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Guide to Networking Essentials, Sixth Edition 1-2

Lecture Notes

Overview
Chapter 1 offers an introduction to basic computer components and operation. Students
learn about the fundamental reasons for networking, as well as how to identify essential
network components. They also learn to compare different types of networks. Students
learn about servers, their role, and the types of servers that are available. Finally, at the
end of the chapter, students are able to describe specialized networks that have recently
gained popularity in the world of networking.

Objectives
 Describe basic computer components and operation
 Explain the fundamentals of network communication
 Define common networking terms
 Compare different network models
 Identify the functions of various network server types
 Describe specialized networks

Teaching Tips
An Overview of Computer Concepts
1. Provide a brief introduction to networking and why it is so important to have a basic
understanding of computer concepts and terminology.

Basic Functions of a Computer

1. Introduce students to the three basic tasks that all computers perform.
a. Input
b. Output
c. Processing
2. Give students an idea of where each of the three basic tasks is utilized. For example, a
keyboard would be used for input, a screen would be used for output.

Teaching Students can view a basic breakdown of a computer’s parts and functions at
Tip http://www.howstuffworks.com/pc.htm.
Guide to Networking Essentials, Sixth Edition 1-3

Storage Components

1. Explain the differences between short-term storage and long-term storage.

Personal Computer Hardware

1. Introduce students to the four major PC components.

Computer Boot Procedure

1. Describe the six steps in the typical computer boot procedure.

How the Operating System and Hardware Work Together

1. Explain the critical services provided by a computer’s OS.

The Fundamentals of Network Communication

1. Describe the most basic network as two or more computers connected by some kind of
transmission media.

Network Components

1. Discuss the three components needed in order to “network” a stand-alone computer.

Teaching Read an in-depth look at different network media types at

Tip http://www.ciscopress.com/articles/article.asp?p=31276.

Steps of Network Communication

1. Basic steps of a user accessing a network resource

Layers of the Network Communication Process

1. Explain how the steps of network communication are referred to as layers, and the two
models used to describe this process: OSI and TCP/IP.
Guide to Networking Essentials, Sixth Edition 1-4

Teaching Have students review Simulation 1: Layers of the Communication Process on the
Tip book’s CD.

Teaching Microsoft has an article on the OSI model that helps explain the workings of a
Tip layered network: http://support.microsoft.com/kb/103884.

How Two Computers Communicate on a LAN: Some Details

1. Introduce students to idea of a computer’s logical and physical address.

2. Use a street address and ZIP code to help explain the difference between a computer’s
two addresses.

Teaching Have students review Simulation 2: Communication Between Two Computers

Tip on the book’s CD.

Quick Quiz 1
1. Name the three basic tasks all computers perform:
Answer: Input, Processing, Output.

2. True or False: Random access memory (RAM) is considered long-term storage.

Answer: False – RAM is considered short-term storage because when power to the
computer is turned off, RAM’s contents are gone.

3. A computer’s _______________________ provides a number of critical services,

including a user interface, memory management, a file system, multitasking, and the
interface to hardware devices.
Answer: operating system (OS)

4. What is the name given to software that provides the interface between the OS and
computer hardware?
Answer: device driver

5. What is the physical address assigned to NICs called?

a. Media Address Control
b. Physical Address Control
c. Media Access Control
d. Media Control Access
Guide to Networking Essentials, Sixth Edition 1-5

Answer: Media Access Control

Network Terms Explained

1. Explain the importance of learning the “language” of computer networking.

LANs, Internetworks, WANs, and MANs

1. Use Figure 1-13 to show the components of a basic network consisting of computers
interconnected by a hub.

For a list of networks and their scopes, see

Teaching
http://en.wikipedia.org/wiki/Computer_network#Types_of_networks_based_on_
Tip
physical_scope.

Packets and Frames

1. Briefly discuss how data is segmented into packets and then encapsulated into frames
for transmission
a. IP addressing information exists in packets
b. MAC addressing added in frames

Clients and Servers

1. Explain the different uses of the term client in relation to software / software suites /
OS
2. “Server” can also be ambiguous, cover different definitions in relation to service-based
software, server operating systems, and server computers.

Network Models
1. Discuss the two major types of network models: peer-to-peer and server-based.

Peer-to-Peer/Workgroup Model

1. Peer-to-peer networking model as it relates to client PCs

a. Cover the benefits (cost) of a peer-to-peer network model versus the
disadvantages (scalability).
b. Members are all simultaneously servers and clients for whichever resources they
may host.

Server/Domain-Based Model
Guide to Networking Essentials, Sixth Edition 1-6

1. Explain what it means to be a part of a domain-based network architecture and how it

affects user accounts and resource access
a. Advantages in relation to peer-to-peer (centralization, scalability).
b. Services that are related and most likely part of a domain architecture should
also be mentioned, such as naming services, or e-mail services.

Microsoft Active Directory hasn't always been the only directory services
Teaching
product. Take a look at Novell's older solution, eDirectory:
Tip
http://www.novell.com/products/edirectory/fsd/comparison.html.

Quick Quiz 2
1. An _________________ is a networked collection of LANs tied together by devices
such as routers.
Answer: internetwork

2. What is the more well-known term for chunks of data sent across the network?
Answer: Packet ( Frame is another term that is often used)

3. What is the difference between a client and a server, in networking terms?

Answer: A client can be a workstation that requests network resources from a server. A
server provides a network service to client computers.

4. Networks fall into two major types: peer-to-peer and client/server (also called
____________________).
Answer: server-based

5. On a Windows-based peer-to-peer network, all computers are members of a:

a. Domain
b. Workgroup
c. Server network
d. WAN
Answer: Workgroup

Teaching You can find a comparison of various operating systems at

Tip http://en.wikipedia.org/wiki/Comparison_of_operating_system.

