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Introduction
Welcome to Building DIYWebsites For Dummies, a book that focuses on building your own website from start to finish. It includes many secrets and best practices that web developers know and implement when building any quality website.
Throughout this book, I walk you through the steps of building a website in a way that streamlines the process and gives you the best result.
AboutThisBook
Building a quality website is not about learning how to use software. Anyone can learn to use software. Building a quality website is not about choosing a theme and uploading text and images. Anyone can take or find photos and write some text.
Building a quality website is about getting people to a thank you page, getting a phone call, an email, or a walk-in because they found your amazing website online, and they think you can solve their problem and want to engage with you. Building a quality website is also about building a website that search engines understand and want to match with Internet searchers when the search intent matches the offer of a website.
There is a lot that goes into building a website. This book teaches you how to think about your new marketing tool and take the most effective building steps in the best order possible. You discover how you can supercharge the tools and the platforms available today to build a website for your endeavor using sound best practices.
This book does not explain how to use software; anyone can learn to use software. Each web building platform also has support and documentation to help you.
This book teaches you all of the other “stuff” that web developers know about building great websites. It teaches you concepts that permanently empower you. You learn about tasks that you need to perform and learn why you are performing them. These concepts will make your digital marketing efforts better.
This book covers the thought process that goes into each step of building a website with the end in mind: more customers/visitors. Whether you end up building the site yourself or handing over the assets to a professional web developer, the skills you learn in this book will help you create websites that work!
ConventionsUsedinThis Book
I’ve established the following conventions to make it easier for you to navigate this book:
New terms are in italics, and I define them for you.
Website URLs are shown in this special font: https://wpengine.com/.
Bold text highlights key words in bulleted lists and action parts in numbered lists.
FoolishAssumptions
In writing this book, I’ve made some assumptions about you:
You want to enhance your organization's online presence.
You want to build a website that attracts visitors and converts leads.
You are not technical or might be semi-technical, but need guidance about how websites function.
You like being empowered.
I’ve used these assumptions to help explain how to build a tool that will work for you by preselling your products or services. My philosophy is that anyone can learn to use website-building tools to get their message out and resonate with visitors This book empowers you with the knowledge to help you market your business overall, not just teach you to click here or there.
HowThisBookIsOrganized
This book begins by helping you get set up. It then moves into thinking about the end users of your website: visitors and search engines. After you are in the right mindset, you will be well prepared (and hopefully excited) to get your content ready and display it with amazing results.
To make the content more accessible, I divided it into six parts:
Part 1, “Getting Started with DIY Websites,” includes lots of ideas about getting your domain name and web building space set up. One of the most frequent questions I see online and hear from soon-to-be DIY website builders is “Which platform is the best?” This part will help you determine the answer to that question.
Part 2, “Creating a Site That People Will Visit,” will get you in the correct mindset to create a site that attracts and converts leads. When you understand why you should perform particular tasks in particular ways, the task changes from a box you need to check off to a marketing strategy. Thinking this way will empower you and excite you to create something that will bring real results.
Part 3, “Architecting Plans for Your Website,” teaches you how to organize your content, what to include on your pages, why certain content will help you more effectively, and how to prepare these assets for the best result. You learn many of the professional tips and tricks that that “regular” people do not know. These concepts are not that difficult to understand, and I give you all of this info at once in an organized fashion.
Part 4, “Designing and Laying Out Your Website,” is the part that most of us think is where we should start when building a website. Once you have everything organized and prepared, it is so much easier to design and lay out your website, which is
why this information appears in Part 4. This section is where the rubber meets the road. If you take the time to prepare your content and work through the other parts of the book that come before this, you will be in a much better mindset to lay out and design an attractive website.
Part 5, “Going Live and Measuring Results,” covers all things SEO (search engine optimization), including optimizing your pages for web search, measuring your results (visits, clickthroughs, forms, and so on) using Google Analytics and other tools, and securing your website from fraud, malware, and hackers.
Part 6, “The Part of Tens,” includes the “cliff notes” to building websites. If you want to read this section first, go ahead, as it might help you think about the big picture.
IconsUsedinThisBook
In the margins of almost every page of this book, you find icons, which are there to alert you to different types of information. Here’s what they mean:
This icon saves you time and energy by explaining you a helpful method or technique for doing something.
This icon points out important information you need to know as you develop your website.
This icon points out potential problems and pitfalls to avoid, as well as positive solutions.
Feel free to skip over (and come back to) the technical information marked by this icon. However, knowledge is power, so it's wise to read them too.
This icon points out sage advice I provide from my years of experience in web design. I have made some mistakes along the way, and I provide advice so you don't have to make those same mistakes!
