acute] he: pa tit is. 
RESULTING FROM THE PRESENCE OF 
BILIARY CALCULI, FOUND IN THE PA- 
RENCHYMATOUS STRUCTURE OF THE 
RIGHT LOBE OF THE LIVER. 
Cure Effected by Opera lie::. 
K«1 irinfed from (lie New Orleans Medical and Surgical Journal, June, 1881. 
By Mr. Frank E. Artaud, Medical Student, Fniversity of Jjouisiana. Acute Hepatitis, 
RHSl I.ITNC FROM THE PRESENCE OF BILIARY CAL- 
Cl Li. L'lHAD IN THE PARENCHYMATOUS STRUCTURE OF 
THE RK'rHT LORE OF THE LIVER. 
Cv. :'i -Y_' ec .Vt: by Opera i ion 
IV Mi Kk\nk K. A kiai i). Medical Snub m. I nivirsitv Louisiana. 
By request, 1 will endeavor to write an account of a case, 
which has been submitted to mv care since December last. 
I am not only prompted by the desire of making known such tacts relating 
to the above a- will be of interest to the medical world; but chiefly because the 
case has been styled by several of the eminent professors of the Medical Depart- 
ment, University of Louisiana, as “a remarkable one ” 
I then fore think I am justifiable in making a report of the case, likewise a 
few remarks pertaining thereto, and the method of procedure which 1 adopted 
to extricate these calculi’ 
The patient, named M. Bell, a resident of New Orleans, is oh years of age, 
of rather slight frame. 
Having enquired into his history antecedent to the present disease, found 
that he was attacked with rheumatism in 1861, resulting ultimately in rheumatoid 
arthritis; I also found on his body the presence of an eruption known as eczema 
arsenica, corroborating his statement, as he had often intimated that he had 
taken large quantities of arsenic since attacked with rheumatism. 
1 inquired whether he had any hereditary predisposition or gouty diathesis: 
and his statements proved conclusively that he had none. 
The hygienic influences to which he was exposed varied largely; and as to 
his constitution and general health, it has been quite good, until about ten years 
ago; since when he dates a severe pain not continuous in the right hypochondriac 
region, radiating posteriorly towards the vertebral column. 
His positions in bed have never been altered or interfered with in any man- 
ner; his bowels have always been loose and has had as many as from ten to 
twenty evacuations per diem. 
Present. Condition.- When my attention was first summoned to the case ( De- 
eeinberWth, 1880), he complained of an acute lancinating pain, confined for the 
most part to the region of the right lobe of the liver and according to his state- 
ment, deeply situated. 
Messrs Editors: He experienced some oppression in breathing, which increased the acuteness 
of the pain, especially when a deep inspiration was taken; probably due to the 
descent of the diaphragm on the liver. A short dull cough of a kicking nature, 
accompanied the attack; hiccough occasionally. Upon further inquiries, I ascer- 
tained that his digestive ap aratus was notablv injured and that little or no as- 
similation was taking place. 
Physical Examination. I then resorted to percussion and palpation, and by the 
former, notable dulness over the whole of right lobe accompanied with a bruit, 
peculiar and remarkable in its character was revealed. 
The latter, namely palpation, enabled me to deduce conclusively that the 
right lobe of tbe liver was by far larger than normally. Furthermore, anterior- 
ly an elevation resembling the under surface of an ordinary size saucer, was 
present, exceedingly prominent and easily circumscribed, measuring three inches 
in diameter, its position was as follows; viz: the upper edge was two inches and 
a half below the costal cartilage of the seventh rib; whilst the lower, bordered 
upon the right lumbar region. 
Taking into consideration what 1 had observed and realized by a careful ex- 
amination which I instituted, again, in order to be more thoroughly convinced, 
I thought myself justifiable in introducing an exploring nedle in the centre of 
the above intimated elevation. My first attempt proved to be fruitless; but upon 
again applying the instrument 1 drew some pus mixed with a little blood. 
