliorax pouraborder la face 
 
 convex du foie,''" These de Paris, 1891. 
 Caussade. — " Cas de jjeri-liepatite tuberculeux suppuree," liev. mens. d. rnal. 
 
 de reiif., Paris, 1887, p. 350. 
 CouPLAXD. — "Subplirenic Abscess simulating Pneumothorax," Brit. Med. 
 
 Journ., London, Mar. 23, 1889. 
 Cramer. — " Beitr. z. Kasuistik der subphrenischen Abscesse und der Quer- 
 
 section der Niere," Deutsche Ztschr.f. Chir., Leipzig, Bd. xlii. s. 597. 
 Deschamps. — " De la peritonite peri-hepatique enkvste," These de Paris, 
 
 1885. 
 Dickinson and Penrose. — " Sul^phrenic Abscess from Gastric Ulcer," Trans. 
 
 Clin. Soc. London, 1893, p. 72. 
 Evvart and Bennet. — " Pneumothorax Subphrenicus, due to a Perforating 
 
 Gastric Ulcer," Lancet, London, 1894, vol. ii. ]). 1147. 
 Lacherriere. — " Abces sous-phrenique droit," A^im. de la Policlin. de 
 
 Bordeaux, Nov. 1895, p. 165. 
 Lampe. — " Ueber subj)hrenische Abscesse," Berl. Idin. Wchnschr., 1895, s. 839. 
 Langenbuch. — "Chirurgie der Leber und Gallenblase,"" Deutsche Chirurgie," 
 
 Leipzig, 1894, Abth. 1. 
 Lannelongue. — "Resection du bord inferieur du thorax," Cong, franc, de 
 
 Chir. Proc.-Verb. Paris, 1888, p. 358. 
 Leith. — " Inflammatory Lesions of the Thoracic Contents, arising from Sub- 
 
 diaj^hragmatic Conditions due to Gastric Ulcer," Edin. Hosp. Eep., 
 
 1895, vol. iii. p. 296 ; " Intrathoracic Inflammation following upon 
 
 Subdiaphragmatic Supjjurations," ibid., 1895, vol. iii. p. 344. 
 Mackenzie and Abbot. — " Subdiaphragmatic Abscess treated by Resection 
 
 of Rib," Lancet, London, vol. ii. p. 1033. 
 Maydl. — "Ueber subphrenische Abscesse," Wien, 1894. 
 Paget. — "Surgery of the Chest," Bristol, 1896. 
 
 Sachs. — " Subjjhrenische Abscesse," Arch.f. klin. Chir., Berlin, 1895, s. 5. 
 ScHLESiNGER. — "Ueber subphrenische Abscesse," Wien. med. Presse, 1896, 
 
 Nos. 4 and 5. 
 ScHtJRLEN. — " Ueber Pyothorax subphrenicus," Charite'-Ann., Berlin, 1889, 
 
 ss. 158-177. 
 Taylor. — "Case of Abscess between Diaphragm and LiA^er," Guifs Hosp. Rep., 
 
 London, vol. xix. p. 257. 
 
 CHAPTER XXIL 
 Biliary Fistula. 
 
 Bristowe. — " Obstruction of the Common Duct by a Calculus, etc.," Trccns. 
 
 Path. Soc. London, vol. ix. p. 285. 
 Brockbank. — " On Gallstones," London, 1896. 
 CoURVOisiER. — " Kasuistische-statistische Beitr. z. Path. u. Chir. d. Gallen- 
 
 wege," 1890. 
 Dreschfeld. — "Biliary Fistula communicating with the Lung," Lancet, 
 
 London, 1879, vol. ii. p. 867. 
 Dujardin-Beaumetz. — " Chirurgie des fistules biliaires intestinales," Bidl. 
 
 Acad, de med., Paris, 1894, p. 258. 
 Galliard. — " Diagnostic des flstules cholecysto-intestinales dans la lithiasis 
 
 biliaire," Semaine me'd., Paris, 1895, p. 309. 
 Guterboch. — " Gallensteinconcremente in der Harnblase," Virchow's Archiv, 
 
 Bd. Ixvi. s. 273. 
 
376 BIBLIOGRAPHY. 
 
 Kehr.— "Die chii'urgisclie Behandlung der Gallensteinkranklieit," Berlin, 
 
 1896, s. 34, 191. 
 Lpjgg. — " Gallstone in the Common Duct ; Abscess in the left Lobe of Liver 
 
 extending into Pericardium and right Pleura," Trans. Path. Soc. London, 
 
 vol. XXV. p. 133. 
 Mtjrchisox. — " Diseases of the Liver," London, 1888. 
 Nauxtn.— " Klinik der Cholelithiasis," 1892. 
 Ord. — " Some of the Rarer Symptoms produced by Gall Stones." Brit. Med. 
 
 Journ., London, 1887, vol. i. p. 496. 
 Smith. — -"A Case of Acute Intestinal Obstruction from Imjjaction of a Gall 
 
 Stone in the Jejunum," Med. Chron., Manchester, April 1895. 
 White (Hale). — " A Case of Gall Bladder containing Gall Stones which had a 
 
 Fistulous Communication with the Duodenum," Trans. Path. Soc. London, 
 
 vol. xxxvii. J). 280. 
 
 CHAPTER XXIIL 
 
 Gallstone Ileus. 
 
 BiRCHER. — " Occlusion des Diinndarmes durch einen Gallenstein," Cor.-Bl. f. 
 
 schioeiz. Aerzte, Basel, 1892, No. 5. 
 Castner. — " Ueber Gallenstein-Ileus," Greifswald, 1894. 
 Glutton. — "A Successful Case of Laparotomy for Intestinal Obstruction 
 
 from a Gallstone, Trans. Clin. Soc. London, vol. xxi. p. 99. 
 CzERNY. — Quoted by Lobstein, q.v. 
 Dagron. — These de Paris, 1891. 
 Eve. — " Intestinal Obstruction due to Gall Stones," B^-it. Med. Journ., London, 
 
 1895, vol. i. -p. 195 ; Trans. Clin. Soc. London, vol. xix. p. 149. 
 GoDLEE. — Brit. Med. Journ., London, 1895, vol. i. p. 478. 
 Harrington. — ^" Intestinal Obstruction from a large Gall Stone," Boston Med. 
 
 and S. Journ., 1896, No. 9. 
 Hutchinson. — Brit. Med. Journ., London, 1896, vol. i. p. 195. 
 KoRTE. — "Ueber den Darmverschluss durch Gallenstein, Arch.f. Idin. Chir., 
 
 Berlin, Bd. xlvi. Heft 2. 
 Lobstein. — "Zur Casuistik des Gallenstein-Ileus," Beitr. z. hlin. Chir., 
 
 Tubingen, 1896, s. 390-426. 
 Margrave. — " Impaction of Gall Stone in Small Intestine," Lancet, London, 
 
 1893, vol. ii. p. 927. 
 Miles. — "Acute Intestinal Obstruction from Impacted Gall Stone," ibid., 
 
 1890, voL i. p. 1121. 
 Murphy. — Intestinal Obstruction due to a large Gall Stone," ibid., 1892, 
 
 vol. i. p. 274. 
 Naunyn.— " Klinik der Cholelithiasis," 1892. 
 Reclus. — "Sur une observation d'enterostomie biliaire," Bull, et m^m. Soc. 
 
 de Chir. de Paris, 1895, p. 152. 
 RoBSON. — "Varieties of Intestinal Obstruction due to Gall Stones," Med. 
 
