Compliments of the Author.

Surgical Relief for BiliaryObstruction.

BY

HENRY O. MARCY, A.M., M.D., LR.D.,OF BOSTON.

SURGEON TO THE HOSPITAL FOR WOMEN, CAMBRIDGE, ETC.

Read in the Section of Surgery and Anatomy, at the Forty-firstAnnual Meeting of the American Medical Association, at

Nashville, Tenn., May , iBgo.

Reprinted from the “Journal of the American MedicalAssociation,’’ December 20, 1890.

CHICAGO :

Printed at the Office of the Association1890.

Compliments of the Author.

Surgical Relief for BiliaryObstruction.

BY

HENRY O; MARCY, A.M., M.D., LE.D.,OF BOSTON.

THE HOSPITAL- FOR WOMEN, CAMBRIDGE, ETC.

Read in the Section of Surgery and Anatomy, at the Forty-firstAnnual Meeting of the American Medical Association, at

Nashville, TennMay, iBgo.

Reprinted trom the “Journal of the American MedicalAssociation,” December 20, 1890.

CHICAGOPrinted at the Office of the Association

lBqo.

SURGICAL RELIEF FOR BILIARY

OBSTRUCTION.

The surgery of the gall bladder opens anotherand an extremely important field for operative in-terference. Biliary obstruction has been, fromthe earliest times, recognized as a cause of mostsevere suffering attended with the gravest dangers.

With very few exceptions, operations for itsrelief have been considered beyond the pale ofsurgical domain, until within a few years, andeven now, although abdominal surgery is almostuniversally accepted as justifiable, in a multitudeof varying conditions, only a very few surgeonshave attempted operation upon the gall-bladder.

My own experience is limited to the followingcases which, inasmuch as they illustrate a varietyof conditions, are of sufficient importance to putupon record.

Case i.—Dr. W , aged 72, a physician ofexceptional intelligence, had clearly diagnostica-ted repeated attacks of suffering, extending over anumber of years, as due to biliary obstruction,a gall-stone. Although somewhat jaundiced, themore prominent and dangerous symptoms werecaused by the continuous vomiting. The attackpreceding the operation, which was performedJuly, 1887, was more severe than any previousone, causing imminent danger to life. Pulserapid, temperature slightly above the normal, nofood retained upon the stomach, rectal alimenta-

4

tion maintained for several days, emaciation pro-nounced. There was pain and tenderness just tothe right of the median line, and upon pressurean ill-defined enlargement was felt.

Upon section, the base of the liver was easilyfound, and a rather small, undistended gall-blad-der, intimately bound to the transverse colon byold and firm adhesions. The finger, carried inthe direction of the common duct, easily detecteda gall-stone of considerable size, which was dis-lodged and retracted into the lower portion of thegall-bladder. A prolonged attempt at separationof the adhesions was made, with considerable lossof blood from the divided tissues, w Thich were ex-ceptionally vascular. After consultation with Dr.Worcester, who ably assisted me in the operation,it was reluctantly determined unwise to proceedfarther, and the wound was closed. Marked re-lief followed for a few days; the exploratorywound healed by first intention. The old symp-toms, however, soon supervened, followed bydeath. A careful autopsy was made by Prof.Frost, of Hanover, who reported that a calculus,about the size of a walnut, was in the greatly di-lated common duct, producing complete occlu-sion. Although the hepatic structure wr as notmaterially changed, yet the old adhesions, bind-ing the gall-bladder to the transverse colon, wereso extensive, that thepost-mortem dissection wasmade with difficulty and, on this account, furtheroperative measures would have been, in his judg-ment, unjustifiable.

Case 2.—Mrs. R , in middle life, extremelyfleshy, a patient of Dr. Cunningham of Cam-bridge. When seen by me in consultation, per-sistent vomiting had continued for several days,ushered in by extreme pain in the right hypogas-trium. She was slightly jaundiced, pulse small

5

and rapid, condition considered one of extremedanger; referable to biliary obstruction. Shehad had several previous attacks less severe. Onsection, extensive adhesions were found, bindinga moderately distended gall bladder to the sur-rounding parts completely overlaid, as in the pre-vious case, by the transverse colon. With somedifficult}'’ I dislodged and retracted a biliary cal-culus from the common duct, but deemed it un-wise to attempt its removal, because of the impos-sibility of freeing the gall-bladder and bringing itwithin the lips of the wound. Rapid recoveryfollowed with primary union, a free flow of bileinto the intestine ensued, and the patient now, atthe expiration of about two years, continues well.