Network Servers
1. Discuss common services found on network servers in various sized networks.
Guide to Networking Essentials, Sixth Edition 1-7

Domain Controller/Directory Servers

1. Explain the use of directory services to centralize account management and unified
resource access.

Give students the chance to take an in-depth look at Windows Server 2008
Teaching
Active Directory Domain Services at http://technet.microsoft.com/en-
Tip
us/library/cc770946%28WS.10%29.aspx.

File and Print Servers

1. File and print servers provide a single point of access for storage and printers, as well as
additional features such as fault tolerance and load balancing.

Application Servers

1. Explain that an application server takes most of the responsibility for processing and
data storage, while a client (such as a Web browser) does considerably less work.
a. Common examples of application servers are web-based platforms.

Communication Servers

1. Emphasize the use of communication servers and their ability to service remote users
with network resources that would not be available otherwise.

E-Mail/Fax Servers

1. E-mail servers handle and deliver e-mail using a variety of different protocols, while fax
servers consolidate incoming and outgoing faxes.
a. SMTP is used to send e-mail
b. POP3 is used to deliver e-mail

Web Servers

1. Web servers host Web pages for access by Web browsers such as Internet Explorer or
Firefox.
a. Web servers often provide additional services such as FTP for remote file
access.

Additional Network Services

1. Discuss the importance of DNS and DHCP to the functionality of domain services as
well as their importance outside of domain environments.

Server Hardware Requirements

Guide to Networking Essentials, Sixth Edition 1-8

1. Emphasize that hardware requirements between client operating systems and server
operating systems differ due to the tasks they’re expected to complete.
a. Servers require increasingly more resources depending on load and services
provided.
b. Client operating system hardware requirements have increased, while server
operating systems have remained relatively the same.

Specialized Networks

1. Discuss various non-computer-centric networks.

Storage Area Networks

1. A SAN provides access to large amounts of networked storage.

a. SANs typically use Fibre Channel or iSCSI.

Wireless Personal Area Networks

1. WPANs help to connect mobile devices to other devices but typically have short range.
a. IEEE 802.15 is the standard for WPANs.

Quick Quiz 3

1. What is the role of an application server?

Answer: Application servers supply the server side of client/server applications, and often
the data that goes along with them, to network clients.

2. What is the role of a communication server?

Answer: Communication servers provide a mechanism for users to access a network’s
resources remotely.

3. What is the name of the network service that provides name resolution services that
allow users to access both local and Internet servers by name rather than address?
Answer: DNS – Domain Name System

4. A ____________________ is a short-range networking technology designed to connect

personal devices to exchange information.
Answer: wireless personal area network (WPAN)

Class Discussion Topics

1. Have any of the students installed/configured a LAN before? If so, ask them to briefly
discuss their experiences.
Guide to Networking Essentials, Sixth Edition 1-9

2. Do students have previous experience configuring servers? If so, ask them to briefly
discuss their experiences.

Additional Projects
1. Students can research a list of operating systems (client or server) and detail their
hardware requirements. Have them look at Microsoft and non-Microsoft solutions, and
compare benefits of either solution in relation to hardware requirements.
2. Give students the chance to look at network comparisons of small, home peer-to-peer
networks versus a larger domain-based server network. Ask them to identify what
services they have in common (DHCP, DNS)

Additional Resources
1. Computer Networking:
http://en.wikipedia.org/wiki/Computer_network

2. Linux Networking-Concepts HOWTO:

www.netfilter.org/documentation/HOWTO/networking-concepts-HOWTO.html

3. Networking Glossary:
www.nextecsystems.com/networking-glossary.html

4. Client-server:
http://en.wikipedia.org/wiki/Client-server

5. How Home Networking Works:

http://computer.howstuffworks.com/home-network.htm

Key Terms

 application server A computer that supplies the server side of client/server

applications, and often the data that goes along with them, to network clients.
 bus A collection of wires that carry data from one place to another on a computer’s
motherboard.
 client Can be used to describe: an operating system designed mainly to access network
resources; a computer’s primary role in a network which is that of running user
applications and accessing network resources; software that requests network resources
from servers.
 communication server A computer that provides a mechanism for users to access a
network’s resources remotely.
 core a core is an instance of a processor inside a single CPU chip. See multicore CPU.
Guide to Networking Essentials, Sixth Edition 1-10

 credentials The username and password or other form of identity used to access a
computer.
 device driver Software that provides the interface between the OS and computer
hardware.
 directory service The software that manages centralized access and security in a server-
based network.
 domain controller A computer running a Windows server OS on which the directory
service role called Active Directory is installed. A domain controller maintains a
database of user and computer accounts as well as network access policies in a
Windows domain. See directory service.
 domain A collection of users and computers in a server-based network whose accounts
are managed by Windows servers called domain controllers. See domain controller.
 encapsulation The process of adding header and trailer information to chunks of data.
 file and print server A computer that provide secure centralized file storage and
sharing and access to networked printers.
 frame A packet with the source and destination MAC addresses added to it. In addition,
an error-checking code is added to the back end of the packet. Frames are generated by
and processed by the network interface. See also packet.
 header Information added to the front end of a chunk of data so that the data can be
properly interpreted and processed by network protocols.
 internetwork A networked collection of LANs tied together by devices such as routers.
See also local area network (LAN).
 local area network (LAN) A small network limited to a single collection of machines
and connected by one or more interconnecting devices in a small geographic area.
 mail servers A computer that handles sending and receiving e-mail messages for
network users.
 metropolitan area network (MAN) An internetwork that is confined to a geographic
region such as a city or county. Uses third-party communication providers to provide
connectivity among locations. See also internetwork.
 multicore CPU A CPU that contains two or more processing cores. See core.
 multitasking An operating system’s capability to run more than one application or
process at the same time.
 name server A computer that stores the names and addresses of computers on a
network allowing other computers to use computer names rather than addresses to
communicate with one another.
 network client software The application or operating system service that can request
information stored on another computer.
 Network Information Service (NIS) A Linux-supported directory service that supports
centralized logon.
 network model Defines how and where resources are shared and how access to these
resources is regulated.
Guide to Networking Essentials, Sixth Edition 1-11