 Chir. Trans., London, 1895, p. 117; "On Intestinal Obstruction due 
 
 to Gall Stones," Brit. Med. Journ., London, 1892, vol. ii. p. 121. 
 Sick.— "Fall von Ileus," Deutsche rued. Wchnschr., Leipzig, 1891, s. 268. 
 Treves.— "Intestinal Obstruction," London, 1884. 
 Thiriar. — " Un cas de laparo-enterotomie pour obstruction intestinale 
 
 determine par un calcul intestinal," liev. de chir., Paris, 1891, 
 
 p. 403. 
 Schuller. — " Gallensteine als Ursache der Darmobstruction," Inaug. Diss. 
 
 Strassburg, 1891. 
 
INDICES. 
 
GENERAL INDEX. 
 
 
 
 PAGE- 
 
 
 PAGE 
 
 Aberrant ducts 
 
 28 
 
 Ascarides as cause of rupture of gall 
 
 
 Abnormalities of the liver and biliary 
 
 
 bladder 
 
 202 
 
 system 
 
 (see Malformations) 
 
 58 
 
 ,, Nuclei of gall stones . . 
 
 214 
 
 Abscess of gall bladder . . 23 
 
 7, 255 
 
 Ascites, diagnosis from hydatid cyst . 
 
 140 
 
 jj 
 
 Hepatic 
 
 70 
 
 Aspiration as a means of diagnosis in 
 
 
 ?j 
 
 „ Complications of 
 
 96 
 
 hepatic affections 
 
 56 
 
 ;) 
 
 ,, Diagnosis 
 
 
 Of the gall bladder . 
 
 325 
 
 
 ,, ,, General 
 
 101 
 
 ,, Of the liver 
 
 306 
 
 jj 
 
 ,, „ From hyda 
 
 
 Auscultation of the hepatic area . 
 
 56 
 
 
 tid cyst 
 
 137 
 
 
 
 J. 
 
 ,, Due to animal para 
 
 
 Bacterium coli commune in abscess of 
 
 
 
 sites 
 
 72 
 
 the liver . 
 
 72 
 
 jj 
 
 , , Due to gall stones 
 
 71 
 
 ,, In relation to 
 
 
 >>'■ 
 
 ,, Etiology . 
 
 70 
 
 gall stones 
 
 210 
 
 J, 
 
 ,, Pathological anatomy 
 
 f 89 
 
 Bile, composition of ... . 
 
 31 
 
 53 
 
 ,, Prognosis . 
 
 107 
 
 ,, Entrance of, into a hydatid cyst 
 
 135 
 
 
 ,, Pyseraic 
 
 75 
 
 ,, Modifications of, in abnormal 
 
 
 ,j 
 
 ,, Rupture of 
 
 96 
 
 conditions .... 
 
 35 
 
 ,, 
 
 ,, Symptomatology 
 
 91 
 
 Bile acids 
 
 32 
 
 J? 
 
 , , Temperature m 
 
 96 
 
 ,, Origin of ... . 
 
 34 
 
 
 ,, Traumatic 
 
 70 
 
 ,, Capillaries 
 
 27 
 
 jj 
 
 ,, Treatment of . 
 
 103 
 
 ,, Pigment 
 
 33 
 
 >> 
 
 ,, Tropical . 
 
 81 
 
 ,, Origin of ... . 
 
 34 
 
 
 ,, Tubercular 
 
 108 
 
 „ Salts 
 
 32 
 
 ,, 
 
 Subdiaphragmatic . 
 
 273 
 
 Biliary apparatus, Anatomy of 
 
 16 
 
 
 ,, Complications 
 ,, Diagnosis 
 
 282 
 
 ,, Malformations of . 
 ,, Nou-penetratiug in- 
 
 62 
 
 
 ,, ,, General 
 
 283 
 
 juries of 
 
 201 
 
 jj 
 
 ,, ,, Fromhydi 
 
 1- 
 
 ,, Operations on (see 
 
 
 
 tid cyst 
 
 138 
 
 Operations) 
 
 347 
 
 J) 
 
 ,, Etiology 
 
 273 
 
 ,, Penetrating wounds 
 
 
 
 „ Prognosis . 
 
 285 
 
 of . . . 
 
 196 
 
 ,, 
 
 ,, Symptoms . 
 
 279 
 
 Biliary calculi (see Gall stones) 
 
 210 
 
 J J 
 
 „ Treatment . 
 
 284 
 
 Biliary colic 
 
 220 
 
 
 Subphrenic . 
 
 273 
 
 Biliary ducts, Anatomy of . 
 
 16 
 
 Absence of common bile duct 
 
 63 
 
 ., Malformations of . 
 
 62 
 
 j> 
 
 of gall bladder and cystic due 
 
 . 62 
 
 \, Operations on (see 
 
 
 jj 
 
 3f left lobe of liver '. 
 
 59 
 
 Operations) 
 
 347 
 
 Accessory lobes of the liver . 
 
 59 
 
 ,, Penetrating wounds of . 
 
 196 
 
 )) 
 
 portal veins . 
 
 13 
 
 ,, Rupture and perforation 
 
 
 Actinomycosis of the liver . 
 
 112 
 
 of ... . 
 
 201 
 
 Adenoma 
 
 of the liver . 
 
 185 
 
 ,, Tumours of . 
 
 261 
 
 
 ,, Cystic . 
 
 154 
 
 Biliary fistulfe 
 
 286 
 
 Allantoic 
 
 veins .... 
 
 23 
 
 ,, External .... 
 
 286 
 
 Amyloid 
 
 disease of the liver 
 
 124 
 
 ,, Internal .... 
 
 293 
 
 Aneurism of hepatic artery or abdomina 
 
 
 Bilirubin 
 
 33 
 
 aorta, 
 
 Jiagnosis from hydatid cyst 
 
 138 
 
 Biliverdin 
 
 33 
 
 Angioma 
 
 of tlie liver . 
 
 182 
 
 
 
 Apertures (congenital) in diaphragm 
 
 60 
 
 Calculi, biliary (see Gall Stones) . 
 
 210 
 
 Arterio-s 
 
 clerosis in multilocular cysti 
 
 
 Ccmvle d demeure, in treatment of 
 
 
 disease 
 
 of the liver . 
 
 1.53 
 
 hydatid cyst 
 
 142 
 
 Ascarides as cause of abscess of th 
 
 
 Carcinoma of the bile ducts 
 
 262 
 
 liver . 
 
 
 
 73 
 
 ,, ,, gall bladder 
 
 249 
 
GENERAL INDEX. 
 
 379 
 
 Carcinoma of the gall bladder — Relation 
 to gall stones . 220, 
 ,, ,, liver 
 
 Catheterism of the gall passages . 
 Caustics, in treatment of hydatid cyst . 
 
 Cholagogues 
 
 Cholecystectomy 
 
 Cholecysteudysis 
 
 Cholecystenterostomy .... 
 Cholecystolithotripsy .... 
 
 Cholecystotomy 
 
 Choledochectomy 
 
 Choledochodnodenostomy 
 Choledochoentei'ostomy 
 Choledocholithotomy .... 
 Choledocholithotripsy .... 
 Choledocholithotrity .... 
 
 Cholehffimatin 
 
 Cholelithiasis (see also Gall Stones) 
 ,, Complications of 
 
 ,, Diagnosis of . 
 
 ,, Occurrence of . 
 
 ,, Pathology of . 
 
 ,, Predisposing causes of 
 
 ,, Symptoms of . 
 