Case j.—Mr. J , formerly a sailor, agedabout 45, had been under ray care for somemonths, suffering from supposed cancer of thepylorus. He developed rather rapidly a fluctuat-ing tumor in the region of the gall-bladder, oifist-size. Was considerably emaciatedand mark-edly senemic. This condition made the formerdiagnosis doubtful, and operative measures wereadvised and gladly accepted. Entered hospitalOctober, 1887, and assisted by Drs. Holt and Nel-son I made an exploratory incision. Immediate-ly upon opening the abdomen, the cystic tumorpressed into the lips of the wound. The tumorwas carefully attached to the peritoneum by adouble row of continuous tendon sutures and thenopened. About six ounces of a whitish, muco-purulent fluid escaped, without a seeming trace ofbile. Exploration detected no trace of biliarycalculi; the finger carried deeply was brought inapposition to a thickened mass in the region ofthe outlet of the stomach. A large double drain-age-tube was inserted, about which the lips ofthe wound were closed. It was washed out for

some days with a weak solution of sublimate ;

the secretion amounted to several ounces daily.Contraction slowly followed, leaving a sinuswhich closed only after several weeks. Markedimprovement followed for a time, but death oc-curred some months later, and the autopsy re-vealed primary cancer of the stomach, with asecondary deposit studding the liver.

The cystic duct had been closed from the sec-ondary changes which had ensued; the interest-ing specimen is here shown.

Case /.—Mr. M—, aged 45, of regular habits,a healthy, hard working man until eighteenmonths previous to operation, April 29, 1889.Had developed rather rapidly a well markedjaundice, with frequently returning intermittentattacks of excruciating pain followed by vomit-ing. Had been supposed by his physicians dy-ing of cancer of the liver. Skin dark coppertint, emaciation not extreme. Stools light gray,urine dark brandy color. Diagnosis, occlusion ofthe common duct, possibly gall-stone. I was as-sisted in the operation by Drs. Didama and Ja-cobson of Syracuse, N. Y., and Dr. Nelson ofBoston. Present Drs, Warner, Cunningham,and others. Diver was enlarged and very darklycolored. Gall-bladder distended, extensive ad-hesions to the surrounding parts. United it tothe lips of the wound as in previous case and in-cised. Careful probing detected no evidence ofstone, and it was determined that the cystic ductwas occluded from an inflammatory process. Putin drainage-tube and closed the wound about itwithout much expectation of benefit. A free dis-charge followed with continued and rapid im-provement. Jaundice lessened and when seen inSeptember had entirely disappeared. The woundclosed, appetite good, strength, in large measure,

7

returned and he does light work. He continuedto gain strength until March of the present yearwhen jaundice returned with a repetition, in aminor degree, of former sufferings.

Case 5. —Mrs. P , aged 40, has had severalattacks ofbiliary colic of a serious character, ac-companied with jaundice. The last attack pre-ceding the operation occurred in August, 1889.Life at that time thought to have been imperilled,she has not been quite well since Entered myprivate hospital. Has severe local pains, somevomiting, markedly jaundiced; dark urine; clay-colored stools. Thick abdominal wall, beneathwhich a considerable sized fluctuating tumor iswell defined, the base of which is quite on theline with the umbilicus. Operation October 26,1889, assisted by Drs. Clark and Nelson.