This icon indicates the presence of concrete examples that illustrate the topic being discussed. I give you examples of situations that have happened to me over the years.
BeyondtheBook
In addition to the book content, you can find valuable free material online. We provide you with a Cheat Sheet that serves as a quick checklist, including the basic supplies you need to draw, where to find inspiration, how to identify common drawing styles, and more. Check out this book’s online Cheat Sheet by searching www.dummies.com for Building DIY Websites for Dummies Cheat Sheet.
To download the Buyer Persona Template, which you learn about in Chapter 3, go to www.dummies.com/go/buildingdiywebsitesfd.
You don’t have to go through this book in sequence, but I suggest that you do to have the best result. It is tempting to just “get some tasks done,” which may be steps that come naturally later in the process. If you don't do the steps in order, and build a sitemap first, you could very well end frustrated, with a process that takes much longer. As Benjamin Franklin said, “if you fail to plan, you plan to fail.”
However, there are some sections that you can skip:
If you have a domain name, you can skip the section on registering a domain name in Chapter 2.
This goes also for a platform. If you have a website up and running and you will be using the same platform to build this new site, you do not need to read the section on choosing a platform in Chapter 2.
The information in this book is the fastest route to the best website for growing your business or endeavor. A route to more sales, faster traction, better user experiences, and trouble-free website functionality.
The practices you learn in this book also translate to social media marketing, email marketing, and more. This book teaches you how to build an online presence. It's more than about websites; it's about your reputation online. It's aboutthat first impression — that long-lasting relationship!
So, are you ready to get started? I’m excited for you! If you read this book and build something great, I would love for you to email me with what you built.
Part 1
Getting Started with DIY Websites
IN THIS PART …
Learning the basics about creating your website from the ground up
Registering your domain registrar and setting up your business email
Chapter 1 From Groundbreaking to Grand Opening: Constructing Your Website Step by Step
IN THIS CHAPTER
Setting up your site for success
Considering the best platform for your needs
Designing a look and feel that works
Getting and analyzing website results
You've embarked on an incredible journey with a remarkable goal: to build an website for your business or endeavor that attracts visitors and converts leads.
You may have tried to build a website in the past, but were left feeling frustrated, angry, or even worse, you lost time and money. Well, that is all over now. I am here to walk with you through every step of the process.
I've been working with people just like you for several decades and I know what questions you have. I know where you can get stuck. I know where a non-technical person needs some help. Most importantly, I know that you want to get the job done and don't want to repeat the process later! This chapter helps you set the stage for building an excellent website and outlines the sequence of steps you'll follow to build an effective, compelling, and modern site that best represents your organization online.
Another random document with no related content on Scribd:
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 gallbladder 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 gallbladder 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 gall-bladder by a previous process of ulceration, and usually into the duodenum, rarely into the colon.
Symptoms.
—Symptoms of this condition, thus produced, will obviously be those of acute obstruction from any cause, the most marked features being severe pain and early frequent vomiting. Bile may be raised in quantities because of the biliary fistula so near the stone, and from which it is supposed to have escaped. The higher the exciting cause the more violent the symptoms and the less the distention of the abdomen by gas. A significant history may help in assigning the cause for the evident obstruction.
Treatment.—Since more than half of these cases treated expectantly die without relief early operation is to be urged. It should always be preceded by lavage in order that the stomach may be thoroughly emptied. When a stone has been exposed within the intestine it is advisable to open the bowel a little below where it rests, so as to make the division at a point where the chances of repair are not compromised by previous excitement. In severe cases a temporary enterostomy may be made, but this should of necessity be high. The volvulus may be relieved by untwisting the kink or by an anastomosis. Obstruction due to adhesions will require separation of these adhesions, with perhaps an anastomosis.
CHOLELITHIASIS, GALLSTONE OR BILIARY COLIC, BILIARY CALCULI.