 ,, Temperature in 
 
 ,, Treatment of . 
 
 Choletelin 
 
 Climate, relation to diseases of the liver 
 ,, ,, tropical abscess of 
 
 the liver 
 
 Coccidia as cause of abscess of the liver 
 
 Colic, biliary 
 
 Common bile duct, Anatomy of . 
 
 ,, Malformations of . 
 
 ,, Operations on (see 
 
 also Operations) 
 ,, Penetrating wounds 
 
 of . . . 
 ,, Rupture and per- 
 
 foration of 
 ,, Topographical 
 
 anatomy of 
 ,, Tumours of . 
 
 Common hepatic duct (see also Biliary 
 Ducts) — 
 ,, Anatomy . 
 
 ,, Congenital ob- 
 
 literation 
 Composition of bile 
 Composition of hydatid iluid 
 Contusion of the liver . 
 " Crystallised bile " 
 Cuvierian veins .... 
 Cystic adenoma of the liver . 
 ,, artery .... 
 
 ,, duct (see also Biliary Ducts)— 
 , , Absence of . 
 
 ,, Anatomy of 
 
 Cysticolithotomy .... 
 Cysts of the liver. Dermoid 
 ,, Hydatid. 
 
 ,, Multilocular cystic 
 
 disease 
 ,, Simple or serous 
 Czerny's modification of cholecyst- 
 eudysis 
 
 239 
 187 
 354 
 141 
 
 36 
 336 
 333 
 339 
 346 
 327 
 351 
 352 
 350 
 347 
 350 
 350 
 
 33 
 210 
 233 
 230 
 217 
 210 
 219 
 220 
 226 
 240 
 
 33 
 
 52 
 
 84 
 74 
 220 
 17 
 62 
 
 347 
 
 196 
 
 201 
 
 21 
 261 
 
 17 
 
 69 
 
 31 
 
 130 
 
 165 
 
 32 
 
 23 
 
 154 
 
 11 
 
 62 
 
 63 
 
 353 
 
 154 
 125 
 
 151 
 
 148 
 
 335 
 
 Dermoid cysts of the liver . 
 
 Development of the liver 
 
 Diagnosis of diseases of the liver and 
 
 biliary system .... 
 Diaphragm, congenital apertures in 
 Distomata as cause of abscess of the 
 
 liver 
 
 Drowsiness, in jaundice 
 
 Ducts, Aberrant .... 
 
 ,, Biliary (see Biliary Ducts) . 
 Ductus Venosus .... 
 Dysentery, relation to tropical abscess 
 
 of the liver .... 
 
 PAGE 
 154 
 
 21 
 
 51 
 60 
 
 74 
 49 
 28 
 16 
 24 
 
 87 
 
 Elastic ligature, in excision of portion 
 of liver ...... 315 
 
 Electrolysis, . in treatment of hydatid 
 cysts 142 
 
 Empyema, of gall bladder 
 Epistaxis in jaundice . 
 Excision of hydatid cyst 
 
 Operations) 
 Exploratory puncture as a 
 
 diagnosis . 
 
 Fseces in jaundice . 
 Fibroma of the liver 
 Fissures of the liver 
 
 ,, Undue depth of 
 Fistulse, Biliary . 
 
 Gall bladder. Abscess of 
 Absence of 
 
 . 237, 255 
 . 49 
 
 (see also 
 
 . 142 
 
 means of 
 
 . 56 
 
 . 47 
 . 185 
 9 
 . 60 
 . 286 
 
 Anatomy of 
 ,, Operations on (see Oper- 
 
 ations) 
 , , Penetrating wounds of . 
 
 ,, Perforation of 
 
 ,, Rupture of . 
 
 , , Topographical anatomy 
 
 of ... . 
 ,, Tumours of . 
 
 Gallstone ileus 
 
 Gall stones 
 
 ,, Complications due to . 
 
 ,, Diagnosis of . . . 
 , , Hepatic abscess due to 
 
 ,, Intestinal obstruction due to 
 
 ,, Mode of formation 
 
 ,, Occurrence . 
 
 ,, Operations for 
 
 ,, Pathology of 
 
 ,, Predisposing causes of 
 
 , , Seat of formation 
 
 ,, Sounding for 
 
 ,, Structure of 
 
 ,, Symptoms of 
 
 , , Treatment of 
 
 , , Varieties of . . 
 
 Geographical distribution of hydatid 
 disease 
 „ multilocular 
 
 echinococcus 
 ,, tropical ab- 
 
 scess of the 
 liver . 
 Glisson's capsule . . . . . 
 Glycocholic acid . . ... 
 
 237, 255 
 . 62 
 
 17,28 
 
 306 
 196 
 201 
 201 
 
 21 
 247 
 295 
 210 
 233 
 230 
 
 71 
 295 
 210 
 217 
 243 
 210 
 219 
 215 
 326 
 216 
 220 
 240 
 217 
 
 127 
 
 145 
 
 82 
 26 
 32 
 
?8o 
 
 GENERAL INDEX. 
 
 Glycogen — 
 
 „ Glycogenic fimction of the 
 
 liver .... 36 
 
 ,, Presence in hepatic cells . 27 
 
 Gmelin's reaction 33 
 
 ,, As applied to urine . 44 
 
 Hematuria in jaundice 
 
 Haemorrhage from the sac of a hydatid 
 
 cyst 
 
 Heister, valves of . 
 
 Hepatectomy ..... 
 Hepatic abscess (see Abscess, Hepatic). 
 Hepatic artery — 
 
 ,, Abnormalities of 
 
 ,, Anatomy 
 
 ,, Terminal branches of 
 
 Hepatic canals ..... 
 ,, cells ..... 
 
 ,, ducts (see also Biliary Ducts) , 
 ,, veins ..... 
 Hepatitis— 
 
 ,, Syphilitic .... 
 
 Hepato-cystic ducts .... 
 
 Hepatomphalos 
 
 Hepatopexy ...... 
 
 Hepatorrhaphy ..... 
 
 Hepatostomy ..... 
 
 Hepatotoniy 
 
 Hydatid cyst of liver .... 
 ,, As cause of abscess 
 
 49 
 
 135 
 
 19 
 
 314 
 
 12 
 10 
 27 
 26 
 27 
 16 
 14 
 
 118 
 
 20 
 
 60 
 
 322 
 
 322 
 
 323 
 
 307 
 
 125 
 
 74 
 
 ,, Diagnosis of . 136 
 
 „ Entrance of bile into 135 
 
 ,, Frequency of . 127 
 
 ,, Haemorrhage from 
 
 sac of . . 135 
 ,, Multilocularechino- 
 
 coccus . . 144 
 „ Prognosis of . . 143 
 
 „ Rupture of . . 129 
 
 „ Situation of . . 128 
 
 ,, Spontaneous cure of 134 
 
 ,, Structure of . . 126 
 
 ,, Suppuration of . 132 
 
 ,, Symptoms of . 128 
 
 ,, Treatment of .140 
 
 Hydrops cystidis fcllem . . .36 
 
 Icterus neonatorum .... 
 Ileus, due to gall stones 
 Incision — • 
 
 ,, Of a hydatid cyst . 
 
 ,, Of the liver .... 
 Inferior vena cava, relation to liver 
 Intiuenza as cause of hepatic abscess 
 Injuries — 
 
 ,, Of the gall bladder and bile 
 ducts— 
 
 ,, ,, Non-penetrating 
 
 ,, ,, Penetrating 
 
 ,, Of the liver . 
 