I felt satisfied that great engorgement was present. The patient complaining 
of restlessness, I ordered syr. morph. 
Dec. 14th.—Dejecta examined and tested for bile, and found totally devoid of 
it—likewise same examination carried out, Dec. 16th, 17th, 18th and 19th, with 
the same results; as usual the feces were very liquid, grayish and extremely 
offensive. 
Dec. 19th.—At 7, P. M., I was sent for by the patient, and upon my arrival he 
stated that he experienced excruciating pains in the right hypochondriac region. 
—I immediately applied cups and spring-lancet; by 8, P. M., he felt much re- 
lieved. Urine tested, bile present. 
On the morning of 20th inst:, I called again and examined his side, detected 
fluctuation above the surface of the right lobe of the liver; whereupon I made an 
incision varying from J to an inch in length with a thumb lancet, and allowed 
the pus to escape into a reservoir, which I had provided, having concluded to 
test it. Accordingly, the ensuing evening I did so and Conclusively obtained 
the reaction that bile assumes with nitric acid. Urine again tested, bile still 
present. 
Dec. 21sf.—Feces again tested, and as heretofore, bile absent. The patient’s 
side was next investigated, and the small opening which I made, explored with 
the probe in order to ascertain, if possible the nature of the surrounding tissues. 
To my complete amazement, the instrument sank about an inch or two when it 
suddenly came in contact with a solid body, firmly imbedded. I made several 
attempts to liberate this substance, but all my endeavors, thus far. were in vain. 
I next deemed it advisable to seek for more such bodies, but in an opposite 
direction, and as before, my instrument came in contact again with a resistible 
mass which I succeeded in fracturing; and by means of forceps, obtained some 
fragments. 
Dec. 22d.—Operation.—I called determined to make an incision and cut down to the liver and remove these calculi, knowing that doubtless they acted as 
foreign bodies in the oigan and were the exciting cause upon which the 
phlegmasia depended and suppuration secondarily. In the meantime I exhibit- 
ed podophyllin in quarter grain doses every four hours, anticipating hepatic 
stimulation. Accordingly, with the above determintaior, I ordered the nurse 
to administer the anaesthetic and when he was thoroughly under its influence, I 
proceeded to make an incision from left to right, transversely, from two to three 
inches in length; just k an inch above the one I had made with the lancet and 
four inches from the linea alba; also two inches below the costal cartilage of the 
seventh rib. 
The hemotrage arising therefrom was small and easily controlled. Having 
divided the several structures; I found that an adhesion had taken place between 
the hepatic and parietal peritoneum; I introduced my fingers and followed the 
path which my instrument had pursued, as a matter of course enlarging it. 
I at length felt a cluster of calculi firmly imbeded in their cavities, and the 
contiguous tissue strongly bound down upon them. 
By means of a probe-pointed bistoury and forceps, I succeeded in extracting 
fifteen of these calculi in the space of two hours. 
Their size varied from £ to \ of an inch in diameter, polygonal in shape, of a 
brownish yellow color, friable and floating in water. 
They were examined by Dr. II. D. Schmidt, Pathologist to the Charity Hos- 
pital, and found to contain cholesterin for the must part, glyko and tauro 
cholate of soda, and those ingredients which usually enter into the composition 
of biliary or gall stones. 
The cavities created by the extraction of these calculi in the liver were tho- 
roughly syringed out with carbolized water, and tents steeped in carbolized oil 
introduced. In other words, Prof. Lister’s antiseptic dressing’s were entirely 
used, and brought forth admirable results. 
The patient stated after the operation that he felt much relieved from .the un- 
easiness and pain which he had heretofore experienced, and only complained of 
the external opening being somewhat sore. Syr. morph, exhibited at night. 
Dec. 23.—Patient labored under severe pains confined posteriorly to the lum- 
bar regions. I ordered enemata of opium, twice daily, and applied to the wound 
iodoform pulv., and hydrarg-chlor. mite, an 2 drachms No symptoms of periton- 
itis present; temperature normal, Pulse likewise. 