 network protocols The software on a computer that defines the rules and formats a
computer must use when sending information across the network.
 network server software The software that allows a computer to share its resources by
fielding requests generated by network clients.
 packet A chunk of data with source and destination IP addresses (as well as other IP
protocol information) added to it. Packets are generated by and processed by the
network protocol.
 peer-to-peer network The network model in which all computers can function as
clients or servers as necessary and in which there is no centralized control over network
resources.
 server Can be used to describe: an operating system designed mainly to share network
resources; when a computer’s primary role is to give client computers access to network
resources; the software that responds to requests for network resources from client
computers.
 server-based network The network model in which server computers take on
specialized roles to provide client computers with network services and to provide
centralized control over network resources.
 stand-alone computer A computer that does not have the necessary hardware or
software to communicate on a network.
 storage area network (SAN) A specialized network that uses high-speed networking
technologies to provide servers with fast access to large amounts of disk storage.
 trailer Information added to the back end of a chunk of data so that the data can be
properly interpreted and processed by network protocols.
 Web server A computer running software that allows users to access HTML and other
document types using a Web browser.
 wide area networks (WANs) An internetwork that is geographically dispersed and uses
third-party communication providers to provide connectivity among locations. See also
internetwork.
 wireless personal area network (WPAN) A short-range networking technology
designed to connect personal devices to exchange information.

Technical Notes for Hands-On Projects

All projects in this book that use the Sharing and Security option for folders assume that the
Use simple file sharing option has been disabled.

Hands-On Project 1-1: This project requires the NET HELP and NET VIEW utilities.

Hands-On Project 1-2: This project requires Windows Explorer and the NET VIEW utility.

Hands-On Project 1-3: This project requires Internet access and a Web browser.
Guide to Networking Essentials, Sixth Edition 1-12

Hands-On Project 1-4: This project requires Internet access and a Web browser.

Hands-On Project 1-5: This project assumes students are using Windows XP Professional as
the operating system, but the tasks can be accomplished in other operating systems.
Students also use a word processor or a simple text editor.

Using Virtualization for Hands-On Projects

The following Hands-On Projects/Challenge Labs have been identified as those that students
can do using virtual machines rather than physical machines.

Hands-On Project 1-1

Hands-On Project 1-2
Hands-On Project 1-3
Hands-On Project 1-4
Hands-On Project 1-5
Discovering Diverse Content Through
Random Scribd Documents
which it has been so long absent. Radical cure will in these cases
leave intra-abdominal viscera in a rather overcrowded condition.
The essential details of radical treatment of umbilical hernia are
the same, modified by the extent of sac which has to be removed,
and by the wisdom in many instances of a large elliptical excision of
the overlying skin and removal of much superfluous tissue. After
freeing the contents and reducing them, the sac wall being
completely separated, there is the choice of two or three methods of
closing the umbilical opening, either by overlapping of flaps, which
may be cut from the thickest portion of the sac, which will be close
to the outlet, or by dissecting them from the aponeurosis, as
suggested by Mayo, and turning the upper down over the lower, or
by any other expedient which individual peculiarities may suggest
(Figs. 621 to 624). I have been able to employ, to apparent
advantage, my method of securing suture material for this deep
closure from the sac wall itself, this not preventing the employment
of any other method or improvement.
 Fig. 623 Fig. 624

Method by transverse closure of both deep and external incisions.

Ventral and postoperative hernias are operated on in essentially

the same manner as the forms above described. Adhesions may be
found in these cases, and plastic methods should be devised for
bringing together irregularly shaped openings and holding them in
the firmest possible manner. In any extensive abdominal hernia,
umbilical or ventral, it is advisable to use buried sutures, closing the
abdominal walls, layer by layer, and finally to insert at some distance
a sufficient number of through-and-through retention sutures,
guarded by plates or small rolls of gauze, these taking off tension
from the wound and affording protection against any special strain,
such as vomiting.
 CHAPTER LII.
THE LIVER.

CONGENITAL DISPLACEMENTS OF THE LIVER.

The congenital defects and displacements of the liver which
interest the surgeon are few. More or less transposition, sometimes
complete situs transversus, is encountered. The same is true of
more or less hernial protrusion into the chest, through a defect in
the diaphragm, or such displacement as may be permitted by some
defect of the abdominal walls or other viscera. Hammond has
recently shown that the left lobe of the liver is sometimes
congenitally enlarged to an extent sufficient to cause symptoms, a
condition alluded to by very few writers. In this way the liver may
cover the stomach and even extend over the spleen. Similarly the
right lobe may be affected, but giving a different train of symptoms.
Under these conditions mistakes may arise. Thus the left lobe might
be mistaken for a large spleen, from which, nevertheless, it should
be separated and differentiated by its free movement during
respiration. Hammond even reports one case of this kind where,
instead of removing the elongated portion of the liver, it was held up
against the abdominal wall by sutures. For a similar condition
Langenbuch has successfully resected a portion of this viscus. What
is said here pertains to a true congenital variety, and not to acquired
displacements or enlargements. In Fig. 625 is represented the case
of xiphopagous twins united by a band of liver tissue and operated
(by division of the band) by Baudouin.