 „ ,, Complications of 
 
 Diagnosis of 
 Prognosis 
 Symi)toms 
 Treatment 
 
 Interlobular veins 
 
 Intestinal oljstruction due to gall stones 
 
 162 
 165, 
 
 67 
 295 
 
 142 
 
 307 
 
 14 
 
 81 
 
 201 
 196 
 160 
 177 
 164 
 178 
 172 
 174 
 27 
 295 
 
 
 
 PAGE 
 
 Intralobular veins 
 
 . 26 
 
 Itching 
 
 of skin in jaundice . 
 
 . 49 
 
 Jaundice .... 
 
 . 88 
 
 jj 
 
 Causes of 
 
 . 40 
 
 )) 
 
 Due to gall stones . 
 
 . 224 
 
 
 Following rupture of the gall 
 
 
 bladder 
 
 . 163 
 
 jj 
 
 Nature of 
 
 . 34 
 
 !) 
 
 Pathology of . 
 
 . 38 
 
 
 Symptoms of . 
 
 . 44 
 
 Liver — 
 
 Absence of left lobe 
 
 Abscess (see Abscess, Hepatic) 
 
 59 
 
 JJ 
 
 Accessory lobes 
 
 
 . 59 
 
 JJ 
 
 Actinomycosis of 
 
 
 . 112 
 
 :5 
 
 Amyloid disease of 
 
 
 . 124 
 
 5) 
 
 Anatomy of 
 
 
 1 
 
 
 Aspiration of 
 
 
 . 306 
 
 
 Blood vessels of 
 
 
 10,25 
 
 J) 
 
 Cysts of 
 
 
 . 148 
 
 
 Development of 
 
 
 . 21 
 
 
 Fissures of 
 
 
 9 
 
 
 Functions of 
 
 
 . 29 
 
 J J 
 
 Histology of 
 
 
 . 24 
 
 
 Hydatid cysts of 
 
 
 . 125 
 
 " 
 
 Injuries of (see Wounds ( 
 Liver). 
 
 jf the 
 
 ) J 
 
 Ligaments of 
 
 7 
 
 
 Lobes of . 
 
 
 9 
 
 ,, 
 
 Lymphatics of . 
 
 
 . 15 
 
 ) J 
 
 Malformations of 
 
 
 . 58 
 
 J) 
 
 Movable liver . 
 
 
 . 156 
 
 
 Nerves of . 
 
 
 16,28 
 
 ,, 
 
 Operations on (see Operations) . 306 
 
 ,, 
 
 Topogra]ihical anatomy of 
 
 . 20 
 
 
 Traumatic affections of 
 
 . 160 
 
 jj 
 
 Tubercular abscess of 
 
 . 108 
 
 jj 
 
 Tumours of 
 
 . 182 
 
 !> 
 
 Wounds of (see Wounds). 
 
 
 Malaria, relation to tropical abscess of 
 
 the 
 
 liver .... 
 
 . 87 
 
 Malformations of the biliary system . 62 
 
 
 ,, ,, liver . 
 
 . 58 
 
 Mares 
 
 chal's test . 
 
 
 . 44 
 
 Micro-organisms — 
 
 ,, In relation to gall 
 
 stones . . .212 
 ,, In relation to hepatic 
 
 abscess . 72, 88 
 
 Movable liver 156 
 
 Multilocular cystic disease of the liver . 151 
 Multilocular echinococcus . . . 144 
 Murpliy's button, in operation of chole- 
 cystenterostomy .... 341 
 
 Neoplasms (see Tumours). 
 
 Obstruction of the intestine, due to gall 
 
 stones 
 
 Operations- 
 
 295 
 347 
 
 Upon the biliary ducts . 
 . , Catheterism of the 
 
 biliary passages 354 
 ,, Choledochectomy 351 
 
GENERAL INDEX. 
 
 381 
 
 Ojierations — 
 
 ,, Upou the Choledochodiiode- 
 
 nostomy . . 352 
 „ ., Choledochoenter- 
 
 ostoniy . . 350 
 ,, ,, Clioledocholitlio- 
 
 toniy . . 347 
 „ ,, Choledocliolitho- 
 
 tripsy . . 350 
 ,, ,, Choledocholitlio- 
 
 trity . . 350 
 
 ,, ,, Choledochostoniy 350 
 
 „ ,, Choledoeliotomy 347 
 ,, ,, „ By lumbar 
 
 incision . 352 
 
 J, „ Cysticolitliotomy 353 
 
 ,, Upon the gall bladder . 306 
 
 ,, „ Aspiration . . 325 
 
 ,, ,, Cholecystectomy. 336 
 
 ,, ,, Cholecystendysis 333 
 ,, ,, Cholecystenteros- 
 
 tomy . . 339 
 ,, ., Cholecystolitho- 
 
 tripsy . . 346 
 
 ,, „ Cholecystotomy . 327 
 „ ,, Sounding for gall 
 
 stones . . 326 
 
 „ ,, Tapping , . 325 
 
 Upon the liver . . .306 
 
 „ ,, Aspiration . 306 
 
 . ,, ,, Hepatectomy . 314 
 
 ,, ,, Hepatopexy or 
 
 Hepatorrhaphy 322 
 
 ,, ,. Hepatostomy , 323 
 
 ,, ,, . Hepatotomy . 307 
 
 ,, ,, Puncture . . 307 
 
 Palpation of hepatic region ... 54 
 Parasites (animal) as a cause of gall 
 
 stones 72 
 
 Parumbilical veins .... 13 
 
 Percussion of hepatic region ... 56 
 
 Pettenkofer's reaction .... 32 
 Physical examination in cases of 
 
 hepatic disease ..... 54 
 
 Platner's " crystallised bile " . . 32 
 Pleural effusion — 
 
 Diagnosis from hyda- 
 tid cyst of the liver 138 
 ,, Diagnosis from subdia- 
 phragmatic abscess . 284 
 
 Portal canals 25 
 
 Portal vein — 
 
 ,, Anatomy of . . .12 
 ,, Communications with gen- 
 eral venous system . . 13 
 Puncture — 
 
 ,, Of a hydatid cyst . . 141 
 
 ,, Of the gall bladder . . 325 
 
 „ Of the liver . . .306 
 
 Pysemic abscess of the liver (see Abscess, 
 
 Hepatic) 75 
 
 Rounded liver 59 
 
 Rupture — 
 
 Of biliary ducts . . .201 
 
 Of gall bladder . . .201 
 
 ,, Of hepatic abscess . . . 96 
 
 Of hydatid cyst 
 
 . 129 
 
 Of liver 
 
 . 160 
 
 ,, Diagnosis . 
 