Dec. 24.— Patient feeling well; pains in the back absent. I though it pru- 
dent to search for more calculi and shortly extracted five more; the fifth having 
larger than those heretofore extricated; wound dressed as before; 
temperature good; pulse the same; nitro muriatic acid ordered, ten drops twice 
daily'. 
Dec. 25.—Patient doing well; dejecta tested and traces of bile present; tem- 
perature normal; pulse likewise; wound suppurating. 
Dec. 26.—Patient rapidly improving; wound once more explored and seven 
more calculi extracted, alike in size to -he others. I made syre that none were 
yet remaining, and continued same dressing. No alteration in either pulse or 
temperature. 
Dec. 27.—Patient improving continually; wound again explored, no calculi 
to be found; feces tested, bile present; no modification in temperature or pulse- urine tested, only a mere trace of bile 
Dec. 28.-—Patient allowed to leave his room; appetite good, assimilation of 
food apparently taking place; stools containing a normal quantity of bile. 
Dec. 29.—Patient doing finely; all functions of the live restored; temperature 
and pulse good. During the latter part of January, 1881, the wound began to 
heal by second intention. 
Readers will remark that during the whole of this attack and even after the 
the operation, there was not an elevation of a single degree of temperature, nor 
alteration in the pulse; and again, I would like to call attention to the fact that 
jaundice, was never connected with this case. 
In February, with Prof. Remiss’ consent, the patient was brought before the 
medical class and lectured upon in the amphitheatre at the Charity Hospital by 
the above named gentleman. I would like just here, before concluding, to make 
a few remarks in regard to the calculi, that I found in the substance of the liver. 
Doubtless, the majority of medical men will claim that the presence of these 
concretions in this locality, is probably due to some tortuous fistulary passage, 
communicating with the bladder, as have occurred in several cases on record. 
The gali-bladder being the seat of the deposits. 
But taking into consideration the symptoms and course of this case, which I 
have had in close observation, 1 can safely assume that there was no analogy to 
those cases in which the gall-bladder has been the seat of the disease. 
However, I cannot conceive why calculi could not be formed in the parenchy- 
ma of the liver. It is quite evident that all biliary ducts, like all the similar 
passages, are liable to inflammation of their mucous membranes; which become 
swollen, and impede, if not arrest entirely, the flow of bile: Such, I am confi- 
dent has been the case, in my patient, with the trunk, forming the hepatic duct 
from the right lobe of the liver, judging from the symptoms. 
The inflammation having been set up in this biliary canal extended as a natu- 
ral sequence to the tubuli biliferi, and a stiffening of coats thus produced, even- 
tually, the bile was dammed back upon these tubules, and this likewise occured 
to the hepatic cells. 
Fibrinous exudation, solidified mucous, or insoluble matter precipitated from 
the bile being natural sequelae, favored the production of these calculi, constitu- 
ting a nucleus around which these concretions were deposited. 
The morbid effect of the gall-stones was an inflammation which aiose from the 
irritation of their presence, and from their direct pressure or distending force, 
The result of the phlegmasia was suppuration. Another morbid effect worthy of 
notice was the obstruction which manifested itself very clearW in this case, as 
being confined to the hepatic duct; or branches pertaining thereto; the tubuli 
biliferi being distended as a secondary effect, and finally enlargement of the liver. 
Furthermore, the size of the.->e calculi would to a certain extent corroborate the 
above statement, and they would not have been bound down by the contiguous 
tissue as they were in this case; if a fistulous opening had brought them forth. 
Concluding: I cannot conceive that I would be presumptuous at all, in assum- 
ing that the concretions which I extracted were formed in the parenchymatous 
structure of tht right lobe of the liver; since the necessary pathological agents 
were favorable for their production'. 
New Orleans, March 25th, 1881.