WANDERING OR FLOATING LIVER.

The relations between congenital laxity of the natural supports of
the liver and certain morbid conditions, especially those produced by
marked enlargement followed by great reduction in size, to the so-
called wandering or Fig. 625
floating liver are very
indefinite. The term
“wandering” implies a
mobility far beyond
the normal, with
more or less yielding
of ligaments,
especially the
suspensory, which
permits undue
displacement. We
often fail to realize
that the liver, which is
the heaviest of the
viscera, is
nevertheless, in man,
placed at their top,
and hence that it has,
in at least some
respects, very meagre
support. This is one
of the disadvantages
of the upright
position, and it does Xiphopagous twins, separated by division of a band of
not prevail in animals. common liver tissue. Case of M. Baudouin.
(Pantaloni.)
In addition to this
may be mentioned the peculiar enlargement of the right lobe, very
rarely of the left, so often seen in connection with biliary obstruction,
and often spoken of as Riedel’s lobe. Floating liver is more common
in women than in men by four to one, and is often ascribable to the
ill effects of tight lacing. Repeated pregnancies, with the consequent
relaxed and pendulous abdominal walls which often follow them,
also conduce to the condition by weakening, in fact almost
removing, its lower supports.
Symptoms.
—The symptoms produced are those of indigestion, dyspnea,
perhaps with cyanosis, nausea, vomiting, and occasionally biliary
obstruction and jaundice. In addition to these the patient will show
the ordinary physical signs of a displaced or displaceable liver,
noticeable in the upright or in the knee-elbow position.
Treatment.—The treatment of milder cases will consist of
support from below by suitably adapted and well-fitting abdominal
binders or supports. Serious cases may necessitate surgical relief.
This consists of hepatopexy, i. e., fixation of the liver to some of its
upper surroundings. The operation is performed through an incision
such as that used for exposure of the gall-bladder. The lower surface
of the diaphragm and the upper surface of the liver are scarified
until they ooze perceptibly. The anterior edge of the liver is then
fastened to the abdominal walls, as also the gall-bladder, if it can be
utilized for the purpose. The patient is then placed in bed with as
much compression of the abdomen below the liver as can be
tolerated, in order that the scarified surfaces may be kept in contact
until adhesions result.

INJURIES OF THE LIVER.

By its size and construction the liver is made peculiarly liable to
certain injuries, while from others it is made more or less exempt by
its protected situation, especially by the ribs, which nearly enclose it.
From contusions it may undergo different degrees of laceration,
sometimes even to the degree of fragmentation and pulpifaction.
Again it is frequently involved in punctured wounds (stab, gunshot,
etc.), which may be inflicted from any possible direction, perforation
sometimes taking place from above and through the chest, and
involving the tissues beneath.
General indications of injury to the liver will be furnished by its
nature and location, the degree of collapse, and the consequent
abdominal rigidity, with the common signs of internal or intra-
abdominal hemorrhage. There is no doubt but that minor injuries of
the liver are nearly always repaired, and that they occur much
oftener than is generally appreciated; but a severe tear of the liver is
a source of great danger because of hemorrhage. In general, of
these injuries it may be said that any traumatism which produces
profound or increasing symptoms should be regarded as indicating a
careful exploration, done with every precaution at hand for carrying
out any possible indication. What the liver may safely bear in the
way of ligatures, sutures, and operative disturbance will be indicated
later. Many fatal cases show a period of a few hours of temporary
amelioration of symptoms which may have lulled to a sense of false
security, and during which internal mischief is still increasing.
Moreover, any blow sufficiently severe to rupture the liver may do
other harm. In such instances, then, it becomes a simple question of
whether there can still be sufficiently early intervention to save life.
To what extent this intervention may be required in stab and
gunshot wounds it is difficult to state. If hemorrhage and puncture
of any hollow viscus can be excluded and if no other serious
symptoms be present, it may be advisable to wait; otherwise the
possible harm of a judicious early exploration is so small, while the
prospective benefits are so great, that it is far the wiser course.
Here, again, the general rule may be applied. When in doubt
operate. Further details of operative procedures will be given below.

ABSCESS OF THE LIVER; HEPATIC ABSCESS.