 . 164 
 
 ,, Symjitonis 
 
 . 162 
 
 ,, Treatment 
 
 . 165 
 
 Rupture- 
 
 Sarcoma — 
 
 ,, Of the gall bladder . . 249 
 
 ,, Of the liver . . .188 
 
 Scarlet fever, hepatic abscess in . . 81 
 
 Secretion of bile 29 
 
 Sounding for gall stones . . . 326 
 Spleen — 
 
 ,, In multilocular echinococcus . 146 
 ,, In syphilitic affections of the 
 
 liver 123 
 
 Subdiaphragmatic abscess (see Abscess, 
 
 Subdiaphragmatic) .... 273 
 
 Sublobular veins 27 
 
 Subphrenic abscess (see Abscess, Sub- 
 diaphragmatic) ..... 273 
 Subphrenic hydatid cyst — 
 
 ,, ,, Diagnosis from 
 
 hydatid cyst 
 
 of the liver . 138 
 
 Suppuration, of hydatid cyst . . 132 
 
 Syphilis of the liver .... 117 
 
 ,, ,, Congenital . . 118 
 
 ,, ,, Diagnosis . . 123 
 ,, ,, Diffuse syphilitic 
 
 hepatitis . . 118 
 ,, ,, Localised syphilitic 
 
 hepatitis . . 119 
 
 ,, ,, Prognosis . . 124 
 
 ,, ,, Secondary . . 117 
 „ Symptoms of 117, 121 
 
 ,, „ Tertiary . . 118 
 ,, ,, Treatment of 118, 123 
 
 Tcenia echinococcus .... 125 
 
 Tapping of the gall bladder . . . 325 
 
 Taurocholic acid 32 
 
 Transposition of the liver ... 58 
 
 Traumatic affections of the liver . . 160 
 Traumatism as cause of abscess of the 
 
 liver 70 
 
 Tropical abscess of the liver ... 81 
 ,, ,, GeograjDhical 
 
 distribution 82 
 ,, ,, Predisposing 
 
 causes . 84 
 ,, ,, Relation to 
 
 other diseases 87 
 
 Tubercular abscess of the liver . . 108 
 Tumours — 
 
 ,, Of the bile ducts . . 261 
 
 Of the gall bladder . . 247 
 ,, Of the liver . . .182 
 
 ,, ,, Innocent , 182 
 
 ,, ,, Malignant . 187 
 Typhoid fever — 
 
 ,, Hepatic abscess in . 80 
 
 , , Relation to cholelithiasis 212 
 
 Urea, formation of, in liver 
 Urine, after injury to liver 
 ,, In jaundice 
 
 37 
 164 
 
 47 
 
382 
 
 GENERAL INDEX. 
 
 Veins, Accessory portal . . .13 
 
 ,, Allantoic 23 
 
 ,, Inferior vena cava ... 14 
 
 ., Interlobular .... 26 
 
 ,, Intralobular .... 27 
 „ Portal— 
 
 , ,, Anatomy ... 12 
 ,, ,, Communications with 
 
 general venous system 13 
 
 ,, Vena Aurantii .... 24 
 
 ,, Venfe advehentes ... 23 
 
 ,, Venffi revehentes ... 23 
 
 „ Vitelline 23 
 
 Wedge-shaped incision in the liver . 319 
 
 
 
 
 PAGE 
 
 Wounds of the biliary ducts 
 
 . 196 
 
 „ Of the 
 
 gall bladder 
 
 . 196 
 
 Of the 
 
 liver 
 
 
 . 160 
 
 )> 
 
 
 Gunshot . 
 
 . 171 
 
 J! 
 
 
 Lacerated . 
 
 . 172 
 
 11 11 
 
 
 Penetrating 
 
 . 171 
 
 Xanthelasma 
 
 
 
 . 48 
 
 Yellow fever, relation to tropical abscess 
 of the liver 87 
 
 Zielewicz's modification of cholecyst- 
 endysis 33.5 
 
INDEX OF AUTHORS. 
 
 Abernethy 
 
 Albers 
 
 Albert 
 
 Anderson 
 
 Andral 
 
 Annesley 
 
 Arnold 
 
 Autona, de 
 
 Auvray 
 
 Bardeleben 
 
 Bardenhauer 
 
 Bargioni 
 
 Barlow 
 
 Bastianelli 
 
 Baudouin 
 
 Bauragarten 
 
 Bayer 
 
 Beck . 
 
 Beckmann 
 
 Bell . 
 
 Bennett 
 
 Bergmann 
 
 Berkley 
 
 Bernhard 
 
 Bertrand 
 
 Binet . 
 
 Binz . 
 
 Blocq . 
 
 Bobbs . 
 
 Boyer . 
 
 Breschet 
 
 Brieger 
 
 Bright 
 
 Bristowe 
 
 Broca . 
 
 Brockbank 
 
 Brodie 
 
 Broussais 
 
 Bruns . 
 
 Bryant 
 
 Buckling 
 
 Buisson 
 
 Bulau . 
 
 Calot . 
 Cantani 
 Cayla . 
 
 
 PAGE 
 
 
 PAGE 
 
 
 31 
 
 Charcot 
 
 218, 226 
 
 
 247 
 
 Chevers 
 
 83 
 
 
 194 
 
 Christiansen 
 
 100 
 
 
 329, 349 
 
 Chvostek 
 
 79, 81, 94 
 
 
 95 
 
 Cimbali 
 
 81 
 
 
 87 
 
 Claude 
 
 152 
 
 
 74 
 
 Coats .... 
 
 268 
 
 
 259 
 
 Colin .... 
 
 98 
 
 
 179, 209 
 
 Copenian 
 
 30 
 
 
 
 Councilman 
 
 95 
 
 
 194 
 
 Courvoisier . 196, 205, 
 
 209, 257, 260, 
 
 
 259 
 
 
 305, 332, 336 
 
 
 73 
 
 Cyr .... 
 
 . 91, 97 
 
 
 204 
 
 Czerny 
 
 250, 259, 335 
 
 
 316 
 
 
 
 
 324 
 
 Dalton 
 
 196, 200 
 
 
 13 
 
 Daniell 
 
 86 
 
 
 151 
 
 Davaine 
 
 73 
 
 65, 
 
 279, 285 
 
 De Castro . 
 
 . 86, 100 
 
 
 338 
 
 Demantke . 
 
 152, 153 
 
 
 196 
 
 Dessauer 
 
 300 
 
 
 261 
 
 Dickinson . 
 
 59 
 
 187, 
 
 198, 319 
 
 Dmochowski 
 
 152 
 
 
 16 
 
 Dufort 
 
 303 
 
 
 81 
 
 Dutroulau . 
 
 . 87, 91 
 
 
 81 
 
 
 
 
 30 
 
 Eberth 
 
 . 81, 212 
 
 
 65 
 
 Edler .... 
 
 178 
 
 
 276 
 
 Eiselberg 
 
 184, 319 
 
 
 327 
 
 Eve . 
 
 301 
 
 
 163 
 
 
 
 
 14 
 
 Fagge .... 
 
 82, 121, 127 
 
 
 135 
 
 Fayrer 
 
 83 
 
 
 35 
 
 Ferrand 
 
 241 
 
 
 152 
 
 Ferrein 
 
 28 
 
 
 338 
 
 Finlayson . . . . 
 
 268 
 
 
 218 
 
 Fleischl 
 
 38 
 
 
 203 
 
 Fontiin 
 
 78, 81, 312 
 
 
 94 
 
 Frerichs . . .48, 
 
 182, 212, 214 
 
 
 147 
 
 Fryer 
 
 204 
 
 
 13 
 
 Fitrbringer . . . . 
 
 283 
 
 
 79, 81 
 
 Ftitterer . . . . 
 
 81 
 
 
 214 
 
 
 
 
 132 
 
 Galloupe . . . . 
 
 98 
 
 
 
 Gee 
 
 282 
 
 
 337 
 
 Gerard-Marchant 
 
 159, 323 
 
 
 157 
 
 Giese 
 
 69 
 
 
 132 
 
 Gintrac . . . . 
 
 . . 94 
 
384 
 
 INDEX OF A UTHORS. 
 
 
 PAGE 
 
 
 
 PAGE 
 
 Gmelin 
 
 33, 44, 46, 203, 208 
 
 Lannelongue 
 
 
 159, 278 
 
 Golowin 
 
 46 
 
 Legg . 
 
