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MIDDLE EAST TODAY

Political Participation in
Iran from Khatami
to the Green Movement

Paola Rivetti
 Middle East Today

Series Editors
Fawaz A. Gerges
Department of International Relations
London School of Economics
London, UK

Nader Hashemi
Center for Middle East Studies
Josef Korbel School of International Studies
University of Denver
Denver, CO, USA
The Iranian Revolution of 1979, the Iran-Iraq War, the Gulf War, and the
US invasion and occupation of Iraq have dramatically altered the
­geopolitical landscape of the contemporary Middle East. The Arab Spring
uprisings have complicated this picture. This series puts forward a critical
body of first-rate scholarship that reflects the current political and social
realities of the region, focusing on original research about contentious
politics and social movements; political institutions; the role played by
non-­ governmental organizations such as Hamas, Hezbollah, and the
Muslim Brotherhood; and the Israeli-Palestine conflict. Other themes of
interest include Iran and Turkey as emerging pre-eminent powers in the
region, the former an ‘Islamic Republic’ and the latter an emerging
democracy currently governed by a party with Islamic roots; the Gulf
monarchies, their petrol economies and regional ambitions; potential
problems of nuclear proliferation in the region; and the challenges
­confronting the United States, Europe, and the United Nations in the
greater Middle East. The focus of the series is on general topics such as
social turmoil, war and revolution, international relations, occupation,
radicalism, democracy, human rights, and Islam as a political force in the
context of the modern Middle East.

More information about this series at

http://www.palgrave.com/gp/series/14803
 Paola Rivetti

Political Participation
in Iran from Khatami
to the Green
Movement
Paola Rivetti
School of Law and Government
Dublin City University
Dublin, Ireland

Middle East Today

ISBN 978-3-030-32200-7    ISBN 978-3-030-32201-4 (eBook)
https://doi.org/10.1007/978-3-030-32201-4

© The Editor(s) (if applicable) and The Author(s), under exclusive licence to Springer
Nature Switzerland AG 2020
This work is subject to copyright. All rights are solely and exclusively licensed by the
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translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on
microfilms or in any other physical way, and transmission or information storage and retrieval,
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known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information
in this book are believed to be true and accurate at the date of publication. Neither the
­publisher nor the authors or the editors give a warranty, expressed or implied, with respect to
the material contained herein or for any errors or omissions that may have been made. The
publisher remains neutral with regard to jurisdictional claims in published maps and
­institutional affiliations.

Cover illustration: © Mikadun / shutterstock.com

This Palgrave Macmillan imprint is published by the registered company Springer Nature
Switzerland AG.
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
 Preface

This volume examines the unintended consequences of top-down reforms

in a semi-authoritarian country, the Islamic Republic of Iran. More specifi-
cally, this book looks at how the Iranian governments between 1997 and
2005 sought to utilise democratic gradual reforms to control independent
activism, and how citizens responded to such a top-down disciplinary
action. While the governments were largely successful in ‘setting the field’
of permitted political participation, part of the civil society that took shape
was unexpectedly independent and autonomous. Ironically, the govern-
ments helped create a civil society they had little control over.
Despite being carried out by a minority, the political work of indepen-
dent activists was not marginal: without them, in fact, the Green Movement
of 2009 would have not taken shape. General comments and observations
about the ‘reformist period’ in Iran tend to credit the government for the
cultural liberalisation that occurred in the public sphere and for the cre-
ation of a more tolerant political environment. In this book, I wish to
honour the work of grassroots activists and organisers. They have defended
and kept safe the spaces for political participation in Iran. They have made
sure that those spaces could exist, no matter how tight or small, working
resiliently government after government and generation after generation.
Therefore, while I engage with theories of political change, social move-
ments, and power, I ultimately see this book as being about political hope:
why and how do activists keep on organising, mobilising, and, above all,
participating in elections, in spite of violence and frustration? My answer
is that we need to look beyond the regime’s elites and structures, into
activists’ hopes—and lives.