There is so much which may be said about the formation of gallstones and the troubles which they may produce that it is necessary here to epitomize as much as possible and to refer mainly to the surgical features of this condition. Gallstones are of all sizes, from the most minute to that of a hen’s egg, are present in numbers varying from a single calculus to thousands of calculi, are found commonly in the gall-bladder, in the cystic duct, or in the common duct, but occasionally are met with just escaping into the duodenum, through the duodenal ampulla, or in the smaller ducts of the liver or the main hepatic duct (Fig. 627). In at least 99 per cent. of cases they will be seen in one of the locations first mentioned. Pages might be devoted to a discussion of the reasons for their formation. That cholesterin, their principal component, should more readily deposit in such a way as to produce these calculi, and more often in some individuals than in others, is hard to explain, but may be held to be largely due to its formation in excess in certain individuals and to concentration of those fluids which hold it in solution. Increase of cholesterin seems to be connected with catarrh of the membrane which produces it, and thus stagnation of bile may predispose. That bacteria have much to do with biliary calculi is now conceded, and a history of typhoid is obtainable in many cases. It
F . 627
has been shown experimentally that aseptic foreign bodies introduced into the gall-bladder remain indefinitely without becoming covered with precipitate, while virulent organisms set up disturbance, and only the attenuated or moderately infectious organisms produce calculi, and usually then only when some trifling foreign body is introduced at the same time. It will thus be seen that a nidus may be afforded by a clump of epithelial cells or débris. It is not at present so much a question of what organisms are at fault, although they are usually the colon and typhoid bacilli and the ordinary pyogenic organism. It has been shown, moreover, that in typhoid fever the gallbladder is often invaded, and that the typhoid bacilli may live there indefinitely, and that they tend to clump or agglutinate themselves in a very suggestive way into trifling masses which may serve as minute foreign bodies. Thus each predisposing factor reacts upon
Gallstone presenting at the ampulla of Vater, i. e., endeavoring to escape into duodenum. (Pantaloni.)
the other, and by a vicious circle either an acute lesion may be established or calculi may be formed in varying numbers.
Gallstones have been found in the newborn, but are relatively infrequent below the age of twenty-five, and are most common in the later years of life. The condition is by four to one more frequent in women than in men. The only predisposing habit seems to be such lack of exercise as gives no expulsive movement to the gall-bladder by action of the abdominal muscles. They are more common in the gouty and in those predisposed to uric-acid diathesis, while abundance of nitrogen seems rather protective. Biliary calculi have never been found in the wild carnivora.
McArthur has formulated the following conclusions of interest in this connection:
1. Not all gallstones originate within the gall-bladder.
2. The origin of a cholesterin stone is probably the gallbladder, with subsequent accretion, either in passing through, or in the duct, where it may have lodged.
3. Bilirubin calcium is the principal constituent of the smaller intrahepatic duct stones.
4. Calculi in immense numbers may exist for months in the ducts without producing serious symptoms.
5. Under these circumstances the surgeon need not reproach himself if there be recurrence of symptoms after common duct drainage.
Biliary calculi are serious menaces to a patient’s welfare, not alone because of the obstructive symptoms which they may produce, but because of the acute or chronic conditions to which they indirectly give rise. These have been in some degree already mentioned. Thus cholecystitis and cholangitis of all degrees of severity, from the milder chronic forms to the phlegmonous and fulminating varieties, may be at least associated with the presence of such calculi and seem to be to a greater or less extent due to their presence. Around such foci of excitement there will always occur local peritonitis, which will result in adhesions, and the consequent tenderness with referred as well as local pains to which it necessarily gives origin. The viscera suffer not only in this direct way, but functional disturbances are produced, and are usually covered under those vague terms
“dyspepsia” and “indigestion” with which patients crudely describe their discomforts, and under which physicians too often conceal their failure to appreciate the actual condition.
Furthermore there is always a possibility of cirrhosis resulting, because of distention of the hepatic ducts and backing up of the hepatic secretion. Thus the liver becomes larger and more dense, is colored green, its edges become more rounded, this occurring especially in the right lobe, or at least attracting more attention in that location because more easily recognized from without. Again the more acute inflammatory conditions sometimes cause paralytic ileus, or at least paralysis of the lower bowel, and thus lead to conditions almost identical with, and difficult to distinguish from acute intestinal obstruction.
Of equally great and growing importance is the fact that, according to Schroeder, some 14 per cent. of gallstone sufferers develop cancer, the presence of these irritating foreign bodies in the biliary passages having much the same relation to cancer of the liver as does the existence of previous ulcer to cancer of the stomach.
Symptoms.
—There is scarcely any morbid condition which is at one time characterized by such significant symptoms and at another by none at all as cholelithiasis. In rehearsing the list of the ordinary symptoms produced by the conditions exceptions should be made, for no matter how complete the list something may be omitted which has been noted in some particular case.
Gallstones confined within the gall-bladder proper may produce few or no symptoms, this being particularly true so long as the ducts are free and there are no persistent consequences of previous acute trouble. A stone may grow in the gall-bladder to a large size and cause little or no distress until it begins to work its way by the ulcerative process. Doubtless small concretions pass with little or no disturbance, or only that which would be considered a “temporary dyspepsia.”