While abscess of the liver is, like all other abscesses, due to germ
activity, it may yet definitely follow injury or be the result of a
primary disease, or an extension from some one of the adjacent
tissues or organs; as from above (empyema, pyopericardium,
subdiaphragmatic, spinal), from below (gall-bladder and ducts,
pancreas, stomach), from the portal circulation (superficial or
ulcerating piles, typhoid and other intestinal ulcers, peculiar or
tropical parasites like amebas), from the appendix, from the general
circulation (pyemic, metastatic), through the lymphatics (mesenteric
nodes), from the intestinal tube (ordinary round-worms and various
parasites), from cancer breaking down, as well as from degenerating
gumma or granuloma and from hydatid cyst.
 Hepatic abscess may be acute or chronic, small or large, solitary
or multiple. The tendency is to enlarge and finally to kill. This they
do usually by rupture, e. g., either into the pleural cavity or the
lungs, after adhesions have been contracted, the pericardium, the
mediastinum, the peritoneum, any part of the upper alimentary
canal, or the biliary passages. Finally they may open externally and
perhaps be followed by spontaneous recovery.
A certain convenience of description is afforded by dividing these
cases into the so-called solitary abscesses and the multiple forms,
the latter being more commonly associated with tropical diseases of
the amebic type or with pyemic processes. In most solitary cases the
abscess is located in the right lobe, its extent varying within wide
limits, especially when the subphrenic space has been involved. Its
contents may be of almost any color and the pus is often thick and
foul in odor. (See Subphrenic Abscess.)
Symptoms.—Symptoms of the solitary type may be at the onset
acute, with or without history of previous sickness, the patient being
suddenly seized with severe epigastric or hypochondriac pain, which
is followed by prostration, with fever, chills, and sometimes cough.
Characteristic rigidity and tenderness follow and the liver increases
in size, the whole type of illness being one of acute abdominal
infection. The slower forms appear to come on without early liver
symptoms, patients complaining of cough and discomfort in the
chest, with loss of flesh and appetite. Gradually the indications point
to the hepatic region, while chills or intermittent fever occur, the liver
gradually increasing in size and becoming tender. Again, in some
cases, the trouble begins with irregular fever, patients running down
rapidly, yet showing few local signs until the abscess invades the
subphrenic region. In such instances examination of the chest gives
negative evidence, save that there may be found elevation of the
diaphragm due to accumulation below it. In nearly all instances
there arise, sooner or later, severe chest pains, with enlargement of
the liver, tenderness, and often indications of fluid in the right pleural
cavity, which on aspiration may be found clear or purulent.
Tenderness along the liver border will be most marked among
characteristic features. Sometimes there is intercostal tenderness.
Any indication of local peritonitis should be taken as evidence of
approach of pus toward the surface. Jaundice is an occasional
accompaniment. Previous malaria should be excluded if possible and
a careful case history is a great help.
Diagnosis is usually to be made between hepatic and subphrenic
abscess and between the single and multiple forms of the former.
The possibility of empyema or of one or two subphrenic abscesses
should be carefully determined. In fact, first of all, the surgeon has
to determine whether the lesion is above or below the diaphragm.
Some of the subphrenic abscesses contain gas, and, should
indications of its presence be found below the level of dulness due
to the presence of fluid, interpretation of the facts is easy. Localized
edema of the chest wall, or of the region of the liver, is of
importance when present. It is necessary, also, to exclude
phlegmons of the abdominal wall. These are cases where it is
justifiable to use an exploring needle repeatedly, if necessary, in
order to determine the presence and location of pus. After
anesthesia the needle may be used even more freely, its use being
not only of assistance in diagnosis, but it appearing to be an agent
of great value in the relief of pain. I have known painful affections of
the liver to be much relieved by such exploration.
The accompaniment of dysentery of amebic type, and the
discovery of amebas in the stools, would quite settle the question of
the origin and nature of such abscess. Hydatids are of slow growth
and are almost symptomless until they produce pressure
disturbances or those due to the presence of pus. The fluid
withdrawn from them is clear and may contain hooklets. Cancer
eventually produces jaundice and the resulting enlargements are
nodular, while the lower border is irregular, and the liver itself less
tender and more movable, and there is usually more or less ascitic
fluid present. Syphilitic gumma may cause enormous enlargement of
the liver, with difficulty in diagnosis, especially in the absence of a
significant history. Under vigorous mercurial treatment it will steadily
improve; without it such gummatous tumors may suppurate. It will
often be advisable, in case of doubt, to make this therapeutic test.
Actinomycosis produces granulomas which tend to increase,
infiltrate, produce adhesions, and gradually work toward the surface,
as well as eventually to break down, the débris thus produced
containing not only pus, but the peculiar calcareous particles
characteristic of this disease.
Treatment.—Multiple foci in the liver scarcely admit of successful
operative treatment and are nearly inevitably fatal. The solitary liver
abscess, even though large, is, on the other hand, usually
satisfactorily treated by the general method of free incision and
drainage, although, in exceptional cases, aspiration alone has
seemed to suffice. Any collection of pus, no matter what the internal
condition, so long as it be not distinctly cancerous, which tends to
present externally, no matter at what point, should be thus treated.
Incision may be made over any protruding or edematous area where
pus seems to be nearing the surface. With a considerable collection
of this fluid in the right lobe, especially nearer its diaphragm-covered
portion, it is usually safe to assume that the upper surface of the
liver has become adherent to the diaphragmatic dome above it, and
that there one may follow the costal border or may enter between
the lowermost ribs, or may even resect one or more ribs if
necessary, and drain posteriorly or by counteropening, as may be
indicated. When approached from beneath, the lower surface of liver
thus affected will usually be found more or less matted to the colon,
omentum, or pyloric region, as the case may be, so that by carefully
opening the abdominal cavity, and walling it off with gauze, pus may
be evacuated from below and cavities satisfactorily drained. In this
work it is of advantage to use an exploring needle, the operator
guiding his further procedures largely by what it may reveal. Vessels
which may be divided and spurt should be ligated or secured en
masse, while oozing is overcome by gauze pressure. Drainage of a
cavity already protected is simple; otherwise it may require a very
careful combination of large fenestrated tube, if possible sewed in
place, with the margins of the opening carefully puckered and
secured around it and protected with gauze. Counteropening may be
made, as well as drainage of any neighboring purulent focus.
 Fig. 626

Abscess of liver, opened by transperitoneal hepatostomy. (Pantaloni.)

HYDATIDS OF THE LIVER.

