That an associated and solitary cancerous growth of this kind may be successfully removed has been proved in my own experience, by the good health persisting at least six years after operation upon a woman from whom I removed a large cancerous gall-bladder containing two large calculi, and with it a considerable amount of the adjoining liver tissue. It is, therefore, possible to successfully remove some benign tumors, as well as occasionally a malignant one, from the liver when other conditions are favorable; but this should always be done before it be too late, as a comparison of cases will demonstrate. If the lymph nodes or any other viscus be involved in malignant disease, then it is too late. The tumor is to be attacked from its most accessible aspect. A pedunculated growth, like a distinct benign hypertrophy, may be tied off, sutures being also used if needed. The actual cautery furnishes the best means of division of liver tissue, while with a sessile growth elastic constriction may be of assistance. The principal danger in these operations is from hemorrhage. Methods of meeting it are discussed below, as well as other general procedures. A tumor stump may be fastened to the abdominal wound, or it is better treated by being packed around with gauze, the latter being allowed to remain for three or four days.[62]

[62] As a means of preventing the ligature cutting in liver sutures Gillette has suggested the use of a piece of rubber tube drawn over a No. 10 catheter and placed along the proposed line of sutures, which are passed around this, and through the abdominal wall, making exit between the ribs, after the manner of a staple.

Von Bruns, in 1870, was probably the first to resect liver tissue, after injury, with good results. Modern surgery has done much to improve the prognosis in these injuries and to show that it can be attacked much more freely than previously supposed. Within the past fifteen years Ponfick and many other experimenters have shown the regenerative capacity of the liver by removing as much as three-fourths of it. The fear of cholemia, due to escape of bile, has also passed, and it has been found that peritoneal complications do not result from its presence, for bile, unless actually mixed with pus, is not septic, although its antiseptic properties have been much overrated. Most of the expedients which have been suggested by various operators for controlling hemorrhage have been abandoned for the more simple methods of the tampon and the suture, although the actual cautery is still generally used for the operative attack. For suture catgut is preferable to silk. Even large wounds may be successfully fastened in this way. Arterial bleeding is easily distinguished from venous oozing. Spurting arteries may be ligated en masse, while continuous oozing usually subsides under pressure. In contusions of the liver, when it is not practicable to bring hepatic surfaces together, loops of catgut may be passed with a large needle through the liver structure in such a way as to bind its edges whenever they are bleeding. The sutures or loops may be drawn tightly to check hemorrhage before they cut through the liver structure. When the attempt is made to actually suture liver tissue it is necessary here as elsewhere to avoid dead spaces. If liver surfaces can be brought into actual contact they will heal kindly. In fact when there is access, and the emergency is not too pressing, the portion to be removed may be excised with ordinary knife or scissors, and this is better when suture methods are to be employed. There are times, however, when the Paquelin cautery knife will perhaps be preferable. It is a mistake in these cases to try to work through too small an incision. For wounds located posteriorly Lannelongue has suggested resection of the thoracic wall along the anterior portion of the eighth to the eleventh costal cartilages, since the pleura does not extend down to that level. He makes an incision parallel with the costal border, 2 Cm. above the same, beginning 3 Cm. from the border of the sternum, and terminating at the tenth costochondral junction. After retracting the muscles the costal cartilages are to be resected. If, now, the rib ends be firmly retracted and pressed apart a large portion of the convexity of the liver can be made accessible.

In order to make better access to the upper margin of the liver it may be well to adopt Marwedel’s suggestion of retracting the rib arches by a curved incision, parallel with the costal margin, with complete division of the rectus and the external oblique, which latter is to be separated from the internal and transverse. The cartilage of the seventh rib is divided at its sternal junction and the cartilages of the eighth and ninth are also exposed and divided by blunt dissection. After thus loosening the lower ribs the lower part of the chest wall can be retracted, and much better access made to the region below the diaphragm. When necessary the left side of the abdomen may be treated in the same manner.

From the liver we pass to the consideration of the surgical aspects of cholelithiasis and other affections of the biliary passages.

THE GALL-BLADDER.