 '. 44, 47, 48, 50, 69 
 
 Gombanlt . 
 
 39 
 
 Lejars . 
 
 
 152 
 
 Gould . 
 
 65 
 
 Lembert 
 
 
 208, 334 
 
 Groube 
 
 186, 187, 194 
 
 Leuckart 
 
 
 126, 127, 144 
 
 Guterboch . 
 
 132 
 
 Leudet 
 Lieutaud 
 
 
 81 
 65 
 
 Hanibursin . 
 
 100 
 
 Lindemann . 
 
 
 143 
 
 Hamilton . 
 
 165 
 
 Lins . 
 
 
 194 
 
 Hammoud . 
 
 101 
 
 Lobstein 
 
 214, 
 
 290, 302, 305 
 
 Hanot . 
 
 39 
 
 Loreta 
 
 
 336 
 
 Harley (G.) • 
 
 326, 327 
 
 Louis . 
 
 
 81 
 
 Haiiey (Vaughau) 
 
 . 38, 39 
 
 Liicke . 
 
 
 194, 195, 316 
 
 Hashimoto . 
 
 98 
 
 
 
 
 Haspel 
 
 . 70, 86 
 
 M'Burney . 
 
 
 353 
 
 Hawkins 
 
 . 67, 69 
 
 MacCallum . 
 
 
 16 
 
 Hay . 
 
 46 
 
 Maclean 
 
 
 92 
 
 Hayem 
 
 135 
 
 Magendie . 
 
 
 79 
 
 Head . 
 
 266 
 
 Manson 
 
 
 88 
 
 Heintz 
 
 135 
 
 Mardchal 
 
 
 44 
 
 Heister 
 
 19 
 
 Mai'kham . 
 
 
 254 
 
 Helfft . 
 
 87 
 
 Marshall 
 
 
 . 84, 164 
 
 Hirsch 
 
 . 84, 85, 88 
 
 Martig 
 
 332,' 336, 
 
 339, 346, 349 
 
 Hochenegg . 
 
 194, 195, 259, 316 
 
 Mayd] . 
 
 
 276, 278, 279 
 
 Hochstetter 
 
 . 13, 19 
 
 Mayer 
 
 
 161 
 
 Huet . 
 
 98 
 
 Mayet . 
 
 
 100 
 
 Hulke 
 
 . 97, 154 
 
 Meckel 
 
 
 79 
 
 Hutchinson, J. . 
 
 305 
 
 Mermann . 
 
 
 338, 349 
 
 
 
 Meyer . 
 
 ". 78, 
 
 163, 171, 173 
 
 Israel . 
 
 194 
 
 Michaux 
 
 Mignot 
 
 
 348 
 215 
 
 Jankowski . 
 
 152 
 
 Minkowski . 
 
 
 . 35, 39 
 
 Jeaffreson . 
 
 300 
 
 ■ Movehead . 
 
 
 84 
 
 Jonassen 
 
 132 
 
 Mouat 
 
 
 84 
 
 Jourdan 
 
 349 
 
 Mourson 
 
 
 135 
 
 Jubiot 
 
 98 
 
 Moxon 
 
 
 261 
 
 Juhel-Renoy 
 
 153 
 
 MuUer, W. . 
 Munk . 
 
 
 151, 194, 317 
 135 
 
 Rallies 
 
 87 
 
 Murchison . 
 
 
 226 
 
 Kartulis 
 
 88 
 
 Murphy 
 
 271, 
 
 272, 340, 346 
 
 Keen . 
 
 194 
 
 Musser 
 
 . 258, 260, 
 
 262, 263, 266 
 
 Kehr . 188, 19 
 
 4, 195, 196, 200, 333, 
 336, 338, 349 
 
 Mylius 
 
 
 32 
 
 Kelsch 
 
 87 
 
 Naucke 
 
 
 214 
 
 Kiener 
 
 87 
 
 Naunyn . 35 
 
 ', 39, 210, 
 
 211, 214, 215, 
 
 Kiernan 
 
 28 
 
 
 217, 
 
 299, 301, 302 
 
 Klebs . 
 
 80 
 
 Nicolle 
 
 
 152 
 
 Koclier 
 
 245, 352, 354 
 
 North . 
 
 
 151 
 
 Kiinig 
 
 154 
 
 
 
 
 Korolkow . 
 
 16 
 
 Ogston 
 
 
 161 
 
 Kiistlin 
 
 . 69, 300 
 
 Ord . 
 
 
 226 
 
 Kousnetsofi' 
 
 185, 186 
 
 Ortner 
 
 
 226, 227 
 
 Kriinleiu 
 
 169, 177 
 
 Osier . 
 
 
 . 79, 88 
 
 Kufferath . 
 
 38 
 
 Otis . 
 
 
 172, 178 
 
 Kuhne 
 
 35 
 
 
 
 
 Kunkel 
 
 38 
 
 Paroisse 
 
 
 196 
 
 Kussmaul . 
 
 303 
 
 Peacock 
 
 
 99 
 
 Kuster 
 
 319 
 
 Pen sky 
 Pettenkofer 
 
 
 185, 186 
 . 32, 33, 46 
 
 Lancereaux . 
 
 122, 123 
 
 PHiiger 
 
 
 16 
 
 Liingenbuch 71, 
 
 81, 91, 159, 194, 323, 
 
 Pilliet . 
 
 
 1 52 
 
 
 336, 350 
 
 Pimser 
 
 
 100 
 
INDEX OF A UTHORS. 
 
 385 
 
 
 PAGE 
 
 
 PAOE 
 
 Pisenta 
 
 185 
 
 Segond 
 
 157 
 
 Pitres . 
 
 218 
 
 Sick . 
 
 300 
 
 Pliitner 
 
 32 
 
 Siegert 
 
 257 
 
 Podrouzek . 
 
 188 
 
 Sims . 
 
 327 
 
 Podwyssozki 
 
 . 74, 75 
 
 Slifosowsky 
 
 194 
 
 Poiret . 
 
 86 
 
 Smith . 
 
 301 
 
 Poland 
 
 196 
 
 Sprengel 
 
 337, 350 
 
 Pi-c^vost 
 
 30 
 
 Stewart 
 
 196 
 
 Purser 
 
 20 
 
 Stiller . 
 
 260 
 
 Pye-Smith . 
 
 46 
 
 
 
 
 
 Tait (Lawson) 
 
 259, 329 
 
 Quain . 
 
 . 12, 13 
 
 Tansini 
 
 142, 143, 318 
 
 Quenu 
 
 349 
 
 Taylor 
 
 162 
 
 
 
 Terrier 179, 209, 3 
 
 i5, 332, 338, 349, 352 
 
 Reclus 
 
 272 
 
 Terrillon . 
 
 143, 147, 316 
 
 Rees . 
 
 127 
 
 Testut 
 
 . 11, 17, 26 
 
 Reid . 
 
 1 
 
 Thierfelder . 
 
 78, 97, 98, 99, 158 
 
 Rendu 
 
 98 
 
 Thomas 
 
 140, 142, 143 
 
 Richelot 
 
 159 
 
 Thomson 
 
 . 64, 67, 69 
 
 Riedel . . . 239, 
 
 247, 250, 259, 333 
 
 Thornton 
 
 323, 324 
 
 Robson . . 30, 
 
 194, 223, 298, 346 
 
 Thorowgood 
 
 301 
 
 Rokitansky 
 
 182 
 
 Tiedemaun . 
 
 203, 208 
 
 Rolleston . 
 
 261, 262, 263, 266 
 
 Tillmanns . 
 
