Ludwig Courvoisier

Ludwig Georg Courvoisier

Ludwig Georg Courvoisier (1843 – 1918) was a Swiss surgeon.

Recognised as a pioneer in surgery of the biliary tract, he was the first surgeon to successfully perform a choledocholithotomy and for developing the early operative techniques for cholecystectomy.

Courvoisier was a respected entomologist and botanist


Biography
  • Born 10 November 1843, Basel
  • 1868 – MD from the University of Basel
  • 1870 – Served in a military hospital in Karlsruhe during the Franco-Prussian war
  • 1871 – Worked for 30 years in the Diakonissenspital in Riehen while running a successful private clinic in Basel
  • 1988 – Appointed visiting Professor of Surgery at the University of Basel
  • 1900 – Appointed full Professor of Surgery at the University of Basel
  • Died 8 April 1918, Basel.

Medical Eponyms
Courvoisier Sign (1890)

Courvoisier’s sign or law refers to Courvoisier’s observations that palpable gallbladder distension in jaundiced patients is unlikely to be caused by gallstones.

Courvoisier published a manual on biliary surgery ‘Casuistisch-statistische Beiträge zur Pathologie und Chirurgie der Gallenwege’, in which he described 187 cases of common bile duct obstruction, making the observation that gallbladder dilatation seldom occurred with stone obstruction of the bile duct. He made his observations in a time without ultrasound, CT, MRCP or ERCP

Original
English

Theile ich sämmtliche für diese Untersuchung verwendbaren 187 Fälle in 2 Hauptgruppen, so erhalte ich 87 Steinobstructionen, 100 andre Obstructionen. Wegen ihrer annähernd gleichen numerischen Stärke lassen sich beide gut vergleichen! Nun collidiren mit den Steinobstructionen weitaus am haüfigsten die Gallenblasenatrophien (70:87 Fällen = 80,4%), viel seltener die Ectasien (17:87 = 19,6%). Die andern Verschlüsse dagegen treffen viel seltener mit Atrophie (8:100), viel haüfiger mit Ectasie (92:100) zusammen. Oder anders ausgedrückt: Bei Steinobstruction des Choledochus ist Ectasie der Gallenblase selten; das Organ ist vorher schon gewöhnlich geschrumpft. Bei Obstruction andrer Art ist dagegen Ectasie das Gewöhnliche; Atrophie besteht nur in 1/12 dieser Fälle

Courvoisier 1890: 57

In a collection of 187 cases, two main groups were usable for this investigation: 87 stone obstructions and 100 other obstructions. Because of their approximately same numerical strength, they can be compared well. Gallbladder atrophy with stone obstruction (70:87 cases = 80.4%) was more common than the rare ectasia (17:87 = 19.6%). With other causes of obstruction to the choledochus, it is rarer to see atrophy (8:100) than ectasia (92:100). Or differently expressed, with stone obstruction of the choledochus, ectasia of the gallbladder is rare; usually, the organ has already shrunk. Ectasia is usual with obstruction of other kinds; atrophy exists in only 1 of 12 of these cases

Courvoisier 1890: 57

Although often described as a ‘law’ and related to malignancy, Courvoisier fell short of making such a definitive statement. It is unclear when this observation became a ‘law’ in the literature. He stated that in cases of a palpable gallbladder in the presence of an obstructed bile duct, that stone obstruction is less likely and that ‘‘other causes’’ (without specifying diagnoses) are more likely.

Original
English

Dieses Ergebnis der Untersuchung ist mir überraschend genug gewesen. Gewöhnlich wird in den Hand- und Lehrbüchern angegeben, Steinobstruction des Choledochus führe durch Gallenstauung zu Gallenblasenerweiterung. Ich finde das gerade Gegentheil und muss das Fehlen einer Ectasie bei Verlegung des Gangs geradezu als charakteristisch für Stein, ihr Vorhandensein als bezeichnend für sonstige Occlusion betrachten. Wenn sich das noch weiter bestätigen
sollte, so wäre damit ein wichtiger Anhaltspunkt für die differentielle Diagnostik gewonnen!

Courvoisier 1890: 58

It is usually stated in the manuals and textbooks that stone obstruction of the choledochus leads to enlargement of the gallbladder by biliary obstruction. I do not find this to be true, and must consider the absence of dilation of the gallbladder due to a gallstone and the presence of gallbladder dilation due to other causes of obstruction. If this were to be confirmed further, this would be an important point of reference for the differential diagnostics!

Courvoisier 1890: 58

The presence of a distended, palpable, non-tender gallbladder in a jaundiced patient is 83 – 90% specific with a sensitivity of only 26 – 55% for malignant obstruction of the bile duct. The sign has been described in a number of conditions including chronic pancreatitis; cholelithiasis; choledocholithiasis; Hartmann’s pouch obstruction; chronic autoimmune pancreatitis; congenital choledochal cysts; and parasitic obstruction of the biliary system.

Original
English

Uebrigens ist die Erklärung für diesen Unterschied nicht schwierig. Laut früherer Darstellung (p. 47) stammen die Choledochussteine in der Regel aus der Gallenblase. Auf ihrem Weg aber haben sie, wie eben dort gezeigt worden ist, den Cysticus und zum Theil die Blase gereizt und in beiden deutliche Spuren eines erzwungenen Durchtritts in Form einer chronischen Entzündung der Wandung hinterlassen, welche häufig zuletzt zur Schrumpfung jener Behälter führt. Ist nun die Gallenblase so verändert, so wird auch die stärkste Gallenstauung sie nicht mehr ausdehnen können. Bei den meisten andern Obstructionen, speciell bei denjenigen durch drückende Geschwülste, findet die andringende Galle eine normale, nachgiebige Blase vor!

Courvoisier 1890: 58

According to the earlier account (p. 47), the stones in the common bile duct originate from the gallbladder. On their way, however, as they have been shown, the stones as they pass irritate the cystic duct as well as the gallbladder and this irritation causes chronic inflammation of the gallbladder wall, which often leads to a shrinking of the duct and gallbladder. If the gallbladder is altered, the strongest biliary stasis will no longer be able to expand it. In most other cases of obstruction, especially those due to tumor, bile flow shows a normal compliant gallbladder!

Courvoisier 1890: 58

While Courvoisier never specifically referred to malignancy or pain in his original observations, Courvoisier’s sign, law or, occasionally, gallbladder, has been erroneously defined and perpetuated over the years to include these terms.


Major Publications

References

Biography

Eponymous terms


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Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM with a passion for rugby; medical history; medical education; and informatics. Asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | vocortex |

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