When, however, gallstones produce symptoms these usually include more or less paroxysmal pain, occurring unprovoked and at irregular intervals, referred not alone to the upper abdomen, but radiating to the rest of the trunk, as well as in the direction of the right shoulder-blade. (The shoulder pains of biliary and renal lesions
are due to the connection of the pneumogastric nerves with the ordinary sensory nerves above, and below with the sympathetic ganglia.) Attacks of pain are usually followed by nausea and vomiting, and if extremely severe by more or less depression and collapse. At times there will be a sensation as of distention in the region of the gall-bladder. Tumor in this location may or may not be present, and jaundice is an uncertain symptom, not occurring unless the ducts are occluded. The stomach so far sympathizes that digestion is at least temporarily disordered. In proportion as angiocholitis is produced by the passage of calculi we may meet with more or less septic features. The pain produced is uncertain in severity and duration, and is often relieved by the relaxation which may accompany or follow vomiting. After subsidence of severe pain there remains a dull ache for several days, lasting perhaps until another acute paroxysm. These pains are sometimes referred to the left side and over the stomach, in which cases it will usually be found that the gall-bladder is adherent to the stomach, while when the pain is felt in the right side of the thorax it is usually because there are numerous adhesions between the lower surface of the liver and the viscera below it. Such pain may even simulate angina pectoris or may involve the genitocrural distribution. In fact it may be referred to almost any part of the body.
Vomiting which is at first paroxysmal and colicky may become persistent, continuous, and even dangerous. It is essentially an expression of pneumogastric irritation. The vomited matter may contain bile or even, by retrostalsis, fecal matter. The depression which at first occurs may merge into complete collapse; it may even be fatal. It will necessarily be more marked when the paroxysms are more frequent.
A significant feature in nearly every case is muscle rigidity, especially of the upper abdominal muscles on the right side, but not necessarily confined to these. This muscle spasm is a symptom common to many serious conditions and is not of itself indicative. It simply implies a serious condition within. Tumor or enlargement in the region of the gall-bladder may be met with, but are by no means constant. These may become more pronounced with each attack, being reduced between times because of the escape of bile between
paroxysms. It is a valuable symptom when noted, but no importance should be attached to its absence.
The presence of gallstones in the stools is, of course, indicative, but most valuable time is often wasted when waiting for their discovery. Moreover, a number of hours, or even days, may elapse, the time depending on the activity of peristalsis, between the escape of calculi into the duodenum and their appearance in the stools. A convenient way to search for them is to let the stool be stirred with a 1 per cent. solution of formalin and then strained through a sieve which has about sixteen meshes to the inch. The question of the wisdom of operation can practically always be decided without reference to the appearance of calculi. In this way the surgeon may feel that his diagnosis is corroborated by it, but in no sense weakened without it.
Jaundice is always a significant sign when present, but is absent in at least four-fifths of cases which nevertheless should be subjected to operation. Its occurrence is a matter of interest along with the previous history of the case. It is, however, of great value if it were noted in connection with the first pains or cramps. In chronic obstruction by stone in the common duct it is important to determine the intensity of the jaundice, since this may indicate whether we deal with calculous disease or obstruction from tumor. In chronic obstruction by stone the color changes are less marked, and often clear up entirely, while when produced by tumor they become gradually more intensified.
Deep and persistent jaundice is suggestive of malignant disease. The degree of cholemia rather predisposes these patients to hemorrhage or persistent oozing during operation. Jaundice gradually deepening with each attack of pain is also very suggestive. Such attacks, coming on with symptoms like those of malaria, chill, sweating, and pyrexia, are extremely suggestive and always call for surgical intervention, i. e., drainage. In brief it may be said that jaundice, with enlargement of the gall-bladder, is at least suggestive of cancer, while a history of gallstone colic, without much enlargement of the gall-bladder, is indicative of stone in the common duct. Although this statement is probably true for the majority of cases there are occasionally marked exceptions to it, as, for
instance, when a gall-bladder is distended with hundreds or even thousands of small calculi, or to such an extent that it may form even a pear-shaped tumor hanging down within the abdomen.
In addition to these features thus rehearsed there might be made a long list of possible “extras,” by which the original condition is complicated and made to appear in unusual aspect or even life endangering. Such a list would include nearly every imaginable lesion of the upper abdomen. Suffice it to say that the liver, stomach, and the pancreas especially may suffer, while other viscera and the larger veins, with the surrounding tissue, may any or all of them become involved.
Diagnosis.
