Injury will either produce such damage as to lead to acute local peritonitis, with extensive exudation for protective purposes, and with all the possibilities of subsequent infection, or there will be actual rupture, with extravasation of bile, and perhaps of blood, and the development of well-marked local as well as general symptoms. Fluid thus escaping will first fill the abdominal pouch, already described above, where it will then be confined by the mesentery until it begins to overflow. A small opening may be sealed by lymph, and a small collection of fluid may even be encapsulated, so that it may be subsequently opened and drained. The symptoms of such injury will include shock, pain, fever, fulness in the right side and hypochondrium, abdominal rigidity and the development in certain cases, after a few days, of jaundice, indicating absorption of bile. Should this bile have been aseptic, no great harm may ensue, but if infected a general and probably fatal peritonitis will result.
In any case where the condition may be recognized or where it is strongly suspected, abdominal section should be promptly made. According to the conditions thus disclosed the opening may be sutured, if possible or the gall-bladder or other cavity containing bile may be drained. It has been possible in some such cases to successfully suture a tear or wound in the duct, while in a few cases the duct has been doubly ligated and the bile flow been turned into the intestine by an anastomosis.
ACUTE CATARRH OF THE BILIARY PASSAGES.
The formation of bile takes place under low pressure and therefore is easily hindered by slight back pressure. In this way jaundice may be easily produced with no greater degree of chemosis of the duodenal mucosa than that produced by a relatively small amount of activity in the duodenum. Inasmuch as the common duct traverses the intestinal wall obliquely its small outlet would be the first to suffer. In minor catarrhal duodenitis it is of small surgical importance, but when the condition becomes chronic the obstruction then becomes a matter to be dealt with by the surgeon. Such conditions may occur in connection with typhoid fever, pneumonia, influenza, ptomain poisoning, and other diseases, and are often accompanied by vomiting and diarrhea, with referred tenderness and possibly enlargement, while even the spleen is sometimes enlarged.
Treatment.
—In the early stage of such a condition the treatment is medicinal, but when the condition has become chronic biliary drainage may be required.
CHRONIC CHOLANGITIS.
This is frequently a sequel to the above acute condition, and generally accompanies jaundice, no matter how produced. It is a frequent concomitant of cancer and often the actual cause of its accompanying jaundice. It has been known to lead up to suppurative lymphangitis, the lymph nodes along the border of the lesser omentum, already described, being nearly always involved and occasionally suppurating. Pylephlebitis may also have this origin. Gallstones nearly always provoke a certain degree of cholangitis and cause the formation of thick, ropy mucus which causes pain when passing, this pain being often mistaken for that produced by calculi. Riedel believes that two-fifths of the cases of jaundice occurring in connection with gallstone disease are really produced by accumulations of mucus and thickening of the mucosa, rather than by the stones themselves. Moreover, there is a form of membranous catarrh, both of the ducts and gall-bladder, where actual casts are shed, this condition corresponding to fibrinous bronchitis or enteritis. Thudichum believes that these casts often form nuclei for gallstones. The condition has been spoken of as desquamating angiocholitis, and casts of the duct or even of the gall-bladder have been found in the stools.
The surgical interest attaching to these conditions lies in the fact that the symptoms produced are often identical with those caused by gallstones, and the desired relief is to be sought in the same way—i. e., by operation. The operator should not feel chagrined if on opening the abdomen he finds the gall-bladder containing such material rather than calculi.