v
vi PREFACE

At a time when scholarship on contentious politics in the Middle East

and North Africa is increasingly interested in exploring the social move-
ments and social non-movements that take shape at the margins of society,
this book returns to the ‘usual suspects’. I have worked in Iran’s capital
with overwhelmingly middle-class NGO (non-governmental organisa-
tion), student, and feminist activists, with whom I shared a common back-
ground as a university student first and as a university lecturer later. I do
not see this as a weakness. On the contrary, I hope to add a fresh perspec-
tive on how ‘usual’ social and political actors can be studied, for they
remain a crucial piece of the puzzle of state and social reproduction.
Looking at how the ‘usual suspects’ of political change shaped the state
through their actions, and how they have been shaped by the state in
return, this book examines what happens to them when hope spreads
through society. It investigates how, against all odds, hope survives and
takes unpredicted turns to resurface in a more or less distant future—once
hard times have yielded to a more favourable political context.
In this book, I attempt to explain how the Iranian state tried to disci-
pline political participation via reformism, and to disentangle how such a
project of political engineering ended up boosting hope for change and
creating unanticipated forms of political agency. I focus on a specific coun-
try during a specific period, but I hope my analysis will be useful to col-
leagues working on different countries and historical eras, for similar
dynamics can be observed and examined in other contexts too. I have
taken inspiration for this book by living through, observing, and partici-
pating in social movements in three different countries: Italy, Ireland, and
Iran. Certainly, I have found similarities between the three, and my experi-
ences have helped me think of activism in Iran ‘through’ Italy and Ireland.
This book has been in the making for far too long. If I was eventually
able to write it, it is thanks to the support of wonderful friends and col-
leagues in Iran, Ireland, Italy, and beyond. My biggest ‘thank you’ goes to
Francesco Cavatorta. Although I understand nothing about football—let
alone his favourite team, the unknown-to-most Parma AC—he has always
been present, supportive, and incredibly generous. His patience with my
sometimes convoluted thinking and passive form-dominated English is
simply limitless. I owe him so much more than I can say here. Heartfelt
thanks go to Shirin Saeidi, a true soulmate and a source of constant inspi-
ration, and Erika Biagini, who teaches me a lot about determination and
straight reasoning. Supervising Erika during her PhD was a learning
opportunity for me, and so is working with her today. I am greatly indebted
 PREFACE vii

to Francesco, Shirin, and Erika, and to those friends and colleagues who
agreed to read early drafts of this manuscript: Arefe, Janne Bjerre
Christensen, Kaveh Ehsani, and Jillian Schwedler offered extremely gener-
ous and constructive comments. I am deeply grateful to them for the time
they dedicated to this book and their willingness to ‘think with me’. Their
criticism fundamentally improved the manuscript as well as the clarity of
my thought. After numerous reads and edits, needless to say, the errors
that lingered are my own.
I have been travelling to Iran since 2005 and I have benefitted from the
kindness of too many people to mention. Crucial to my work and my
emotional attachment to Iran are Arefe, Farid, and Pari, who have skilfully
guided me through the complexity of the world of activism in Iran and the
diaspora; Milad, who has always supported and helped me; and Farnaz,
Hamed, Mersedeh, and Roya, who are good friends and have helped me
with translations from Persian. I have been privileged to meet Mohammad
Khatami, who gave me an interview, and a number of other ‘big shots’,
who found the time to sit down with me. While I appreciated that, my
work was literally made possible by other, less well-known people, who
listened and talked to me, instilling doubts, offering interpretations, and
challenging my views. They opened their houses and offices to me,
patiently making sense of my precarious Persian and sometimes rambling
reflections. While I cannot name them here, I wish to extend my deepest
gratitude to them. I hope I’ve respected your voices and honoured your
fundamental role in my work.
I have been privileged to enjoy the support of the Irish Research Council
to conduct research for this book, as well as the support of the School of
Law and Government and the Faculty of Humanities and Social Sciences
(through the book publication scheme) in Dublin City University (DCU).
Gary Murphy, Iain McMennamin, and John Doyle have lent me support in
their official capacities as Heads of School and Dean of Faculty. I am grateful
to Maria-­Adriana Deiana, who shared book-writing tips and material with
me, and every single colleague in DCU’s School of Law and Government.
Among them, a special thank you goes to Walt Kilroy, who replaced me
as director of our MA programmes while I was on sabbatical writing up
this book. Maura Conway, Yvonne Daly, James Fitzgerald, Niamh Gaynor,
Diarmuid Torney, Gëzim Visoka, as well as all other colleagues in the
School, have supported me and offered advice during the years.
I would also like to thank the Department of Culture, Politics and
Society in the University of Turin for hosting me during one semester in
viii PREFACE