Immediately upon dividing the peritoneum,the cystic growth distended the lips of the wound.It was attached to the peritoneum by a doublerow of tendon sutures and incised. Ten ouncesof thin, light colored bile escaped, floating outwith it a gall-stone, the size of a large almond.Careful probing revealed the presence of anothercalculus in the common duct. All effort at dis-lodgment failed, and as much force as was deem-ed justifiable was used in the attempt to crush it,but without avail. The bladder was washed outwith a sublimate solution, the stitches cut away,the wound packed with a sponge after havingsomewhatforcibly drawn the gall-bladder throughit. Even this procedure did not enable us toseize and remove the calculus. I then dividedthe walls ot the duct with scissors, and evertedits edges from over the roughened calculus whichwas even then removed with difficulty. Thethickened mucous membrane of the duct andbladder was joined by a fine continuous tendon

8

suture, and in like manner the peritoneal edgeswere carefully coapted, while over all a third layerof suturing with tendon, a continuous sero serousstitch intrafolded the edges of the entire woundof the viscus measuring about four inches. Theabdominal wound was closed by buried animalsutures, in the usual manner, and sealed withiodoform collodion. Free vomiting of a largeamount of bile followed the recovery from ether.Rapid convalescence ensued without incident,and the patient remains vigorous and active.This rough mulberry-looking calculus, grape-size,was the offending member, weighing when driedfifty-nine grains.

A brief review of the history of the surgicalmeasures devised for the relief of biliary obstruc-tion is of great interest and value. Thudicutnreports that Johannes Fabricius removed gall-stones from the bladder of a living subject in1618.

Monsieur Petit of Paris first published his ad-mirable memoir, on the diseases of the gall-bladder in 1743. I review, at considerable length,his article, found in the Memoires of the RoyalAcademy of Surgery, 1 since nothing more valu-able, even to the present, has been publishedupon this interesting subject. In the first part ofhis contribution, he analyzes with remarkableclearness the differentiation of the varying con-ditions of the obstructive diseases of the biliarypassages. He cites a long series of interestingcases occurring under his own observation, sup-plemented by a report of autopsies. He clearlydefines clinical distinctions between abscess of theliver and the distention of the gall-bladder asfollows. “ Fluctuation in consequence of retainedbile appears suddenly, in an abscess it is some

1 Tom Premier, 1781, Page 265, 56, etc.

9

length of time before it is apparent; in the one it issuspected before it is recognized; in the other recog-nized before suspected. In the one there may bedoubt as to the point of fluctuation, while in theother it is known at once by the touch.” Hepoints out very clearly the dangers from opera-tive measures which he thinks would be necessa-rily fatal if the contents of the gall-blader shouldescape into the peritoneum, and as a consequencerestricts all operative measures to the class ofcases where inflammatory changes have causedadhesion of the cyst to the peritoneum.

He analyzes these changes with the closestscrutiny in order to make definite, as far as possi-ble, such conditions before operation and thenstates, ‘‘What I have observed should moderatethe ardor of young men who desire always to cut,but should therefore an unwise timidity causethem to let pass the occasion of operation in caseswhere they are persuaded the tumor is caused bydilation of the gall-bladder, occasioned by reten-tion of the bile ? If the observations on the firsttwo cases show that a few of these tumors cannotbe opened except at the risk of the life of the pa-tient, those on the third case show that there arethose cases which raa}- be opened without dan-ger.” . . . “If convinced that the tumor is ad-herent, that the life of the patient is in peril, weshould not hesitate to open the bladder, for weshould not -wait for nature to perform mir-acles. It is true she does commence, since shecauses the adhesion, and opening the gall-bladderwithout adhesion is always fatal, but it is theduty of the skilful surgeon to observe nature andto profit thereby, to seize upon the favorable mo-ment to act himself, when he sees that natureneeds his aid, and that she cannot complete whatshe has commenced without it. If we can be as-

sured of the adhesion, then we may open with-out danger the tumors which are found in theseparts, and then shall we add two hew operations tosurgery, one, in cases where the retention of thebile is extensive and danger to life imminent, theother, lithotomy, or extraction of stones from thegall bladder. The existence of the stone and ad-hesion being assured, the operation is withoutdanger. It is in just these cases that the skillfulsurgeon can show his genius. We can pass thesound into the urinary bladder for determiningstones in it, why not pass the sound into the gall-bladder for the same purpose, and if stones arefound, why not extract them as from the urinarybladder? If we can without rashness open thegall bladder when it is adherent, we can pass thesound without rashness, and if stones are foundthere, what reproach should be to him who doesnot dare to extract them, and what praise shouldbe given to the surgeon who would removethem?”