 317 
 
 Rosenberg . 
 
 35 
 
 Tricomi 
 
 194, 317 
 
 Rosentlial . 
 
 185 
 
 Tschering . 
 
 159 
 
 Ross . 
 
 79 
 
 Tungel 
 
 81 
 
 Roth . 
 
 69 
 
 
 
 Rothe . 
 
 14 
 
 Vierordt 
 
 144, 145, 146 
 
 Rouis . 
 
 . 86, 91 
 
 Virchow 
 
 . 33, 34, 144, 182 
 
 Routier 
 
 202 
 
 
 
 Ruepp 
 
 177 
 
 Wagner 
 
 153 
 
 Rutherford . 
 
 35 
 
 Waring, E. J. 
 
 . 84, 85, 86, 91, 98 
 
 
 
 Watson 
 
 196 
 
 Sabatier 
 
 196 
 
 Wertheimer 
 
 30 
 
 Sabourin 
 
 152 
 
 Wiedeman . 
 
 247 
 
 Sanger 
 
 276 
 
 Wilks . 
 
 261 
 
 Sappey 
 
 . . 13 
 
 Willemin 
 
 241 
 
 Saux . 
 
 86 
 
 Winiwarter . 
 
 259, 343, 350 
 
 Scheube 
 
 99 
 
 Winkler 
 
 157 
 
 Schiff . 
 
 30 
 
 . Winston 
 
 30 
 
 Schlagdenhautfen 
 
 135 
 
 Wittig 
 
 60 
 
 Schlatter . 
 
 169, 176 
 
 Wolfes 
 
 100 
 
 Schlier 
 
 81 
 
 
 
 Schmidt 
 
 154, 194, 316 
 
 Yeo . 
 
 241 
 
 Schmorl 
 
 144 
 
 
 
 Schroder 
 
 217 
 
 Zancarol 
 
 . 86, 104, 107 
 
 Schllller 
 
 301, 302, 305 
 
 Zenker 
 
 164 
 
 Schiippel 
 
 247 
 
 Zielewicz 
 
 ... . 335 
 
 See . 
 
 241 
 
 Ziemssen 
 
 138 
 
 25 
 
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YOUNG J. PENTLAND. n 
 
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YOUNG J. PENTLAND. 13 
 
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YOUNG J. PENTLAND 15 
 
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YOUNG J. PENTLAND. 17 
 
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 EXAMINATION QUESTIONS. Set for the Professional Exam- 
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 APPENDICITIS AND PERITYPHLITIS. Translated from the 
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 A PRACTICAL GUIDE TO MEAT INSPECTION. Third 
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 and Professor of Comparative Anatomy, Royal Veterinary College, 
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 TEXT-BOOK OF OBSTETRICS, including the Pathology and 
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 and Students of Medicine. Translated from the German under 
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 and 
 
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 PATHOLOGICAL MYCOLOGY : An Enquiry into the Etiology 
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 [Classified Index. 
 
MEDICAL PUBLICATIONS ISSUED BY 
 
 CLASSIFIED INDEX. 
 
 Abdominal Surgery, 
 Abortion (Causes and Treatment), 
 Abscesses (Treatment), 
 Ambulance Lectures, 
 Anatomy (Practical), 
 
 (Medical), 
 
 (Regional), 
 
 (Compend of), 
 
 (Surgical), 
 
 (Examination Questions), 
 
 (Female Pelvic), 
 Appendicitis, 
 Aseptic Surgery, . 
 Atlases (Brain), 
 „ (Eye), 
 „ (Skin), 
 „ (Venereal Diseases), 
 
 Bacteriology, 
 
 ,, and Pathology, Journal of. 
 
 Bandaging, 
 
 Beri-Beri, .... 
 Bones and Joints (Disease of), 
 Botany (Text Book), 
 
 „ (Manual), . 
 
 ,, (Exam. Quests.), . 
 Brain (Tumours), . 
 
 „ (Illustrations of Nerve Tracts), 
 
 Chemistry (Exam. Quests.), 
 Children (Diseases), 
 
 ,, (Compend of Diseases), . 
 
 ,, (Cyclopaedia, Diseases of), 
 
 ,, (Treatment of Diseases), 
 
 „ (Diseases), 
 
 ,, (Digestive Organs in). 
 Clinical Diagnosis, 
 
 „ Gynaecology, 
 
 Keith. 
 
 Rentoul. 
 
 Cheyne. 
 
 Lawless. 
 
 Cunningham. 
 
 Kenwood. 
 
 M'Clellan. 
 
 Potter. 
 
 Sheild, 
 
 Smith. 
 
 Webster. 
 
 Talamon. 
 
 Lock WOOD. 
 
 Bruce. 
 
 Frost. 
 
 Crocker. 
 
 Maclaren. 
 
 WooDHEAD & Hare. 
 
 Wharton. 
 
 Pekelharing. 
 
 Cheyne. 
 
 Behrens. 
 
 Johnstone. 
 
 Smith. 
 
 Bramwell. 
 
 Bruce. 
 
 Smith. 
 Carmichael. 
 Hatfield. 
 Keating. 
 
 MUSKKTT. 
 ROTCH. 
 
 Starr. 
 
 SeIFERT & MULLER. 
 
 Keating & Coe. 
 
YOUNG J. PENTLAND. 
 
 23 
 
 Clinical Medicine (Studies in), 
 
 Cyclopsedia of the Diseases of Children, 
 
 Dental Pathology, 
 Dentistry (System of), 
 Dermatology (Atlas), 
 
 Diagnosis (Ophthalmoscopic), 
 
 „ (Physical), 
 
 „ (Medical), 
 
 „ (Clinical), 
 
 „ (Medical), 
 
 Dictionary of Terms (5 languages) 
 
 )j )) 
 
 „ „ (Pocket), 
 
 Diet, 
 Digestive Organs in Children, 
 
 Ear (Diseases), 
 
 >) >) • • 
 
 Ectopic Gestation, 
 Edinburgh Hospital Reports. 
 Epidemic Ophthalmia, 
 Epilepsy, 
 
 Examination Questions, 
 Eye (Diseases), 
 
 „ (Atlas), 
 
 ,, (Diseases), 
 
 „ (Ophthalmia), 
 
 First Aid to Injured, 
 
 Genito-Urinary Diseases, . 
 Geographical Pathology, . 
 Gestation (Ectopic), 
 Gynaecology (Text Book), . 
 
 „ (Medical), 
 
 „ (Exam. Quests.), 
 
 „ and Obstetrics (System of), 
 
 Harrogate Waters, 
 Heart (Diseases), . 
 
 Bramwell. 
 Gibson & Russell. 
 
 MUSSER. 
 ViERORDT. 
 
 Keating. 
 Warren. 
 
 LiTCH. 
 
 Crocker. 
 
 Jamieson. 
 
 Morrow. 
 
 Berry. 
 
 Gibson & Russell. 
 
 Musser. 
 
 Seifert & Muller. 
 
 ViERORDT. 
 
 Billings. 
 Keating. 
 
 LONGLEY. 
 
 Bruen, 
 Starr. 
 
 Burnett. 
 M'Bride. 
 Webster. 
 
 Stephenson. 
 
 Alexander. 
 
 Smith. 
 
 Berry. 
 
 Frost. 
 
 NoRRis & Oliver. 
 
 Stephenson. 
 
 Lawless. 
 
 Morrow. 
 Davidson. 
 Webster. 
 Keating & Coe. 
 
 Skene. 
 Smith. 
 Mann & Hirst. 
 