2018/2019. It would be difficult to list all those who, within this depart-
ment, left a mark on me, considering that the university is my Alma Mater
and the department is my ‘second home’. However, I wish to extend a
special thank you to Sandro Busso, who enjoys my highest esteem, Valeria
Cappellato, Rosita Di Peri, Enrico Gargiulo, Gianfranco Ragona, and
Elena Vallino. They have immensely enriched my life and my work with
their friendship and the many exchanges across the years. I am also grate-
ful to the Département de Science Politique at Université Laval for wel-
coming me during one semester in 2017/2018. There, Marie Brossier,
Aurélie Campana, Sule Tomkinson, Alessandra Bonci, and Pietro Marzo
have made my séjour productive and pleasant. While in Quebec City,
Francesco Cavatorta, Severine and their sons Raphaël and Alexandre alle-
viated my homesickness making me feel at home, as they did when I
arrived in Dublin in 2011, alone and a bit lost.
In the past decade or so, I have been able to count on wonderful col-
leagues and friends, who have joined me in formative and fundamental
conversations and in other more or less consistent exchanges, which have
stayed with me to this day. This has been possible thanks to modern tech-
nology and so-called social media, and thanks to the fact that I could travel
and meet them with no visa restriction (a privilege I have done nothing to
deserve). Last but not least, my thanks go to Fariba Adelkhah, Enrico
Bartolomei, Jean-François Bayart, Francesca Biancani, Koen Bogaert,
Marina Calculli, Estella Carpi, Katerina Dalacoura, Vincent Durac,
Masserat Ebrahimi, Béatrice Hibou, Shabnam Holliday, Angela Joya,
Laleh Khalili, Hendrik Kraetzschmar, Matteo Legrenzi, Mark LeVine,
Marilena Macaluso, Mohammad Maljoo, Serena Marcenò, Kamran Matin,
Shervin Malekzadeh, Stella Morgana, Arzoo Osanloo, Nicola Perugini,
Gabriele Proglio, Riccardo Readelli, Mahmoud Sariolghalam, Naghmeh
Sohrabi, Lucia Sorbera, and Maaike Warnaar.
Thank you Riccardo James Vargiu for enhancing my English. Thanks
to Alina Yurova, Mary Fata, and the editors at Palgrave Macmillan who
have worked to keep me focused on deadlines while supporting me.
Thanks to the book’s reviewers too, who offered intelligent and encourag-
ing comments.
Thanks to my very precious friends Beatrice, Hanna, Pina, and Simona
for believing in me throughout, and for much more. During the writing
process, Chiara has offered a listening ear while providing much needed
supplies such as comfort food, drinks, and wild dancing-and-singing ses-
sions. This book was written in three different locations. They outline a
 PREFACE ix

geography of love: Tehran, Dublin, and my hometown Chivasso. As a

high school student, I used to spend my afternoons studying in Chivasso’s
public library. It was such a great joy and privilege to be able to do the
same two decades later.
I dedicate this book to my mother Pinuccia and my sister Marta, who
have always encouraged me to be a free woman.

Chivasso, Italy Paola Rivetti

31 May 2019
 Acknowledgment

This book received financial support from the Faculty of Humanities and
Social Sciences Book Publication Scheme at Dublin City University.

xi
 A Note on Translation, Transliteration,
and Dates

All translations for Persian are mine unless indicated otherwise. I am using
the transliteration system adopted by Mehrzad Boroujerdi and Kourosh
Rahimkhani in their Postrevolutionary Iran: A Political Handbook (2018).
For purposes of readability, this book does not use any diacritics for the
names of individuals or organisations, except for ayn and hamza which are
represented by an opening quotation mark and an apostrophe respectively,
and which are dropped only at the initial position.
Anglicised forms for foreign words, such as shari‘a or Islam, and place
names, such as Mashhad or Tehran, found in the Oxford English Dictionary
Online have been utilised in this book. Names of political figures known
in the West have been used as found in the New York Times (Mahmoud
Ahmadinejad, Hassan Rouhani, Mohammad Khatami, Ali Khamenei).
Names of authors whose work is referred or cited in this book are written
as indicated in the publications. To capture ezafeh, -e and -ye are used, with
the exception of first and last names of individuals (Hezb-e Kargozaran-e
Sazandegi-e Iran but not Mohammad-e Khatami). Where appropriate,
colloquial Persian pronunciations have been preferred (Hojjatolislam,
Ayatollah, hejab, Hezbollah, ku-ye daneshgah, Cheshmandaz-e Iran).
All dates are given as Western calendar dates. Iranian calendar dates are
calculated using Iran Chamber Society’s converter tool. Iranian dates are
used for sources, publications (both in-text references and lists of refer-
ences), and for temporal references during interviews, and are given with
their Western calendar correspondent.

xiii
 Praise For Political Participation In Iran From
Khatami To The Green Movement