Petit then gives a series of interesting illustra-tive cases in detail, one of which is that of a wo-man, 37 years old, previously * vigorous, where atumor of the gall-bladder supervened after anattack of biliary colic. This increased in size,until it extended even to the crest of the ileum,suppuration and discharge followed, with theescape of seven or eight gall-stones. Six monthsafter, the patient came under Monsieur de laPegronee. At this time the discharge was abun-dant, of purulent character, mingled with bile.After careful probing of the fistula, he made anincision about three inches in length, extendingto the middle of the right rectus muscle, whichwas followed by the escape of a considerablequantity of pure bile. Without difficulty a soundwas carried into the gall-bladder to the depth of

about four inches which he believed entered thecommon duct, in which location he thought asmall stone was lodged and displaced. He re-ports the case two years later, the fistulous tractremaining through which is a free escape ofhealthy bile, and the patient appears to have en-tirely recovered her former health.

Case ii.—Observed b}' Monsieur Sarran. Awoman, aged 64, had colic, followed by com-plete jaundice. A tumor appeared in the righthypochondrium which finall}r opened sponta-neously, leaving a fistula, which, from time totime, discharged. At the time of operation thefistulous opening was at the side and a little be-low the umbilicus. The sound entered the fis-tula to some distance, beneath the muscles of theabdomen, where was felt a hard foreign body.

An incision was made upon it, and a biliarycalculus four inches long by three in circumfer-ence was withdrawn. Upon the opposite side, atthe left of the linea alba, was felt another massat the depth of an inch and a half, from whichwas extracted a second stone by the prolonga-tion of the first incision. Complete cure followedin about two months.

Case 12.—Reported Monsieur Habert, Doc-teur de Sarbonne. A woman, having beenjaundiced for a long time, with a very consider-able tumor in the right hypochondrium, after asevere attack of colic accompanied with convul-sions, passed by the bowel a gall-stone, weighingthree and a half drachms, two inches and a halfin length, one and a half in diameter, three anda half in circumference, polished at its ends infacets. The tumor diminished in size, andhealth was slowly reestablished.

Petit’s work was discussed by some of theleading surgeons of his time, with little resulting

12

profit to sufferers, and in large measure was for-gotten, even Richter, who published a half acentury later, making no reference to it, in hismonograph upon the subject. The latter madeoriginal studies upon jaundice and the causalconditions. He determined that the generalpigmentation of the tissues might occur withoutobstruction to the free flow of bile from the gall-bladder, and also that the outflow might be en-tirely prevented and the jaundice-state not super-vene. The more common cause, he believed,lay in a perverted action of the liver, dependentupon a derangement of the hepatic circulation.He gives, however, in symptomatic detail a caseof obstruction in the common duct from acalculus which went on under his care to death,and figures the specimen, without the hint of apossible relief from surgery. As an interestingillustrative case I quote the report of the au-topsy. 2

“Mr. S., gouty diathesis, age 40. Troubledwith jaundice four years. In hospital two weeks.The gall-bladder was five inches long and twobroad, quite full of dark bile and contained thirtygall-stones. The ductus choledochus and theparts about were preternaturally distended. Oncutting into the substance of the liver a verygreat quantity of dark brown bile issued as froma sponge, of the same nature with that whichwas found in the gall-bladder. There was a stonein the ductus choledochus which, on account ofits uncommon size, I have caused to be engravedon the annexed plate. It weighed three ouncesand five drachms. All around the stone therewas fluid bile, so that this fluid had evidentlypassed by the stone into the duodenum. It fell

2 Aug-, Gottlieb Richter, M.D., Prof. Med. University, Goettingen, 1793.

13

into three pieces on being taken out. The ex-ternal surface resembled a very firm extract ofliquorice. On some places there are evident marksof smaller stones adhering to it. The thick endof the stone was in the duodenum, the mostpointed was turned towards the neck of the gall-bladder.” He gives another case of interest asfollows: ‘‘A woman died in the hospital in thehighest degree of jaundice. On inspecting herbody, no gall-bladder was found, but in its placeonly a skinnj'- substance of a very small size, inwhich no cavity could be discovered. The wholeliver was full of white concretions, apparently ofthe nature of calcarious earth, of different sizes,from thatof a cherry to that of a pea, which floatedon water Most of the concretions layunder the external membrane, some few in thesubstance of the liver. These probably containedthe irritating matter which occasioned the jaun-dice.”