—Diagnosis has to be made mainly from non-calculous obstruction; from the acute gastric conditions, ulcer, etc.; from renal colic; from the acute or subacute pancreatic affections, duodenal ulcers, renal lesions, localized peritonitis from some other cause; from cancer, lead colic, angina pectoris, pneumonia, pleurisy, and even hysteria. Not so rarely pneumonia and pleurisy begin with pains which are referred to the upper abdomen and are suggestive of gallstone disease, while they seriously perplex the medical attendant. Much stress is to be laid on the first location of the pain, especially if this be in the direction of the right shoulder, and upon concomitant vomiting and jaundice, if present, as well as on the location of the greatest tenderness and muscle rigidity. Recurrence of more or less similar attacks is also suggestive. Diaphragmatic pleurisy may cause pain, referred especially along the esophagus, and intensified during the act of swallowing or vomiting. Affections of the appendix and gall-bladder may co-exist, as well as be easily mistaken one for the other. The former is so true that when operating for one condition it is always advisable to explore in regard to the other. When the appendix is placed high, especially behind the colon, confusion may confound. Biliary colic is usually free from the associated ordinary symptoms which are so often met with in renal colic, while in the latter the urine will contain no bile pigment and the pain will usually be referred to the external genitals. In lead colic the characteristic line upon the gums and the habitual constipation which always accompany it will be suggestive. When the stomach is at fault and the pylorus
obstructed this viscus will usually be dilated, and the vomit is of a different character, while, at the same time, actual stomach movements may or may not be made visible. With gastric or duodenal ulcer pain it is more regular and associated with food taking after a definite interval, longer in the latter case.
Chronic pancreatitis is so often associated with cholelithiasis that it is impossible to disassociate their symptoms, but the referred pain is rather midscapular or even on the left side. It will be particularly suggested by rapid loss of flesh. In acute pancreatitis the symptoms are usually more excessive, the distention earlier and greater Cancer of these various organs does not commence with pain, but has a more gradual, distinctive downward course, with cachexia. These are some of the considerations which may aid in differential diagnosis.
The detection of bile pigment in the urine and blood will have corroborative value.[63]
[63] Hanel has shown that a small capillary tube filled with blood, sealed at both ends, may afford a convenient corroborative test After standing for a few hours in a vertical position its separated serum can be examined against the light Normal serum is colorless, while even a trace of bile pigment will give it a distinctive yellow tint
Baudouin’s test for the urine will be the most satisfactory in the matter of precision and simplicity. If two or three drops of a ¹⁄₂ per cent. solution of fuchsin be dropped into urine containing bile it immediately develops a fine orange tint, in marked contrast with its own red No other coloring matter in the urine gives this reaction; which is very delicate (Mayo Robson ) Methyl blue and methyl violet each give a reddish tint; Loeffler’s blue solution gives a green tint which vanishes on heating, to reappear on cooling There are numerous other tests, but these are the simplest and most satisfactory
Treatment.
—The general subject of cholelithiasis and its associated lesions constitutes an important topic in the so-called “border-land” between medicine and surgery, where views and advice regarding prognosis and treatment will depend on the experience and the training of the medical attendant. Surgeons now recognize, and physicians are being gradually converted to their view, that gallstone disease is essentially a surgical disease, i. e., one to be combated by surgical intervention. While it is not to be
gainsaid that many patients live and die with gallstones who are never conscious of their presence, and while others who have had serious attacks live to die of some other disease, nevertheless the general statement may be boldly made and easily defended, that when the disease is well marked and when patients suffer more or less constantly from it the only successful method of treatment is the surgical, and that, in other words, operation offers the only prospect of permanent relief. Regarding its associated dangers it may be said that danger comes from delay rather than from operation, and that here, as with many other conditions, patients often wait too long, partly from lack of proper advice, partly from timidity, and that a septic and moribund patient, allowed to become so for lack of earlier application of the resources of surgery, is a reflection on the one who waits rather than on the surgeon, who, endeavoring to save, still unfortunately loses his patient.
This is not the place to discuss non-operative measures—i. e., medicinal and dietetic treatment—valuable as they may be in certain cases. Most of the drugs which are supposed to be effective in their power of solution of gallstones or of facilitating their escape are disappointing, and at best are vague and uncertain in their action. The hydrotherapeutic treatment, such as carried out, for instance, at Carlsbad, will do good in many cases, especially for those who have been indulgent in their appetites and careless in their habits. Cases of any description not too far advanced would be benefited by a careful regimen of this character, but that Carlsbad or any other waters will certainly cure cholelithiasis is now absolutely disproved. As a preparation for operation a sojourn at some such place may be advised; as a substitute for it, never. Large doses of glycerin (50 to 150 Cc.) often temporarily relieve the pain of biliary colic.
In general, then, it may be said that cases which give a history of recurring attacks of biliary colic, with or without recurrent jaundice, and with those varied concomitant symptoms which are usually grouped under the term “indigestion,” in which there is definite tenderness over the region of the gall-bladder, with or without muscle spasm, and with the other referred pains so often present in this condition, should be regarded as legitimately surgical, where operation is more than justifiable and usually decidedly advisable,
even too often imperative. The same is true of those cases of distended gall-bladder with obstruction of the duct where perhaps no calculi are present, but where the patient suffers in much the same way as though they were present. Biliary drainage is equally called for, and the presence or absence of calculi is but a minor feature upon which too much stress should not be laid nor too much disappointment expressed if they be not found.
