yet furnishes just as complete drainage. I append the histories of two cases
of common duct stone illustrating the fact that in aseptic cases no special
drainage is necessary.
Case I. — E. M., female, aged twenty-two years, was admitted to the Xew York
Hospital. Two months ago this patient began to have attacks of cramplike pain
in the right hypochondrium, radiating to the shoulder and back, accompanied by
chilly sensations, fever, and vomiting, but no jaundice. These attacks have been
repeated every few days since. They have lasted from twenty-four to forty-eight
hours and have confined the patient to bed. Four days before admission to the
hospital an attack set in, and the patient noticed, twenty-four hours later, that she
was jaundiced and that her urine was very high-colored. Stools not noted. Bowels
regular. The pain had shifted to the epigastrium in the median line. On admis-
sion, the patient was well nourished and in good general condition. She was mark-
edly jaundiced. The abdomen was flat. There was tenderness on deep pressure in
the right hypochondrium and in the epigastrium. The liver did not appear to be
enlarged. The gall-bladder could not be distinctly felt. The urine contained much
bile. The stools were clay-colored. Temperature, 100° F. ; pulse, 106 ; leucocytes,
10,000.
The following morning the patient was put under gas and ether. A vertical
incision was made along the outer border of the right rectus muscle three and a
half inches long, beginning above at the free border of the ribs. The gall-bladder
was found distended. Palpation of the common duct between a finger introduced
into the foramen of Winslow and the thumb detected a small hard mass low clown
in the common duct.
With some difficulty this portion of the duct was brought into view, and a small
incision over the hard body permitted the extraction of a spherical calculus about
the size of a pea. The removal of the calculus permitted the escape of a consid-
erable quantity of bile-stained mucus. The gall-bladder then collapsed.
The cut in the common duct was sutured imperfectly with fine catgut. The
exposed viscera was cleansed with salt solution and dried. Closure of the wound
in the abdominal wall. Drainage with a rubber tube and a strand of gauze down
to the hole in the common duct.
There was no rise of temperature following the operation, nor any disturbance
of wound healing. A large movement of the bowels, containing abundant bile, on
the second day. Drainage removed on the third day. Stitches removed on the
eighth day. The jaundice had notably diminished after three days, and had entirely
disappeared after ten days. The patient was allowed to sit up on the twentieth
day. Urine and stools normal.
TUMORS OF THE GALL BLADDER 17!i
Case II. — II. II., forty-sij years of age, was admitted to the New York II<> -
pital. During the pas! eighl years she had Buffered from numerous severe ati
of pain in the region <>f the gall-bladder. The attacks lasted for several days ;m<l
were often followed by jaundice. During the past four years the attacks have
recurred every two months or bo. During the past three months the patient has
had severe attacks of biliary colic, and the jaundice has I »«-«-* i constant, with remis-
sions. The last attack began four days before admission to the hospital. The pain
lasted two Hays and a half, accompanied by a chill, followed by fever and sweating.
At the present time the patient is well nourished; she is deeply jaundiced.
The abdomen is soft. The liver extends an inch below the free border of the ribs
in the aipple line. There is tenderness in the region of the gall-bladder upon deep
pressure. The urine and the stools are characteristic of biliary obstruction. The
coagulation of the blood is notably delayed.
Under gas and ether anesthesia, a three-inch vertical cul was made at the outer
border of the right rectus, beginning above, an inch below the tree herder of the
ribs. The gall-bladder was found rather deeply placed beneath the liver. Moder-
ately distended. Palpation detected a stone of considerable size in the gall-bladder.
Palliation with the linger introduced into the foramen of Winslow detected t\v<>
large stones in the common duct. Gall-bladder opened, permitting the escape of
bile-stained mucus. A single stone, measuring three quarters of an inch in it-
greatest diameter, was extracted by means of a scoop. Efforts to move the stones
in the common duct upward into the gall-bladder were not successful. An incision
of the common duct behind the duodenum, permitting extraction of two >t.uie> of
aboul the same size as the first. Suture of the common duct and the gall-bladder
with line silk. Cavity cleansed with salt solution. Closure of the wound, except
for a small rubber drainage-tube and a strand of gauze which were introduced down
to the wound of the common duct. Sterile dressing.
There was a slight escape of bile into the dressing for about forty-eight hours:
alter that time, none. The tube was removed on the third day. alter which a
small gauze wick was inserted a short distance for several days longer.