He concludes by stating, “that real obstruc-tions are very seldom the cause of jaundice;where they do occur, they occasion an incurabledisease, for this cause neither can be discovered,or removed.” .

.

. ‘‘lf stones are sometimes thecause of the jaundice, they act probably by occa-sioning irritation and spasm, which stops thebiliary ducts, or deranges the course of the fluids

~in the hepatic system, and in such cases no othermedicines but sedatives are of any use.”

In 1798, Richter devised a litho-triptor forcrushing gall-stones, and explained how the frag-ments could be removed by washing. In certaincases he also advocated operative measures, byfirst bringing about adhesive inflammation of thegall-bladder to the abdominal wall, and makingan incision, as a second operation, after sufficienttime had elapsed for securing a firm union.

Morgagni 3 mentions a case where the commonduct was as large as the stomach and containedcalculi of different sizes.

Dufresne, in 1847, recommended the use ofcaustic over the dilated gall bladder in order tocause adhesive inflammation before opening.About that date, Recamier advised the use of thetrocar. Thudicum, in 1859, reviewed the entiresubject carefully. He recommended abdominalsection over the cyst, and the suturing of the un-opened gall-bladder to the peritoneum, and aftersufficient time had elapsed for a firm union, com-pletion of the section.

Trousseau furnishes an interesting chapter uponthe subject, with the report of cases, advisingsurgical procedure after the manner of Petit, buthe emphasizes the observations of Boyer who de-clared that there was but two signs which indi-cated the adhesion of the cyst, immobility of thetumor and puffiness of the integuments. In orderto insure adhesion, Trousseau advised the inser-tion of thirty to forty steel needles with largeheads which were allowed to remain three or fourdays. This process is repeated three

%times be-

fore peritoneal adhesion is supposed to be firm.He states that internal biliary fistulse are quitebeyond our means of treatment. He dismissesthe subject with the acknowledgement that littlegood is to be expected from treatment exceptopiates and sedatives.

Frerichs, in his classical treatise upon diseasesof the liver, offers little of value as to treatmentof biliary obstruction and states, “We must neverthink of evacuating the contents of the gall-blad-der by means of puncture, except when therapid increase of the tumor endangers rupture, orwhere symptoms of hectic consumption super-

3 Morgagni—better 37

vene.” When there are adhesions, the operationmay be had recourse to without hesitation; butwhen there are no adhesions, or their existenceis doubtful, he precautions to secure first adhe-sive inflammation, as advised by Begin and Re-camier. This consisted in dividing the perito-neum and dressing the wound with charpie, inorder to produce firm adhesions.

It would appear that the first case of cholecys-totomy, successfully performed in modern times,was by Dr. J. S. Bobbs, 4 of Indianapolis, re-ported under the title, “A Case of Lithotomy ofthe Gall Bladder.” A woman, aged 30, tumorjust inside of iliac bone, tender to pressure, diag-nosis doubtful, probably ovarian. OperationJune 16, 1867. Incision made between the um-bilicus and pubis, omentum adherent, incisionenlarged to an inch above the umbilicus on theright side, tumor five inches in length, two indiameter. Incision through the lower margincaused several small bodies, size of rifle bullets,to escape. Closed the incision of the sac bysingle stitch and cut the ends of the sutureclosely. Closed the wounds wdth suture andadhesive plaster. Examination of the calculileft no doubt as to their character; were of lightspecific gravity, and numbered between forty andfifty. The fluid was perfectly free from coloringmatter. Recovery very satisfactory with no re-turn of local trouble at the time of report, tenmonths after operation.

Dr. J. Marion Sims operated in Paris, April 18,1878.6 Patient under observation by her phy-sician since previous January. Aspirated whatwas supposed to be a cyst of the liver, thirty-twoounces ofdark-colored fluid. She continued deeply

4 Transactions of Indiana State Medical Society, 1868, p. 68.5 British Medical Journal, 1878, Vol, i, page Sir.

jaundiced, clay-colored stools, scanty high-col-ored urine. Under antiseptic precautions, an in-cision was made three inches in length, upon theright side, parallel to the linea alba. Cyst wallexposed, aspirated by trocar twenty-four ouncesof dark fluid. Withdrew the emptied gall-blad-der quite external to wound. Enlarged the in-cision and removed sixty gall-stones varying insize. Stitched gall-bladder to lips of wound. Op-eration tedious and difficult, lasting one hourand sixteen minutes. Death occurred eight daysafter, and at autopsy sixteen more calculi werefound remaining in the duct. Dr. Sims’ reportof the case is in careful detail, and to the opera-tion he gave the name since adopted, cholecys-totomy CfoAC—bile, kv oris— bladder, ropiC.—incision).