Many cases of chronic cholelithiasis have become more or less toxemic, as well as cholemic. It is a well-recognized fact that cholemic patients are more likely to cause inconvenience to the surgeon from free hemorrhage or persistent oozing, because of the slowness with which coagulation of their blood takes place. When time is afforded for preparation it is of great value in these cases to administer calcium chloride, of which several doses may be given each day, in considerable water, the former varying in amount from 1 to 2 Gm. When time suffices, too, it is always of value to prepare these patients for the operation by measures already discussed, improving their elimination, reducing the degree of their toxemia, and fortifying their circulatory systems by well-known measures. The value of such preparation is perhaps more apparent in such instances than in most others. On the other hand, many cases calling for operation are almost as imperative as those of acute appendicitis, where every hour’s delay is to the disadvantage of the individual. The operations which are practised upon the biliary tract will all be discussed together in a section by themselves.
TUMORS OF THE GALL-BLADDER.
This expression refers rather to actual neoplasms of the gallbladder itself than to distention of the sac by which an intraabdominal tumor may be formed. The latter subject may be dismissed with the mere statement that the gall-bladder may become distended with bile, with mucus, with pus, with concretions, or with the products of such disease as echinococcus, actinomycosis, etc. In this way it may be so much enlarged as to be easily felt through the abdominal walls or to be even mistaken for other conditions. In the latter case it may have to be differentiated between such a condition
and a movable right kidney, a tumor of the kidney itself or of its capsule, as well as from tumors of the stomach, especially the pylorus, of the liver, or of the intestine and from the enlargement of the right lobe which often accompanies cholelithiasis, or from fecal impaction. It would be best to abstain from the use of the aspirating needle in these cases, as more harm might be done by the escape into the abdomen of deleterious fluid than would be atoned for by the information which the procedure would afford. Even when the abdomen is open the gall-bladder should rarely be punctured in this manner, unless one is prepared at the same time to open it and drain. In other words, there is less risk about a small exploratory incision than in puncture.
Nearly all varieties of malignant and many of benign tumors have been reported as occurring in this location. It will be sufficient in this place, however, to say that cancer of the gall-bladder, which, of course, may extend in various directions, is by no means an uncommon affection, and is usually a complication of gallstones. In fact, it may be doubted whether primary cancer of the gall-bladder ever occurs in the absence of such a source of irritation. These cancers vary in type between the round-cell and the squamous, most of them, however, being of the former character. Although Musser has put the percentage at 65 and Zenker as high as 85 of instances where gallstones are found within cancerous gall-bladders, it does not follow that the above statement may not be true regarding their almost universal association and causal relation, for any gall-bladder found empty at a given time may at some other time have contained a calculus. This frequent association is justly among the valid arguments which surgeons may now use in making a plea for earlier operation, and for making it a more standard procedure.
Cancer may be suspected in cases of progressive and unintermittent jaundice, especially when there can be felt in the region of the gall-bladder a distinct tumor or an enlargement of the liver Pain is a frequent but by no means a constant or reliable symptom. As the disease spreads the adjoining textures will become matted together, and a low grade of local peritonitis may still further cement them into a mass which will occupy a considerable portion of the upper part of the abdomen.
But few cancers of the gall-bladder which are so apparent as to be recognized without exploration can be considered as still amenable to surgery, which for them can hold out but little prospect save perhaps a temporary relief by biliary drainage. It is the cases in their earlier stages, when the condition is made out by exploration, and by it alone, which still afford prospects of more or less permanent relief. The very impossibility of detecting the condition in these earlier stages without exploration affords one of the strongest arguments for such a procedure in every vague case of the kind. That cases of this character are not necessarily hopeless is instanced by an experience of my own, where on opening the abdomen of a large and fleshy woman I found a distinctly cancerous gall-bladder containing two large calculi, and removed the entire mass, with a considerable portion of the surrounding hepatic tissue, the removal being effected with the actual cautery. At present date of writing, nearly six years after the operation, the patient is apparently perfectly well and doing her own housework.
OPERATIONS UPON THE GALL-BLADDER AND BILIARY PASSAGES.