The movements from the bowels contained bile on the third day. The wound
healing was aseptic, producing a linear scar. The disturbance of pulse ami tem-
perature dining convalescence were unimportant. The patient left the hospital
on the twenty-fifth day, well.
TUMORS OF THE GALL-BLADDER AND OF THE BILIARY PASSAGES
A variety of benign tumors of the gall-bladder have been observed. They
are scarcely likely to admit of an accurate diagnosis before operation. Tf they
cause obstruction of the biliary passages they will produce symptoms more
or less resembling those due to gall-Stones.
Cancer of the Gall-bladder. — Cancer of the gall bladder is relatively a fre-
quent disease. By far the commonest cause i< chronic irritation produced by
gall-stones. Thus, "Musser collected one hundred cases of cancer of the gall-
bladder. Tn sixty-nine of these gall-stones were also found, and in many of
the remaining cases there was a history pointing to gall-stones.
180 INJURIES AND SUEGICAL DISEASES OF THE LIVER
The secondary cancers of the gall-bladder, due to extension from cancer of
the liver, etc., are without surgical interest. Primary cancers of the gall-
bladder, on the other hand, are interesting for two reasons: First, if operated
upon very early they are curable in a very small percentage of cases. Second,
if already involving surrounding structures, the diagnosis of cancer is a posi-
tive contraindication to operative interference.
Two principal forms of cancer of the gall-bladder are distinguished by
Morin : cancer arising from the epithelium of the gall-bladder ; cancer arising
from the glandular cells of the mucous membrane of the gall-bladder. The
first form rapidly infiltrates the liver substance and clinically cannot be dis-
tinguished from cancer of the liver. The second form remains for a longer
time confined to the wall of the gall-bladder, and may grow to a considerable
size before the liver itself is invaded. In the larger number of cases the
disease begins near the fundus; in other cases the vicinity of the neck is
the starting point. Pressure upon the common and hepatic duct in these cases
is accompanied by jaundice in the later stages of the disease.
Cancer of the gall-bladder rarely occurs before the fortieth year of life,
and becomes more frequent with advancing age. ' As is the case with gall-
stones, it is several times as frequent in women as in men, whereas malignant
disease developing primarily in the common duct occurs with equal frequency
in men and women.
One of the difficulties in the early diagnosis of cancer of the gall-bladder
is that it is so frequently accompanied by the presence of gall-stones, and hence,
that the symptoms during the early stage of the disease are mistaken for those
of cholelithiasis; nor are there any definite symptoms pointing to a new
growth until a palpable tumor is formed. Mayo points out, however, that
while there will usually have been a distinct history of gall-stones in these
cases, there will often be a distinct period of remission before the symptoms
due to the cancer develop. The only cases in which operation is likely to be
successful will be those, with few exceptions, in which the operation is done
for supposed cholecystitis from gall-stones; in other words, the diagnosis will
only be arrived at after opening the abdomen, sometimes only after micro-
scopical examination of sections of the gall-bladder, because a thickened and
infiltrated gall-bladder frequently resembles, or is accompanied by, carcinoma-
tous infiltration not distinguishable with the naked eye.
The early symptoms are rarely characteristic. There will usually have been
a history of gall-stone disease in the past. The patient will complain of loss
of appetite and of disturbances of digestion. Actual biliary colic is usually
absent. If the disease has existed for several months, the patients may appear
cachectic, and will have lost a good deal of flesh. There will usually be a
sense of dull pain or oppression in the region of the gall-bladder. After a
time a palpable tumor will be present. The tumor usually feels hard; its
surface may be nodular or smooth ; it is situated in the region of the gall-
bladder, and is evidently connected with the liver. In cases not complicated
TUMORS OF THE GALL BLADDEB isl
by infection or empyema of the gall-bladder the tumor will nol I"- especially
tender, oor will there be the sign of marked abdominal rigidity.
As the disease progresses jaundice ia slowly developed. The progr<
the jaundice is steady, nol intermittent. As the disease progresses and invades
the liver a considerable tumor mass will be formed. The patient will become
progressively more and more anemic, emaciated, and cachectic. In the later
stages of the disease there may be ascites or cancerous peritonitis. The dura-
tion of life is very short, rarely more than a year, and with an extreme limit
of life of two years.