 Echinococcus disease is almost a surgical curiosity in the central
portions of the North American continent, whereas in some parts of
the world it is extremely common. Thus while very rare in the United
States, in Winnipeg it is an exceedingly common disease, being
brought there by immigrants from a locality where it is still more
prevalent, namely, Iceland, where it is said that nearly half the
inhabitants die of some form of hydatid disease. In New Zealand,
also, as elsewhere, this form of parasitic invasion is very common.
With most American practitioners, however, it is so seldom seen that
its mere possibility may be overlooked. In the liver it produces cystic
disease whose symptoms are rarely significant until the cysts have
attained considerable size and have begun to suppurate. That the
liver is so frequently affected is easily understood, as the parasites
make their first invasion along the duct from the intestinal tract. The
history of these cases is always slow, as four years is a short time
and twenty-five years not an exceedingly long one in which hydatid
cysts run their course. Small cysts may even undergo spontaneous
retrogression and calcify. These cysts when large may rupture, just
as do hepatic abscesses, and in various directions. (See above.)
Ordinarily it is only when suppuration occurs that the general health
suffers, and not until that time are they, at least intentionally, seen
by the surgeon.
Hydatid cyst of the liver appears as a tumor, evidently cystic or
fluctuating, growing painlessly and attaining considerable size. It
may usually be excluded from abscess, cancer, dilated gall-bladder,
aneurysm, gumma, hydronephrosis, renal cysts, or tumors of
unknown origin. A tumor peculiar to the liver will move with that
organ. The aspirating needle will probably need to be used before
diagnosis is complete, the fluid withdrawn being clear unless
suppuration has begun.
Treatment.—Hydatid cysts require radical treatment. Aspiration
does not remove the mother-cyst nor any of its semisolid contents.
Even the injection of iodine and resort to electrolysis hitherto in
vogue have been abandoned. Open incision, first, of the abdomen,
and then, after careful protection of the abdominal cavity, of the cyst
itself, with scrupulous attention to prevention of escape of its
contents save externally, is the only radical and promising procedure.
These precautions should be taken because of the possibility of
implantation of some living fragment of the parent organism, or its
offspring, elsewhere in the abdomen and the growth of the same in
this new location. After free evacuation of such a cyst it should be
explored and thoroughly cleaned out, after which its edges are to be
affixed to those of the parietal peritoneum if practicable, a large tube
inserted and suitably connected up for drainage, while the opening
around it is closed with sutures or packed with gauze. This
connection of an interior cavity with the exterior of the body is called
marsupialization.

SYPHILIS OF THE LIVER.

The operating surgeon as such is only concerned with gummatous
tumors, not with diffuse expressions of syphilis which produce
interstitial hepatitis or cirrhosis. The latter are often met in cases of
general syphilis, and yield to suitably directed treatment. Either the
diffuse or the gummatous form may produce enormous enlargement
of the liver, with suspicion at least of an abscess. In one case of this
kind, known to the writer, the lower border of the liver extended
below the crest of the ilium, and yet within a short time, under
vigorous treatment, the liver resumed its normal size. Gummas have,
then, an interest for the surgeon, as no other similar enlargement
ever reduces its volume so speedily under any other circumstances.
Moreover gummas may occasionally break down and produce
abscesses requiring incision and drainage. If syphilis can be
recognized as the etiological factor prognosis is satisfactory in nearly
every instance.

ACTINOMYCOSIS OF THE LIVER.

The specific fungi of this disease may be easily carried from the
alimentary canal to the liver through the portal circulation, and its
peculiar granulomas, appearing first here, may spread to the
diaphragm, to the abdominal wall, or in any other direction. Unless
aided by the presence of other distinctive lesions diagnosis is rarely
made until the presence of a granulating tumor and its ulceration,
with the escape of the distinctive calcareous particles, makes it
recognizable to touch as well as to sight. This often might be
secured by an exploratory operation, which circumstances might
justify. (See chapter on Actinomycosis.)

TUMORS OF THE LIVER.

Benign tumors in the liver are rare. So-called adenomas of
somewhat indistinct type, and fibromas, have been described as
occurring here. The former are of uncertain origin and probably do
not deserve the name given here. Nevertheless they have a
structure more or less simulating true gland tissue. Fibromas may
spring from any of the fibrous structures. Other benign tumors occur
here so rarely as to scarcely warrant mention. Aneurysms and large
venous dilatations also occur occasionally in the liver. Any of these
lesions may justify exploration, and those favorably situated may be
enucleated or excised, with subsequent suture of the liver and
drainage of any remaining cavity.
Of the malignant tumors the sarcomas and endotheliomas may
arise in almost any part of the organ. Primary carcinomas have their
origin only about the gall-bladder and its ducts, from whose
epithelial lining they may spring; otherwise they are products of
extension or metastasis. By far the larger proportion of cancers arise
from the gall-bladder, within which they begin to grow, either as the
expressions of irritation or of parasitism. The presence of gallstones
in the gall-bladder is now known to be an extremely common
provocation of cancer, and the relation obtaining between the two is
certainly more than accidental or casual. (See Cancer of the Gall-
bladder.)
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

Surgical Anatomy of the Gall-bladder and of the

Omental Foramen and Cavity. (Sobotta.)
The probe enters the omental (epiploic) foramen. By retraction and removal of
its anterior covering the cavity of the lesser omentum (omental bursa) is
exposed, revealing especially the pancreas in situ.