The gall-bladder is a convenient but more or less superfluous receptacle or reservoir for bile, whose normal capacity is from 50 to 60 Cc., but which, when distended, may, by virtue of its elasticity, contain at least 200 Cc. of fluid. Its normal position is beneath the ninth costal cartilage, at a point where it crosses the outer edge of the rectus. Only its lower surface is covered by peritoneum, in average cases, but when it is distended or hangs well down in the abdomen the peritoneum may enclose the larger amount of the sac. Its neck is bent into an S-shape, and contains two folds of mucous membrane, which serve as valves. When this neck is mechanically obstructed the sac itself may be distended with glairy, bile-stained mucus, amounting even to 500 Cc., but in patients who have had repeated attacks of gallstone colic and have suffered for a long period of time, the gall-bladder is usually contracted, shrivelled, and sometimes almost obliterated. Under these conditions there is a strong resemblance between it and so-called appendicitis obliterans, and when so contracted and buried in adhesions it may not be easily found. In certain cases of cirrhosis of the liver the gall-bladder is carried up well beneath the ribs and then descends with whatever motion depresses the liver. On the other hand when distended it may hang down into the abdominal cavity as a pear-shaped mass, which may even cause doubt and uncertainty in diagnosis, for it may be then found in the cecal region or in the pelvis.

The common duct is from 6 to 8 Cm. long. Its size is about that of a No. 15 French sound. It is both extensile and distensible, and may be dilated even to the size of the small intestine. About one-third of it is in intimate relation with the pancreas, whether wrapped within its head or lying in a groove upon it. This is of surgical import, for in enlargement of the pancreas the duct may be first pushed away and then obstructed; this explains why biliary drainage is indicated in so many pancreatic cases. The part which passes obliquely through the duodenum is expanded into a reservoir beneath the mucosa, into which opens also the pancreatic duct, the latter lying lower and being separated by a fold of mucous membrane. This dilatation, the ampulla of Vater, is 6 or 7 Mm. long, and is surrounded by an unstriped muscle fiber—a miniature sphincter. Its opening constitutes the narrowest portion of the entire biliary canal. Seen from within it forms a little caruncle or papilla, distant 8 Cm. from the pylorus. The duct of Santorini opens normally about 2 Cm. above this papilla, and is patent in about one-half of these cases, while in about 80 per cent. of cases it communicates with the duct of Wirsung. Many variations from the normal, as above epitomized, occur—especially in and about the ampulla. They are both congenital and acquired. Thus an hour-glass gall-bladder is occasionally seen, or one so divided by a partition that one part may contain mucus and the other calculi. It is worth remembering in this connection that along the free border of the lesser omentum there are three or four lymph nodes which, when enlarged, may be easily mistaken for calculi. The gall-bladder lies in a peritoneal pouch, having the colon below it, the spine and the pancreas to its inner and posterior aspects, the liver above and the abdominal wall on its outer side. When this pouch is seriously affected it may be drained not only from in front but often to great advantage from behind, i. e., by posterior drainage. This pouch may hold a pint before it overflows into the pelvis, or through the foramen of Winslow into the greater peritoneal cavity. The right lobe of the liver is sometimes enlarged so as to form a tongue-shaped projection which may extend some distance below the costal margin. This is frequently called Riedel’s lobe. (See [Plate LV].)

The gall-bladder is essentially a biliary reservoir, convenient but not essential, storing bile between meals and expelling it during digestion. It is absent in the horse and in many animals, and individuals from whom it has been removed seem to suffer thereby no inconvenience. Consequently there need be no hesitation in removing it when necessary. Bouchard claims that bile is nine times more toxic than urine, and that the liver of man may produce sufficient in eight hours to kill him if it cannot escape. Consequently biliary obstruction may become a very serious matter. Besides containing bile the gall-bladder has numerous minute glands of its own, which secrete the ropy mucus with which it is so often found distended. A mixture of bile and pancreatic juice seems ideal for perfect emulsification and digestion of fat. Hence the disadvantage of anything which interferes with the escape of bile into the duodenum. Bile possesses by itself slight antiseptic properties, yet when uncontaminated is not septic. It may be regarded as mainly excrementitious, and its function as an intestinal stimulant has been much overrated. The average quantity secreted in twenty-four hours is about thirty ounces. Its excretion is constantly going on, but is more abundant by day, is not much influenced by diet, nor nearly so much by the so-called cholagogues as has been generally supposed. All these points have a practical interest for the surgeon who has to do with the consequences of biliary obstruction, or who has to watch its progress for lack of a biliary fistula.

PLATE LV