To Mr. Dawson Tait, of Birmingham, how-ever, is justly accorded the high honor of havingestablished, upon a sure basis, operative interfer-ence upon the gall bladder. Up to date, Feb. 18,1888,6 he reportsfort}^-onecases of cholecystotomy,with only two deaths, these occurring on accountof malignant disease. Mr. Tait follows closelythe principles first laid down by Dr. Sims. Hesays, “The conclusions drawn from the surgicalexperience of these cases, is that the entire pos-sibilities of the treatment of gall-stone and dis-tended gall-bladder are exhausted in Dr. Sims’original paper, and that no further extension ofit seems possible.”

Recently Dr. Senger reported in the BerlinerKlinischer Wochenschrift what he calls a new op-eration. The gall bladder is drawn as far as pos-sible up from the wound, and sutured to its mar-gin. After a day or two, adhesions will have

6 British Medical Journal, Feb. iS, 1888.

formed and it is then opened and emptied, butimmediately closed. When the wound in thebladder shall have healed, the surrounding adhe-sions are divided and the organ returned withinthe abdominal cavity. The object of these meas-ures is of course to restore their parts to theirpre-vious normal condition, deemed by him unsafe toattempt at a single operation. Eangenbeck criti-cises the operation as untrustworthy by reason ofadhesions being too recent and offering little ad-vantage over that of biliary fistula which canusually be readily closed if it seems desirable.

Every physician of experience has met withcases of biliary obstruction from varying causeswith fatal results. These conditions are muchmore common than might at first appear. Manyinteresting clinical histories are reported in thejournals, too frequently followed with verificationof diagnosis by post-mortem examination. Inall the pathological collections, more or less in-teresting specimens are found in considerablenumber. In Dr. Jackson’s catalogue of the War-ren Anatomical Museum, in Boston, published in1870, no less than sixty specimens, from asmany different patients, are preserved, showingdiseases of the gall-bladder and ducts; the largernumber, ofbiliary calculi.

It was earlier believed that simple extravasa-tion of bile into the peritoneum was fatal. Ourpresent knowledge would teach that the bile perse may be absorbed by the peritoneum withoutcausing much trouble, although wounds of thegall bladder are generally fatal because of atten-dant septic infection.

The most important question that arises in thediscussion of the subject is, If cholecystotomy isa justifiable operation, when should, it be per-formed ?

18

Injuries. — Without doubt, in every case otwound or perforation of the gall-bladder, operativemeasures should be instituted without delay, sincewithout surgical interference, there is little pros-pect of recovery.

Empyema. —Where empyema of the gall-blad-der exists, therecan be no doubtbut that recourseshould be had to operation, as early as the condi-tion of the patient may seem to warrant. Thetemptation to aspirate should be resisted, since itis in itself dangerous and cannot afford permanentrelief.

Cystic Dilatation.—When the gall bladder hasbecome cystic, in all cases, surgical interference isindicated. Aspiration may aid in diagnosis as tothe character of the fluid, and possibly the detec-tion of the calculus, but at the most, it is onlypalliative.

Biliary Obstruction.—Although patients do livean indefinite number of years with gall-stones,frequently dying of other diseases, the recurrentattacks of colic are exhaustive and often fatal intheir complications; jaundice induces dangerouscholemia; suppuration may be incident upon thechanges which supervene from the presence offoreign bodies in the gall-bladder. Long con-tinued obstructive jaundice and the changeswhich have occurred in the tissues, is doubtlessan unfavorable complication, since thereby thepatient’s vital power is greatly depreciated. Incomplete obstruction of the common duct, chole-cystotomy may prevent death from cholemia bypermitting the escape of the biliary fluids exter-nally. It is clearly established that the nutritionof the tissues may be maintained without themingling of the biliary secretion with the con-tents of the intestinal canal.