The RIayos report forty operation- for malignanl diseases of the biliary
passages. Of these, nine died in the hospital. Two cases of cancer of the
gall-bladder remained well nl'ter more than two years. In two other cases the
outlook appeared hopeful. A few cases only of actual cure are reported by
other observers. I have had one successful case, which remains well now at
the end of six years.
Author's Case of Cancer. — John A., policeman, a temperate, healthy man.
aged forty-four, entered the New York Hospital, April 1, 1903. He had Buffered
from attacks of indigestion during the past year. Four months before I saw him
lie began to suffer from a dull pain in the region of the gall-bladder. The pain
was more or less continuous, with exacerbations. Subsequently he began to suffer
from attacks of vomiting. His digestion became impaired and he ran down in
health. He had lost thirty-five pounds in weight during the last few months, and
had slowly become jaundiced during the past few weeks. The jaundice has been
constant and slowly progressive, but is now of only moderate intensity. The upper
I 'oil ion of the abdomen is slightly distended and tympanitic. The liver dullness
extends one inch below the free border of the ribs. No tumor could be felt. Ab-
dominal rigidity was scarcely noticeable. He was notably anemic. Temperature
and pulse normal. There was slight leucocytosis, but the differential count showed
nol liing distinctive.
The absence of very acute attacks of pain, the more or less continued character
of the pain, the marked deterioration in general health and loss of weight, the
absence of tenderness and of fever, led me to suspect cancer of the gall-bladder.
April (!, 1D03, the gall-bladder was exposed through a four-inch incision. It
was rather deeply situated and considerably distended, but not adherent. Upon
palpation one could feel that the third of the gall-bladder away from its fundus
was occupied by a tumor of considerable size.
The complete removal of the gall-bladder was attended with some difficulty on
accounl of hemorrhage from the liver, in which the gall-bladder was rather deeply
embedded. The bleeding was very free, and had to he controlled by temporary
packing. After removal of the entire gall-bladder, together with the malignant
growth, down to a point opposite the hepatic artery, the wound in the liver was
packed and a small drainage-tube inserted.
After removal, the gall-bladder was opened. There was considerable thicken-
ing of its walls, and that half >^\' the organ away from the fundus was occupied by
the malignant growth: the fundus did not seem to be involved. The gall-bladder
contained a few minute stones. The diagnosis of carcinoma could be made with
182 INJURIES AND SURGICAL DISEASES OE THE LIVER
comparative certainty from the gross appearance of the tumor. The patient made
an uneventful convalescence. On May 27, 1903, he had gained over twenty-five
pounds since the operation, and there were no evidences of any secondary growths.
In April, 1909, this man was still in perfect health, and remained, as he had been,
on active duty on the police force.
Tumors of the Gall-ducts. — Both benign and malignant growths are observed
in the common bile duct and in the hepatic duct. As a diagnostic entity car-
cinoma alone will be here considered. The disease occurs at least as often
in men as in women, thus differing from cancer of the gall-bladder. The
causative relation between gall-stones and cancer of the ducts is thus not
entirely clear, although Mayo Robson believes that such a relation does exist
in most cases. Primary cancer of the common duct is a rare disease. Among
eighteen cases collected by Musser, fourteen were in the common duct and three
were in the hepatic duct. The favorite site is at or near the papilla — nine cases.
The other sites are at the junction of the cystic and hepatic ducts and at the
bifurcation of the hepatic duct. The type of the disease is usually of the
columnar-celled variety. Kehr states that scirrhus is the ordinary form, and
that the softer forms of carcinoma are extremely rare. Disseminated infection
appears to be long delayed. The lymph nodes in the gastrohepatic omentum
are the first glands to be involved, but this infection may not occur until late
in the disease. In some cases, long after the condition has ceased to be oper-
able, the lymph nodes at the root of the neck behind the clavicle, usually upon
the left side, may be found enlarged and hard (jugular gland). The diagnosis
of cancer of the bile ducts can rarely be made before operation.
The symptoms closely resemble those of cancer of the head of the pancreas.
The gall-bladder is usually distended and enlarged. There is jaundice, which
may at first be intermittent, but soon becomes progressive and intense. There
are the ordinary digestive disturbances, clay-colored stools, and bile-stained
urine of cholemia. There is progressive emaciation, anemia, and debility.