Paola Rivetti’s fascinating study of the potential for revolutionary change in Iran
links social movement studies theory to political science debates about elite-led
liberalization and the potential for meaningful institutional reforms. While exam-
ining how government officials seek to utilize gradual reforms to deflate the revo-
lutionary potential of challengers, Rivetti brings forth the agency of citizens and
how they have independently imagined a trajectory for participation beyond what
the regime intended. Based on years of field research with activists and civil society
groups, this book offers a careful look at how regime-citizen relations have evolved
and how even micro shifts in those relations—changes that seem insignificant in
the near term—can create the potential for greater challenges down the road.
—Jillian Schwedler, Hunter College & The Graduate Center, City University of
New York

This is a groundbreaking book on the complex internal dynamics of Iranian poli-

tics that led to the emergence of a reformist movement and the election of Khatami
as president. Although reformist politics in Iran has proven its resilience during the
Green Movement protests and subsequent elections, there are clear rifts among
the grassroots whose agendas are diverging from the established formal leaders.
Rather than focusing exclusively on formal institutions and ruling political elites,
as most academic writings on Iran tend to do, this book questions how and why
grassroots organizers and activists have managed to create and maintain autono-
mous political spaces of participation despite relentless state repression and
attempts by reformist elites to co-opt and control their momentum. This is a major
contribution to understanding how social movements create spaces of autonomy
and popular counterpower from below.
—Kaveh Ehsani, DePaul University
In this remarkable book, Paola Rivetti sheds a light on how authoritarian reforms
have produced an independent activist milieu in Iran. During years of immersion
in the field, she has acquired an intimate knowledge of the activists’ life stories,
their fears and hopes. Through grounded analysis and patient observation, this
book transforms our understanding of the interaction between institutional poli-
tics and political contestation in authoritarian contexts.
—Frédéric Vairel, University of Ottawa
 Contents

1 Reformism and Political Participation in Iran  1

Political Change and Participation   1
The Short-Circuit   5
Locating Political Participation and Reformism in the
Relevant Scholarship   6
Five Elements of Iran’s Dissonant Institutionalisation   9
Approaching Eslahat  11
Non-insularity  11
Power and Reformism: Contesting Governmentality  14
Securitised Research: Navigating Fieldwork in Iran  16
The Geopolitics of Political Participation  18
Searching for Political Participation  20
Book Content  23
References  25

2 Political Participation in Context: Reformism and Elite

Factionalism After the Iran-Iraq War 31
The Foundations of Factional Politics  32
Mobilising the Democratic Discourse: The velayat-e
motlaqeh-ye faqih and the Constitutional Reform  34
Mapping Iran’s Factions  39
The Rise of the Islamic Right and the Origin of Reformism
During the 1990s  41
The Decline of the Islamic Left  41
The Islamic Left’s Objections Against Marginalisation  45

xvii
xviii Contents

The Convergence of the Democratic Left and Right  46

Political Expediency and the Transformation of the
Islamic Left  51
The Reform Era (1997–2005)  51
The Reformists’ Discursive Frames and Factional Conflicts  52
Trends and Groups Within the Reformist Front  54
Two Phases of the Reform Era  57
Conclusion  60
References  61

3 Reformism As a Governmental Project: The ‘Reform

Discourse’ and Political Participation 65
The Power of Discourse, the Discourse of Power  66
Shifting Persuasions  71
Recurring Themes  80
National History, Anti-Authoritarianism, and Moderation  81
Constitutionalism and the Rule of Law  86
Civil Society and Participation  89
Conclusion  92
References  92

4 Civil Society: Crafting Consensus from Above,

Appropriating Reformism from Below 99
Theorising Civil Society As a Field 101
The Contours of Political Participation and the Morality
of Civil Society 103
International Civil Society and Its Domestic Configuration 103
Reclaiming Civil Society 107
Structuring Civil Society During the Reform Era: Political
Parties and NGOs 109
Two Phases of Civil Society-Government Relations
(1997–2005) 113
Building Subjectivities and Mentality 114
Reasons to Commit, Aspirations to Modernity, and Contention  116
Professionalisation: Independence from and Closeness
to the Government 122
Conclusion: Emerging Political Agency 129
References 130
 Contents  xix

5 The Formation of Residual Counterpower and Autonomous

Subjectivity During and After the Reform Era135
The Unintended Consequences of Top-Down Reforms 137
Surpluses of Participation During the Reform Era 141
Frustration and Disillusionment with Reformism 141
Marginalisation, Radicalisation, and Alternatives to
Reform: Student Activism During the Reform Era 146
Residual Counterpower and Activism Post-2005: Mobilisation
Strategies and Grassroots Organising, Networking, and
Campaigning 154
The One Million Signatures Campaign 156
Negotiating Strategies of Mobilisation After Eslahat 156
Women’s Activist Networks After the OMS Campaign 161
Conclusion 163
On-Campus Activism 164
Two Phases of Post-2005 Student Activism (2005–2009):
Phase One 164
Phase Two: The 2009 Election and the Revival of Student
Activism 167
Conclusion: The Potential and Limits of Residual Counterpower 169
References 171