The small area included under the above title has been made the field for a variety of operations, dignified with formidable names, the entire list of which might be made quite long. In order to simplify their arrangement and illustrate their purposes they may be referred to as (1) operations upon the gall-bladder proper; (2) those upon the ducts; and (3) the more complicated operations upon one or both of these in connection with some other part of the intestinal tract; or, to catalogue them somewhat definitely, the operations upon the gallbladder include cholecystotomy, cholecystostomy, and cholecystectomy, according as the surgeon opens the gall-bladder and closes it, makes a more or less permanent opening, or completely removes it. Again, upon the ducts he may make cholangiotomy or cholangiostomy, or, using their practically equivalent synonyms, choledochotomy or choledochostomy, these terms referring to operations upon the cystic and the common ducts; while when similar procedures are applied to the hepatic duct they
have been spoken of as hepaticotomy and hepaticostomy Cholecystenterostomy refers to an anastomosis between the gallbladder and the upper bowel, while when this is effected between the common duct and the bowel it is referred to as choledochenterostomy. When a stone lies partly in the common duct and partly within the wall of the duodenum, and it becomes necessary to incise the latter, it may be spoken of as duodenotomy. The operation of merely crushing biliary calculi, hoping that the fragments will be passed on with the flow of bile, and spoken of as cholelithotrity, is now almost abandoned, and the term has historical rather than present value.
To even attempt to epitomize directions for these various operations into space available here would be impossible, for large volumes have been devoted to this subject alone. The main thing for the student and the junior practitioner is to appreciate the indications for their performance, at which he should certainly have assisted before attempting to perform them himself. General directions, however, may be given as follows, the usual preparations having been made both of the patient and the environment: A woman who has borne children and who has, in consequence, relaxed abdominal walls, makes a more favorable subject for operation than a muscular man whose abdominal muscles cannot be relaxed until a profound degree of anesthesia has been obtained. In many instances exposure is made better by placing a sandbag behind the region of the liver, especially on the side to be operated, by which the costal angle is more outlined and the parts pushed forward.
A preliminary incision should be made of, say, three inches in length, and is best placed a little to the inner side of the outer border of the rectus, whose fibers are separated and its tendinous intersection divided. This incision may be extended upward and curved toward the middle line, as recommended by Bevan, or downward, as the exigencies of the case may require. The beginner especially should provide himself with sufficient space for manipulation. The posterior sheath of the rectus and the peritoneum are best divided together. Sufficient opening being thus made, a finger may be inserted for the purpose of exploration. In the presence of adhesions, and especially in acute cases in which pus is
likely to be present, this should be done with great caution. When no adhesions are present gauze pads may be inserted and so disposed as to permit exposure to view of the lower surfaces of the liver. The operator should be prepared for any and all conditions—one of dense adhesions or their complete absence, as well as for cobweblike adhesions which surround foci of infected exudate or of pus. The more reason he may have for suspecting the presence of pus the more carefully should the region be walled off with protective gauze. Adhesions are most likely to form between the omentum and the colon, in front and below, and with the stomach, duodenum, and colon below and behind. Those who have had experience with abdominal operations will appreciate whether these adhesions are recent and likely to cover purulent foci, or old, and will proceed accordingly. Occasionally tissues will be so matted that even an experienced operator will scarcely be able to differentiate them.
The endeavor should be, if possible, to expose the gall-bladder itself, both to touch and sight, in order that after orientation concerning its actual condition its duct may be followed into the common duct, and this into the intestine. This is sometimes an exceedingly easy matter, and again impossible. The presence or absence of pus will of itself indicate what should be done. When, for instance, the gall-bladder is found black or partly gangrenous the surgeon will content himself with doing the least possible amount of separating, endeavoring rather to provide the widest outlet for drainage. It might be better to make simply a small opening and permit the escape of fetid débris, and to postpone until a later day further attempt to remove the calculus, which presumably has produced the difficulty. Local indications, then, should be considered along with the general condition of the patient.
The lower surface of the liver will afford the guide to the location of the gall-bladder, and when the latter is nearly obliterated its discovery sometimes taxes the resources of the surgeon. When not contracted it is usually easily exposed, and so far freed that it may be even drawn up into the wound. After having thus isolated and perhaps secured it, it must be decided by further exploration how it shall be treated. It is of great importance to liberate the ducts from surrounding adhesions.
Cholecystotomy.
—Cholecystotomy, sometimes fallaciously spoken of as ideal, consists in simply opening the gall-bladder, emptying it of calculi or other contents through a small incision, and closing this by sutures. The operation is ideal in but one way, but conditions which permit it rarely justify it, for any gall-bladder so diseased as to call for operation needs either removal or drainage.
Cholecystostomy.