 Liddell. 
 Bramwell. 
 
24 
 
 MEDICAL PUBLICATIONS ISSUED BY 
 
 Hospital Reports (Edinburgh). 
 
 Human Monstrosities, 
 
 Hydatid Disease, 
 
 Hygiene and Diseases of Warm Climates, 
 
 Infective Diseases, 
 Intracranial Tumours, 
 
 Joints (Tuberculous Disease), 
 Journal of Pathology. 
 
 Laboratory Reports (R. C. P. Edinburgh), 
 Lead Poisoning, 
 
 Malignant Disease of Throat and Nose, 
 Materia Medica (Exam. Quests.), . 
 Maternity, Infancy and Childhood, 
 Meat Inspection, . 
 Medical Anatomy, 
 „ Diagnosis, 
 
 „ Dictionary (5 languages), 
 
 (Pocket), 
 „ Gynaecology, 
 Medicine (Compend of), . 
 „ (Text-Book of), . 
 ,, (Exam. Quests.), 
 Midwifery (Compend of), . 
 „ (Text-Book of), 
 
 ,, (Exam. Quests.), 
 
 ,, (System of), 
 
 (Text Book of), 
 Mineral Waters (Harrogate), 
 Monstrosities (Human), 
 Morbid Anatomy, . 
 Mouth, Throat and Nose (Diseases), 
 
 Natural History (Exam. Quests.), 
 „ ,, (Illustrations), 
 
 (Text Book), 
 Nervous Diseases (Epilepsy), 
 
 „ (Text-Book), . 
 (Nursing), 
 Nose (Diseases), 
 „ (Diseases), 
 
 Hirst & Piersol. 
 
 Graham. 
 
 Davidson. 
 
 lockwood. 
 
 Br AM WELL. 
 
 Cheyne. 
 
 Oliver. 
 
 Newman. 
 
 Smith. 
 
 Keating. 
 
 Walley. 
 
 Kenwood. 
 
 MUSSER. 
 
 Vierordt. 
 
 Billings. 
 
 Keating. 
 
 Longley. 
 
 Skene. 
 
 Hughes. 
 
 Osler. 
 
 Smith. 
 
 Landis. 
 
 Parvin. 
 
 Smith. 
 
 Mann & Hirst. 
 
 WiNCKEL. 
 LiDDELL. 
 
 Hirst & Piersol. 
 
 Hall. 
 
 Schech. 
 
 Smith. 
 
 Smith & Norweli 
 
 Thomson. 
 
 Alexander. 
 
 Dercum. 
 
 Mills. 
 
 McBride. 
 
 Schech. 
 
YOUNG J. PENTLAND. 
 
 25 
 
 Nose and Throat (Malignant Disease of) 
 Nursing (Obstetric), 
 
 „ (Children), . ■ 
 
 „ (First Aid), 
 
 ,, (Insane), . 
 
 Obstetric Nursing, . 
 Obstetrics (Compend of), . 
 
 „ (Science and Art of), 
 
 „ (System of), 
 
 ,, (Text Book of), . 
 Ophthalmia (Epidemic), 
 Ophthalmology (Text-Book of), 
 Ophthalmoscopic Diagnosis, 
 Ophthalmoscopy (Atlas of), 
 
 Parasites of Man, . 
 Pathological Mycology, 
 Pathology (Geographical), 
 
 „ (Practical), 
 
 „ (Compend of), 
 
 ,, (Dental), 
 
 „ (Practical), 
 Pathology and Bacteriology (Journal of) 
 Pediatrics, 
 
 Pharmacology, 
 
 Phthisis (Pulmonary), 
 
 Physical Diagnosis, 
 
 Physiology (Exam. Quests.), 
 
 Poisoning (Lead), . 
 
 Practice of Medicine (Compend of), 
 ,, „ (Text Book of), 
 
 ,, ,, (Exam. Quests.), 
 
 Pregnancy (Ectopic), 
 
 Prescribing and Treatment of Children's 
 
 Newman. 
 Haultain & Ferguson. 
 Keating. 
 Lawless. 
 Mills. 
 
 Haultain & Ferguson. 
 Landis. 
 Parvin. 
 Mann & Hirst. 
 
 WiNCKEL. 
 
 Stephenson. 
 NoRRis & Oliver. 
 Berry. 
 Frost. 
 
 Leuckart. 
 WooDHEAD & Hare 
 Davidson. 
 
 GiBBES. 
 
 Hall. 
 
 Warren. 
 
 WoODHEAD. 
 
 Carmichael. 
 Keating. 
 
 ROTCH. 
 
 Schmiedeberg. 
 
 James. 
 
 Gibson & Russell. 
 
 Smith, 
 
 Oliver. 
 
 Hughes. 
 
 OSLER. 
 
 Smith. 
 Webster. 
 Diseases, Muskett. 
 
 Regional Anatomy, 
 Reports, Edinburgh Hospital. 
 
 „ R. C. P. Laboratory, Edinburgh. 
 
 M'Clellan. 
 
 Septic Diseases, 
 
 Sexual Organs (Diseases), 
 
 Cheyne. 
 Fuller. 
 
26 
 
 MEDICAL PUBLICATIONS. 
 
 Skin Diseases (Atlas of), . 
 
 Crocker. 
 
 )> )) ... 
 
 Jamieson. 
 
 >j >> ... 
 
 Morrow. 
 
 Stomach (Diseases), 
 
 EWALD. 
 
 ,, (Diseases), 
 
 Martin. 
 
 Surgery (Compend of), 
 
 HORWITZ. 
 
 „ (Abdominal), 
 
 Keith. 
 
 (Aseptic), 
 
 LOCKWOOD. 
 
 „ (Exam. Quests.), . 
 
 Smith. 
 
 (Minor), . 
 
 Wharton. 
 
 Surgical Anatomy, 
 
 Sheild. 
 
 Syphilology, 
 
 Morrow. 
 
 System of Dentistry, 
 
 Litch. 
 
 „ Genito-Urinary Diseases, 
 
 Morrow. 
 
 „ Therapeutics, 
 
 Hare. 
 
 Therapeutics (Synopsis), , 
 
 AlTCHISON. 
 
 (System), 
 
 Hare. 
 
 „ (Physical and Natural), 
 
 Hayem & Hare 
 
 ,, (Exam. Quests.), 
 
 Smith. 
 
 Throat (Diseases), 
 
 SCHECH. 
 
 „ and Nose (Malignant Disease 
 
 of), . Newman. 
 
 „ Nose and Ear (Diseases), . 
 
 McBride. 
 
 Traumatic Infection, 
 
 LoCKWOOD. 
 
 Tropical Diseases, . 
 
 Davidson. 
 
 )) )) • • • 
 
 Felkin. 
 
 Tumours (Intracranial), 
 
 Bramwell. 
 
 Ulcers (Treatment), 
 
 Cheyne. 
 
 Urine, .... 
 
 Holland. 
 
 Venereal Diseases, . 
 
 . Maclaren. 
 
 !> >> • • 
 
 Taylor 
 
 Warm Climates (Diseases), 
 
 Davidson. 
 
 Women (Diseases of), 
 
 Keating & Coe. 
 
 „ (Diseases), 
 
 Skene. 
 
 Wounds (Treatment), 
 
 Cheyne. 
 
 Zoology (Exam. Quests.), . , 
 
 Smith. 
 
 „ (Illustrations of), . , 
 
 Smith & Norwell. 
 
 „ (Outlines of), 
 
 Thomson. 
 
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