BILIARY FISTULAS.
These may be due to accidental injury during operation or to
disease processes. They may be direct or indirect, and internal or
external. An example of direct, external traumatic fistula is afforded
by a cholecystostomy or a cholangiostomy; of indirect internal when
the gall-bladder has burst into an abscess and this into a hollow
viscus. A fistula might arise from a local abscess outside the biliary
passages, later communicating in both directions, or it may be
connected with the thoracic organs, with evacuation into the bronchi
or esophagus, and cases are on record where gallstones have been
passed from the mouth. The external or cutaneous fistulas tend in
most instances to spontaneous healing, but the time required is
often long. They may discharge thin, biliary mucus or true bile.
Mucous fistulas result from cholecystostomy where the obstruction
in the cystic duct has not been overcome, as when it is the seat of
stricture or extrinsic pressure. They cause but little inconvenience.
Nevertheless if allowed to close the mucus accumulates and pain
results from distention. In these cases either a small tube or drain
should be worn, or a cholecystenterostomy may be made.
Sometimes after the discharge of some foreign body, such as a silk
ligature or small stone, such a fistula will close of itself, or it may be
possible to frequently cauterize its interior with a bead of nitrate of
silver melted upon the end of a probe, or perhaps by using a long
curette to so destroy its mucus lining as to do away with the
condition and its consequent discharge. Ordinarily cholecystostomy
will not be followed by permanent or even long-continued fistula if
the common duct have been thoroughly cleared, and if the gall-
bladder be fastened to the aponeurosis and not to the skin.
Postoperative biliary fistulas, with discharge of large amounts of bile
(one to two pints per day) and their consequent inconvenience, will
ordinarily not be long tolerated by the patient, who will insist on
some further procedure for relief. If possible, in every such case, the
real cause of the difficulty should be removed. If the ducts be
cleared and stimulation with caustic be not sufficient, then the
abdomen should be opened, the gall-bladder detached, and its
fistulous opening freshened and sutured. If the patency of the
common duct can be established this will be sufficient. Otherwise,
after closing the gall-bladder, it should be anastomosed with the
small intestine as near the duodenum as possible.
 Spontaneous or pathological fistulas often open at the umbilicus,
the disease process having followed the track of the umbilical vein
up to that point. Here, too, calculi are thus spontaneously extruded,
one case on record including the discharge in this way of a stone
three inches in diameter. In any such case as this the fistula cannot
be expected to close until the calculi are all extruded. In the
treatment of any such lesion the margin of the wound and the entire
track of the fistula should be carefully curetted and disinfected, as at
least a part of the procedure.
Biliary intestinal fistulas, due to escape of calculi into adherent
intestine, are also occasionally seen. These often form without
marked disturbance until perhaps at the last, when there may be
destructive symptoms, both biliary and intestinal, symptoms which
will suddenly subside when perforation or passage of a calculus
occurs. After their occurrence patients may enjoy some relief for a
considerable time, or until the contraction of the fistula may
necessitate a subsequent operation. At other times their formation
by ulceration is often accompanied by severe pain and fever, and
possibly even by hemorrhage. Impaction of a gallstone in the intra-
intestinal portion of the common duct is perhaps the most frequent
cause of this kind of trouble. Fistulas into the colon are less common
than into the small intestine. Such fistulas should never be
intentionally made if it be possible to utilize any part of the small
intestine. Although the pylorus and the gall-bladder often become
firmly united to each other gastric biliary fistulas are rare. If,
however, there be vomiting of gallstones, such a sign would make it
quite certain. Mayo Robson has reported one such case where he
separated adhesions, pared the stomach opening, closed it with
sutures, and utilized the opening in the gall-bladder for the removal
of calculi and subsequent drainage, the patient recovering.

INJURIES TO THE BILIARY PASSAGES.

These are less common than injuries to the liver proper. They may
be caused by penetration or by severe blows and concussion. In
those already suffering from local disease accidents are more likely
to be followed by rupture. Injuries have also been attributed to
traction and later adhesions. The fundus of the gall-bladder is the
most exposed portion; therefore, that part is most often injured;
while neighboring organs may suffer simultaneously—for example,
the liver, stomach, and colon.
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.

CHRONIC CATARRHAL CHOLECYSTITIS.

This is often mistaken for cholelithiasis, although when the gall-
bladder is opened only thick, ropy mucus will be found. This, as just
remarked, may give rise to very painful spasm. The trouble when
present is usually connected with similar trouble in the ducts.
Moreover, around such a gall-bladder numerous adhesions are
formed which give rise to much pain, tenderness, and local distress.
Under these conditions the gall-bladder is enlarged and thickened.
Here, too, the curative treatment is essentially surgical, although
pain may sometimes be temporarily relieved by aspirin in doses of
from 0.5 to 1 Gm.
Cholecystitis obliterans corresponds closely to appendicitis
obliterans, and is a condition characterized by a reduction in the size
of the gall-bladder or its almost complete obliteration. In order to
account for this it is seldom necessary to assume a congenital
defect. The morbid process which produces it begins early, perhaps
even during fetal life. The bile ducts are extremely small at birth and
further stenosis is easily produced. The accompanying enlargement
of the spleen will illustrate the toxicity of the condition which led up
to it, and which may have occurred in infancy or early childhood. In
a small proportion of cases early constriction of the ducts produced
by local peritonitis and infection along the track of the umbilical
vessels may account for the condition.

ACUTE CHOLECYSTITIS AND CHOLANGITIS SUPPURATIVA.