A tumor other than the distended gall-bladder is not likely to be felt. There
is nothing characteristic about the pain except that it is not apt to be severe,
at least not so severe as the pain of gall-stone impacted in the papilla. Septic
symptoms may appear from infective cholangitis. The liver in many cases
wall be somewhat enlarged. The spleen may also be enlarged. The local signs
in the vicinity of the gall-bladder are usually rather negative — that is to say,
there is not much localized pain and tenderness. Cancer of the papilla has
been operated upon with temporary benefit by Halsted, Mayo, and a very
few others.
CHAPTEE VI
INJURIES AND DISEASES OF THE SPLEEN
THE SPLEEN: TOPOGRAPHICAL AND ANATOMICAL REMARKS ADAPTED
FROM MERKEL
The spleen under normal conditions is a soft and elastic, rather fragile,
organ, whose shape is largely molded by contact with the surrounding viscera.
The form of the spleen is that of a tetrahedron whose base is directed toward
the diaphragm and whose apex is turned toward the interior of the belly. The
diaphragmatic surface is molded to the shape of the diaphragm, and since the
anterior surface exhibits a concavity, the general contour of the spleen is con-
cavo-convex. Beginning at the apex of the tetrahedron, three other surfaces
may be distinguished — a gastric, renal,
and basal surface. The diaphragmatic
surface, the largest, lies beneath the
ninth, tenth, and eleventh ribs. The
longest diameter corresponds very near-
ly with the direction of the tenth rib.
Behind the diaphragm, and between it
and the chest wall, the pleural cavity ex-
tends below every portion of the spleen.
The lung readies posteriorly to the level
of the eleventh dorsal vertebra, SO that
the spleen is also partly covered by
lung. .1 stab wound reaching the spleen
through the thoracic wall thus Inevitably
wounds the pleura, sometimes also the
lung. The gastric surface is in contact
with and molded upon the posterior
surface of the fundus of the stomach;
this contacl obtains only when the stomach is full, not when it is empty.
The renal surface is in contact with the outer border of the upper pole of the
left kidney. The extent of surface in contact with the kidney varies with the
position of that organ. The basal surface, the smallest of all, is in contact
with the tail of the pancreas and the splenic flexure of the colon. The spleen
extends toward the middle line nearly to the border of the eleventh dorsal ver-
183
Fig. 27. — Position "i rai Spleen in Rela-
tion TO i in Hi us. Viewed from the left
side. (Merkel.)
184 INJURIES AND DISEASES OF THE SPLEEN
tebra. It may actually touch it, or the separation may be an inch. Laterally
the lower part of the spleen usually extends as far forward as the midaxillary
line, but not normally beyond a line drawn from the left sternoclavicular joint
to the tip of the eleventh rib (the left costoclavicular line). The spleen moves
with the diaphragm with respiration, but less so than the liver. The condi-
tion of fullness or emptiness of the stomach and colon respectively has some
effect upon the position of the spleen. If an individual lies upon the right
side of the body, the upper and anterior border of the spleen moves downward
and forward a distance of 3 to 4 cm. farther than when the subject stands
erect or lies on his back. The spleen cannot be palpated when normal, nor can
its limits be made out accurately by percussion except its lower and outer end.
As stated, it is partly covered by the lung. The proximity of the kidney, the
thick muscles of the back, the condition of fullness or emptiness of the colon
and stomach, whether filled with gas or solid or liquid material, are all con-
ditions which render percussion of the outlines of the spleen difficult. The
area of splenic dullness may be abolished in emphysema or covered by pleuritic
effusions. Tumors of the spleen may displace the diaphragm upward, causing
dyspnea. This is more apt to occur in children than in adults, because in the
former the phrenocolic ligament affords firmer support to the organ, holding
it more firmly against the diaphragm. The size of the spleen in the adult
is on the average about five inches in length, three in breadth, and one and
a quarter in thickness. The weight of the spleen in the cadaver is from 150
to 200 gms., and a sixth more when filled with blood. Its size varies under
different conditions more than any other organ in the body. It is larger in
proportion in children, increases in size after eating, and becomes regularly
enlarged in a great variety of diseases, notably in febrile conditions, malaria,
typhoid, and in many other infectious diseases. The spleen may become so
large that it reaches to the pelvis, fills the abdomen, and has "been mistaken
for pregnancy. Some of the diagnostic characters of a splenic tumor have
already been dwelt upon under Diagnosis of Diseases of the Abdomen ; others
will be mentioned under suitable headings. The spleen is held in place by
folds of peritoneum containing firm bands of fibrous tissue. Such a fold passes
from the left cms of the diaphragm to the spleen. The suspensory ligament,
phrenosplenic ligament and the phrenocolic ligament, sustentaculum lienis;
the latter, passing from the diaphragm to the splenic flexure of the colon, sup-
ports the colon, and since the spleen rests upon the colon, supports it also, form-
ing a kind of pocket for its reception. The gastrosplenic omentum, necessarily
a loose connection, on account of the movements of the stomach, has but little
influence in the fixation of the spleen. The ligaments of the spleen may
become relaxed, permitting the spleen to fall down and hang free in the ab-
domen, supported by its vessels. (See Movable Spleen.) The spleen is
surrounded by a firm connective-tissue capsule, which sends connective-tissue
septa into the interior of the organ, affording support to the soft and friable
parenchyma.
