The principles and practice of modern surgery

by Roswell Park

Diagnosis.

—The diagnosis consists virtually in a recognition of the cause of the intense local peritonitis, after which a history of previous disease, if obtainable, may help. The condition is to be differentiated especially from perforated ulcer of the stomach or duodenum, from acute pancreatitis, and from acute mesenteric embolism or thrombus with gangrene of the intestine. It is also occasionally to be distinguished from an acute appendicitis, and this may be difficult, since the appendix is sometimes found high up and the pain widely referred or not accurately localized. In acute cholecystitis the pain is more likely to be subcostal, and the tenderness and muscle spasm are more marked in the upper part of the abdomen, to which the various local expressions of the disease are referred rather than to the lower. In any or all of these troubles symptoms of acute peritonitis are likely to be present and paralytic ileus or bowel obstruction may complicate the case.

Ransohoff has called attention to a hitherto unnoted sign of gangrene of the gall-bladder—namely, a localized jaundice about the umbilicus, apparently brought about by staining of the fat beneath the peritoneum, and noted after incision, if not previously. He considers it the result of imbibition, and that it appears at the navel first because here the abdominal wall is thinnest, it being also possible because of the anatomical relations of the round ligament of the liver to the transverse fissure, where there may be a retrograde flow of bile through the lymphatics and toward the navel.

Fortunately all of these acute conditions as between which doubt may arise are to be dealt with in only one way—namely, by prompt operative intervention—and minute diagnosis is of less importance than ability to appreciate necessity for immediate operation as it may arise.

Gangrene is the extreme degree of disaster in these cases, and its occurrence may be marked by sudden cessation of the pain, a most important symptom, which may be deceptive to the uninitiated. Gangrene may be due to thrombosis of the vessels of the gall-bladder, to bacterial invasion, to extreme tension because of obstruction of the duct, or to all three.

Acute cholangitis was first described by Charcot, who called it intermittent hepatic fever. It is usually due to the presence of one or more gallstones in the common duct, but any obstruction of the hepatic or common ducts may favor infection of retained bile and involvement of the duct. Thus it has followed chronic pancreatitis, cancer, hydatid disease, pancreatic calculus, typhoid fever, and the presence of the parasites. Mertens has collected forty-eight cases in which ascarides have been found in the bile-duct, their entrance having probably been facilitated by the previous escape of gallstones and enlargement of the duct end. Round or lumbricoid worms have also been found in the duct, as they are occasionally met with in the duodenum, and I once saw a long one in the appendix. Cancer in this neighborhood is also a not infrequent exciting cause in producing acute cholangitis.

Symptoms.—There is usually a history of spasmodic pain covering a considerable period, and then of such an attack followed by chill and fever, with more or less jaundice, which may persist for some time. Such attacks as these become more severe and more frequent; the gall-bladder enlarges if it contain no stone, or contracts if calculi be present. This association was especially noted by Courvoisier, who formulated a statement to this effect, often absurdly known as his “law.” Later the entire liver or its right lobe may enlarge, while patients complain of tenderness over the gall-bladder, as well as of loss of appetite and flesh, and those vague symptoms included in the term “dyspepsia.”

Such a condition may possibly subside in time, but is more likely to be followed by acute trouble of one of the types already described. In the matter of diagnosis it may be distinguished from malaria, especially in districts where malaria prevails by absence of relief from quinine, and the results of a carefully completed examination, combined with the fact that in the former it is usually the gall-bladder which is enlarged, and in the latter the spleen. When the condition has proceeded to its suppurative form the occurrence of still more significant symptoms and signs should lead to prompt operation.

Treatment.

—In the acute infections and affections, both of the gall-bladder and of the duct, operative intervention is imperative. The more acute the case the more urgent the indication. Free evacuation and drainage are the indications to be met, and as early and completely as possible. These cases call for cholecystostomy, often for choledochotomy, with drainage of both gall-bladder and duct, and perhaps of the peritoneal cavity, while possibly even posterior drainage may be indicated. So true is this that the back should be as carefully prepared for operation as the abdomen, in order that no time be lost during the operation, should one decide on the wisdom of a posterior counteropening. Of course much will depend upon the patient’s condition at the moment and what it may appear he can endure. By free opening of the gall-bladder evacuation of its septic contents and removal of calculi are secured, if present, while the ducts are permitted to empty themselves and free flow outward of all septic material is invited and permitted, pressure is relieved, the tumor is disposed of, respiration allowed to become normal, and no small load removed from the kidneys; and the chronic pancreatitis which so often accompanies many of these cases is allowed to subside by virtue of the other relief thus afforded.