6 Cycles of Hope, Eslahat, and the State177

Ordinary Discontent and Extraordinary Mobilisations in Iran
and Beyond: The Book’s Main Argument 177
Ordinary Discontent 177
Extraordinary Mobilisations 180
Resistance and Hope 182
Hope and the State in Post-2009 Iran 184
Cycles of Hope and Eslahat 187
Conclusion 189
References 190

Index193
 About the Author

Paola Rivetti is Assistant Professor of Politics and International Relations

in Dublin City University. She was awarded the 2018 Early-Career
Researcher of the Year Prize by the Irish Research Council. In 2018, she
also received the Dublin City University President’s Award for Research.
Her work has been supported by the Irish Research Council, European
Commission, Gerda Henkel Foundation, Goria Foundation, and the Italian
Ministry of University and Research. She has extensively published on
social and political mobilisations, Iranian politics, migration, and academic
freedom. She is co-editor of Islamists and the Politics of the Arab Uprisings:
Governance, Pluralisation and Contention (2018) published by Edinburgh
University Press, and Continuity and Change Before and After the Arab
Uprisings: Morocco, Tunisia and Egypt (2015) published by Routledge.

xxi
 Abbreviations

Bassij (Sazman-e Basij-e Mostaz’afin)

Behzisti State Welfare Organisation (Sazman-e Behzisti-ye Keshvar)
DAB Students for Freedom and Equality (Daneshjuyan-e Azadikhah va
Barabaritalab)
DTV Office for the Strengthening of Unity (Daftar-e Tahkim-e Vahdat)
EC Expediency Council (Majma’-e Tashkhis-e Maslahat-e Nezam)
GC Guardians’ Council of the Constitution (Showra-ye Negahban)
IIPF Iranian Islamic Participation Front (Hezb-e Jebheh-ye Mosharekat-­e
Iran-e Islami)
IRGC Islamic Revolution Guards Corps (Sepah-e Pasdaran-e Enqelab-­e
Islami)
IRP Islamic Republic Party (Hezb-e Jomhuri-ye Islami)
JDK Second of Khordad Front (Jebheh-ye Dovvom-e Khordad)
JRM Association of the Combatant Clergy (Jame’eh-ye Ruhaniyyat-e
Mobarez)
KS Servants of Reconstruction (Hezb-e Kargozaran-e Sazandegi-e Iran)
MRM Assembly of the Combatant Clerics (Majma’-e Ruhaniyun-e Mobarez)
NGOs Non-Governmental Organisations
OM Organisation of the Mojahedin of the Islamic Revolution of Iran
(Sazman-e Mojahedin-e Enqelab-e Islami-ye Iran)
OMS One Million Signatures campaign (Yek Miliun Emza baraye Laghv-e
Qavanin-e Tabʽiz-e Amiz)

xxiii
 CHAPTER 1

Reformism and Political Participation in Iran

Political Change and Participation

Kaveh and Mohammad, activists from Tehran in their late thirties, do not
know each other but have a number of friends in common. Both were
active in Mir Hoseyn Musavi’s electoral campaign in 2009 in Tehran and,
after protests erupted in June 2009 upon the announcement of the
re-election of Mahmoud Ahmadinejad as president of the Republic, both
became very active in attending, organising, and participating in the pro-
tests that came to be known as the Green Movement.1 Kaveh and
Mohammad enjoyed a certain degree of popularity within activist circles,
because they had already been politically active as university students.
They had a network they could mobilise and indirect access to other social
circles outside Tehran. The marches, demonstrations, and sit-ins lasted
into 2010, and were met with increasing state violence. In 2010, both left
for Turkey where they became asylum seekers and where I met them in
2011 and 2012. Kaveh and Mohammad’s words reflected the excitement
and enthusiasm that characterised the days of the mobilisation in the

1
The Green Movement (jonbesh-e sabz) was the name by which the popular protests
erupted in 2009 in several cities across Iran came to be known. The movement objected to
the re-election of Ahmadinejad at the presidency and deemed it to be fraudulent. Jonbesh-e
sabz was a contested name, however, because some activists considered it to be too con-
nected to the reformist elite and excluding all other political traditions and subjectivities
involved in the protests. See Holliday and Rivetti (2016).

© The Author(s) 2020 1

P. Rivetti, Political Participation in Iran from Khatami
to the Green Movement, Middle East Today,
https://doi.org/10.1007/978-3-030-32201-4_1
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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