[NJURIES OF THE BPLE]
Blood Supply. — The Bpleen receives for its size a very large Biipply of blood.
The splenic artery run- ;i tortuous course, from righl t.. left, and dh ■i« I«-~, before
reaching the organ, into from six i<> twelve branches. These vesa r the
liiliiin of the spleen, bul do nol anastomose in its substance. This explains the
occurrence of wedge-shaped infarcts in the spleen a< the result of th<- lodgment
of emboli in its substance. The splenic vein runs parallel with the artery, i-
double its size, less tortuous, lies below it. and empties into the portal vein.
The multiplicity of the arteries entering the spleen makes it necessary for the
Burgeon to use great caution when tying off the pedicle in the operation of
splenectomy to Becure all the bleeding points. The Bpleen may be reached by
;i vertical incision in the outer border of the left rectus muscle, or by an i n<i
sion parallel with the ribs, similar to thai used for removing the kidney. It
may also be reached by resecting the tenth rib, <>r the ninth, tenth, ;m<l eleventh
ribs, it' more space is needed, behind the axillary line and passing through the
pleural cavity. In some cases this may l>e a favorable avenue to the spleen
in eases of abscess, and especially if the infection has caused adhesions between
the diaphragmatic and costal pleura. In tumors of the spleen it i- to he borne
in mind thai the splenic vessels are enormously enlarged, that their walls are
thin, and that they are often under considerable ten-ion; great gentleness and
care must, therefore, be used in ligating them.
INJURIES OF THE SPLEEN
Injuries of the spleen may he subcutaneous or open wounds. The former
may he divided into ruptures and contusions; the latter into stab and gunshot
wounds. The subcutaneous injuries are much the more frequent, and injuries
of the spleen are five times as frequent among men as among women. P>< _
collected 467 cases; among these, 308 were subcutaneous injuries by blunt
violence; of these, 264 wire ruptures, 44 were contusions, 159 were open
wounds; of these, )51 were stab and incised wounds, 98 were gunshot wounds,
and ."»! were eases of prolapse of the uninjured spleen through an external
wound. It goes without saying that an enlarged and thickened spleen is much
more apt to be ruptured by moderate degrees of blunt violence than is the
normal spleen. Thus, in malaria, miliary tuberculosis, typhoid fever, as well
as in some other diseases in which the spleen is enlarged and softened, rupture
may occur from very slight degrees of violence, even from muscular effort; as,
for example, during a violent attack of vomiting. As compared with subcu-
taneous injuries, stab and gunshol wound- of the spleen are, relatively, very
rare indeed. Nearly all the subcutaneous ruptures of the spleen which I have
seen in the hospitals in New York — numbering twelve or more — have been
produced by "run-over" accidents or by falls from a height In two or
three cases only, from a blow in which the body was struck by a hlunt ob-
ject over the region of the spleen. The illustration represents the spleen
of a man who was stabbed in the side and who hied to death from a com-
186
INJURIES AND DISEASES OF THE SPLEEN
paratively small wound in the spleen; he was a patient in the Hudson Street
Hospital.
The crushing injuries of the spleen which I have seen have been of several
varieties. In one, a little boy upon whom I operated some years ago in the
Roosevelt Hospital, there was a vertical
tear an inch in depth through the hilum