A suppurative condition within the gall-bladder is necessarily an
expression of an infection, in nearly all instances proceeding from
the intestine. The colon bacilli and those of typhoid are the
organisms usually at fault. As has already been shown in the earlier
part of this work they are facultative pyogenic organisms. Mixed
infection with the ordinary pus-producing germs may also occur
here. Such infections may spread through the walls of the gall-
bladder and cause at least local and sometimes fatal general
peritonitis. The condition is an especially frequent complication of
typhoid fever, occurring sometimes relatively early, at other times
after apparent recovery from the disease. In most of these instances
it is supposed that the bacteria reach the gall-bladder by migration
along the ducts, although direct penetration or infection through the
blood is not to be denied. Impacted gallstones especially predispose
to such infections. The result of all such cases is the formation and
retention of pus—i. e., empyema of the gall-bladder—save in those
rapid virulent or fulminating infections when it quickly becomes
gangrenous, as does the appendix when similarly infected.
Symptoms.—In acute infections of the bile passages patients
suffer severe pain, made worse by movement, with general malaise,
rapid loss of appetite and flesh, extreme tenderness over the gall-
bladder and often around it, because of the accompanying local
peritonitis. It is frequently possible to make out enlargement of the
gall-bladder, which will move with the liver during respiration—this at
least until it has become fixed by local inflammation—after which the
patient will have thoracic rather than abdominal respiration. As such
a case progresses local indications of disease will be added, with
finally visible tumefaction and redness of the overlying skin. Jaundice
is an uncertain feature, depending on the patulency of the common
duct.
Pus when formed may escape and burrow in various directions;
thus it may follow the suspensory ligament of the liver and appear at
the umbilicus, or it may pass along other reflections of the
peritoneum and appear about the cecum or above the pubes, or it
may pass into the liver and appear as an hepatic abscess, or around
it and thus give rise to a perihepatic or subphrenic abscess. It may
even perforate the diaphragm and produce such collections of pus or
such phenomena as have been described in the previous chapter,
including empyema, pericarditis, abscess of the lung, etc. Again it
may burst into the hollow viscera, stomach or intestines, or into the
general peritoneal cavity, where it will cause speedily fatal
peritonitis. Pulmonary abscess, with discharge of pus and bile, has
been cured by Mayo Robson by removing a stone from the common
duct. Gallstones have also been found in the pleural cavity and have
even been passed by the mouth. Finally pus collecting in the right
abdominal pouch may also be mistaken for perirenal abscess.
Acute phlegmonous cholecystitis, with gangrene, corresponds to
the fulminating form of gangrenous appendicitis, and only received
its first description in 1890 by Courvoisier. This is not common, but
when met with becomes a disastrous lesion. It is essentially a still
more virulent expression of infection and consequent necrosis than
the condition described above. It may be so rapid as to destroy the
gall-bladder before it has had time to fill with pus. It may occur with
or without a history of previous trouble, in the absence of which a
diagnosis will be made more perplexing. As the condition declares
itself and progresses there will usually form about its site a
protective barrier of lymph and omentum, which may prove, when
present, the salvation of the patient, especially if the surgeon who
makes the operation, and this should be early, recognizes the value
of these protections and does not break them down. The condition
occurs in connection with gallstone disease, but may follow typhoid
fever, cholera, puerperal fever, or other intense infection.
Symptoms of gangrenous cholecystitis are essentially those of the
less severe types of infection, only more pronounced. They include
severe pain of sudden onset, rapidly growing worse, spreading over
a larger area, extreme tenderness and muscle spasm, rapid thoracic
respiration, quick pulse, intense depression and collapse, vomiting,
rapidly increasing tympanites, anxious facies, with every expression
of intense sapremia. Jaundice is an inconstant symptom, while fever
is usually present, but is of little importance. The disease may be so
rapid as to quickly kill. At all events local destruction occurs early,
either with abscess or gangrene, or both.
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.

ULCERATIONS AND PERFORATIONS OF THE BILIARY

PASSAGES.
These may occur anywhere along the biliary tract, and vary as
between the superficial and the perforating, the former being
sometimes multiple, the latter solitary. Of these lesions cholelithiasis
is the most common cause, while typhoid and cancer should be
ranked next. They are all of pathological import, because of their
possible sequels, i. e., not merely perforations with fistulas, but
possible strictures or hemorrhages, or peritonitis with sepsis. When
ulceration is extensive a previous local difficulty may be supposed,
with more or less adhesions, but as the trouble becomes more
serious the local excitement will extend to the peritoneum, at least
that of the area involved. In fact most cases of gallstone disease are
accompanied by more or less peritonitis, and adhesions which are
protective, although they may cause other troubles as well, such as
dilatation of the stomach from displacement of the pylorus.
Hemorrhage is not a frequent event, for thrombosis usually precedes
erosion. Some degree of sapremia or septicemia will be present in
nearly all cases.
 Stricture of the ducts is the most common result, especially of the
cystic duct. If this occur and the mucous membrane be still active
the gall-bladder will become distended with pus or mucus, or both.
These are the cases which perhaps give the best results after ideal
cholecystectomy.
Perforation is a constant possibility whose menace cannot be
estimated, but which is always actual, the great danger depending
on the virulence of the extruded material and the consequences of
delay in operating. Although healthy bile is but slightly toxic, these
cases do not furnish it, and one may always look for consequences
of infection. Nevertheless if diagnosis be made sufficiently early to
bring about immediate operation prognosis is good. Occasionally
during such an operation there will be found a gallstone endeavoring
to extrude itself, but not yet completely escaped. It might be, in rare
instances, possible to utilize the opening which it has partially made
for subsequent drainage purposes.
It is not advisable to permit patients with distended gall-bladders
to go unoperated, even in the absence of serious symptoms,
because the risk of operation is small and that of rupture is large.
Acute intestinal obstruction due to gallstones will usually, but not
invariably, involve the upper intestinal tract. It may be due to the
actual occlusion of a large stone which has escaped from the gall-
bladder or duct, or it may be caused by volvulus due to intense colic
accompanying peristaltic effort, or it may depend upon adhesions
after a local peritonitis due to previous disease of the gall-bladder or
to stricture following ulceration; or again it may be purely paralytic,
and in this way result from a local peritonitis. Impaction of a biliary
concretion may happen at any point, but most often at the ileocecal
valve, where the intestinal tube is narrowest. The size of the stone is
not the only consideration. Obstruction depends perhaps as much
upon spasm above and below as upon any local disturbance that its
presence may have caused. Biliary concretions may enlarge as they
pass downward, growing by accretion of calcareous and of fecal
matter. The larger the calculus the more likely it is to obstruct the
upper intestine. The majority of these calculi have escaped from the