—Cholecystostomy includes provision for drainage over a considerable length of time. A distended gall-bladder which permits of easy manipulation and isolation may be sufficiently long and large to justify uniting its surface to the peritoneum and deep margins of the wound, in such a way as to permit discharge of its contents through the latter. The old method was to unite it to the skin. This should never be done, as fistulas thus resulting are more likely to be permanent. If the gallbladder be thus affixed to the parietal peritoneum the better way is to insert a drain, its arrangement being left somewhat to the choice of the operator. For my own part I prefer a rubber tube, not too flexible, inserted two or three inches into the gall-bladder, through a small opening closed around it, with invaginated edges, by a purse-string suture of chromic gut, by which it is intended to prevent leakage into the abdominal cavity. By another suture of common gut the tube may be so fixed as to avoid danger of being lost in either direction. If the gall-bladder be sufficiently long to permit additional fixation to the depths of the abdominal wound the operation is made still more ideal; but in the case of a short and contracted cavity the tube may be left to follow it into the abdominal recesses. Within forty-eight hours the exudate which has been thrown out around it will have become sufficiently organized and well ordered to form a canal in which the tube shall rest, and which shall serve later as a conduit to conduct bile to the surface after removal of the tube itself. Into such a tube, after the application of the dressings, may be conducted another more flexible tube, whose upper end shall connect with a receptacle of some kind, which may later be a bottle held within the dressing, to receive the discharge, and thus avoid soiling. This operation has been done occasionally in two sittings, the gallbladder being brought into the upper part of the wound and fastened
to the peritoneum by sutures, which should not perforate its walls, as that leakage would occur which the method is intended to avoid. After waiting a day or two for adhesions to form the cavity is then opened with a knife or scissors and drainage thus accomplished. This method has been practically abandoned, for the reason that it permits no digital exploration by combined manipulation.
Cholecystectomy.
—Cholecystectomy includes the removal of the whole or the greater part of the gall-bladder. It has already been stated that this is a reservoir, convenient and advantageous, but not needed in a way, and not essential to life. It figures as a superfluous organ, then, similar to the appendix, and there is no reason why, when diseased and troublesome, it should not be extirpated. Its removal will sometimes be a matter of choice, and at other times a necessity. The former is the case when the surrounding conditions lend themselves to its dissection from the lower surface of the liver without too much violence to other tissues; the latter when it is involved in malignant processes or when its interior is seriously infected. An incomplete method of treating the gall-bladder under the latter circumstances might include the scraping or removal of its thickened mucosa, without removing the entire thickness of its structure. In this case, however, drainage would be required. That the gall-bladder may be completely separated and thus isolated, with comfort and speed, requires that its wall be sufficiently strong to stand the ordinary manipulation. This may not be true of the perfectly normal gall-bladder, but in such case no one would think of removing it, whereas the cyst, which is diseased sufficiently to justify removal, will usually permit of the necessary manipulation. Even if somewhat torn in the process the procedure may be effected without much added difficulty. This procedure consists essentially in separation of the overlying peritoneum and enucleation of the gall-bladder from its bed or the depression in the liver in which it lies, which, as already indicated, may be narrow or wide and deep. Actual separation from liver tissue will be followed by oozing and at least two or three vessels in the surrounding structures and at the neck of the gall-bladder will require to be secured. Removal should not be attempted in cases which do not permit of it, but may be practised in those cases not too infected,
when after emptying the sac (full of calculi, for instance) it can still be established with the probe that the common duct is patulous. These are ideal cases for such complete work. The gall-bladder having thus been isolated down to its cystic termination, the surgeon proceeds much as though it were the appendix, by firmly ligating the duct with chromic gut, guarding against escape of contents while it is divided on the distal side of the ligature thus applied. The stump of the duct is then cauterized with pure carbolic, after which oozing is checked by tamponing for a few moments. It then is often possible to bring together the peritoneum beneath the torn liver surface and almost completely cover it anew. The liver tissue will bear a ligature or suture not too tightly drawn. If the case have been one otherwise surgically clean, and the operation properly conducted, the abdominal wound may be closed without drainage. If, however, doubt be felt a small cigarette or a tubular drain may be placed, to be left not more than thirty-six hours. Every infected gall-bladder, if not removed, should be thoroughly cleansed, its interior being mopped with gauze, preferably with the addition of hydrogen dioxide. An important step, next to attention to the gall-bladder proper, is to demonstrate the patency of the ducts. This is done by gently passing a probe, which should be bent to suit the case, along the duct and into the intestine. This, of course, cannot be done if calculi are discovered by manipulation, neither can it always be done when calculi are not present. Gallstones in the duct can usually be distinguished by the fingers with which the exploration is made, and failure to thus pass a probe may be brought about by stricture rather than by calculous obstruction. The importance of this determination will be seen in removing the gall-bladder, as to remove it in an obstructed case is to leave no outlet for bile except into the abdominal cavity, whereas to fail to drain such a case is to plainly neglect to meet the indication.