A very considerable class of cases where ob-

19

struction exists in the common duct, merit onrserious consideration, as to the means to be es-tablished for its relief. The earlier measureswhich we have reviewed, where only a fistuloustract was sought to be formed externally, fail inmany cases of the desired result. The theoreticperfection of the operation consists in the resto-ration of the parts, as far as possible, to theirformer normal conditions. For every reason apermanent fistula has very serious objections.

When the cystic duct alone is obstructed, andno bile enters the gall-bladder, an abundant quan-tity of clear albuminous fluid is secreted from themucous surface more or less changed, and thisis illustrated in my case number three, where theorgan contained no foreign body. If the hepaticand common ducts are unobstructed, there will re-main a free flow of bile into the intestine withoutjaundice and the consequent changes which ensuefrom the liver. Where these conditions exist, withconsiderable cystic dilatation, there remains to thesurgeon a choice of operative measures, either ofopening the bladder with drainage, or of removingit altogether—cholecystectomy, as recommendedand performed by Langenbeck. Dr. Smith7 reportsnine published cases of cholecystectomy where“one death only can be attributed to the oper-ation.”

Only recently Dr. Meredith8 states that “thisoperation has lately been performed with successin several instances, notably by Mr, Thornton,with excellent results. After thoroughly cleans-ing the interior of the injured gall-bladder, theperitoneum covering its neck is cleanly incised,and the cystic duct is then freed from its connec-tions sufficiently to allow of its being ligatured

7 Greig Smith, “Abdominal Surgery,” p. 552.B l,ancet, April 19, 1890, ‘‘Present Position of Abdominal Sur-gery.”

20

and divided. Any bleeding vessels are then tied,and the edges of the divided peritoneum are ac-curately united by suture over the ligatured duct,a glass drainage tube being finally inserted beforeclosing the abdomen.”

Cholecystectomy can be favorably consideredonly in a very limited number of cases, where thegall-bladder has undergone marked pathologicalchanges and its duct is so altered that the func-tions of this viscus are not likely to be restored.When these conditions pertain, there can be littledoubt but that it better be removed, in the samemanner as a cystic growth in any other part ofthe abdomen, yet in many cases the ease of oper-ation and resultant safety will cause suturing totheabdominal wall, with drainage, to be preferred.When excised, the entire secreting membrane ofthe cyst should be carefully removed from thebase, and the divided edges inverted by a contin-uous sero serous suture. The operation is com-pleted by closure ofthe abdominal wound, usuallybetter without drainage.

Obstruction of the Common Duct. —In a greatmajority of operative cases there is obstruction ofthe common duct, and when this occurs from abiliary calculus, methods of procedure, to be ef-fective, must be such as to clear the passage, inorder to allow a free escape of the biliary secre-tion into the intestinal canal.

A calculus in the gall bladder alone rarelycauses obstruction in the common duct. On thisaccount the surgeon should not content himselfin a completion of the operation without ascer-taining, as far as possible, the patency of thecanal into the intestine. This cannot always beeasily determined. When a calculus is found inthe common duct, it may often be dislodged by

21

gentle manipulation and removed from the gall-bladder.

When it is impossible to do this, the efforts ofthe surgeon should be directed towards the possi-bility of safely crushing it in situ with well pad-ded forceps after the method of Richter, revivedby Mr. Tait. It must remain a matter of indi-vidual judgment, as to how much force may beapplied safely in the crushing, as well as to itsmethod of application. If it shall prove impos-sible to remove the fragments by irrigation, theyshould be made sufficiently fine to allow theireasy escape through the undilated portion of theduct into the intestinal canal. If, on account ofthe hardness of the calculus, or the condition ofthe surrounding parts, it shall be deemed unwiseto attempt crushing, the further division of theduct, in order to obtain access to the stone, is ad-vised, as illustrated in Case 5 in my series abovereported.

Mr. Meredith9 recommends the following : “Indealing, however, with a small and friable sacwhich has been unavoidably much injured duringthe extraction of the calculi, the above proceduremay prove exceedingly difficult, if not impossible.Under such circumstances, one of two courses maybe followed, provided always the patency of theduct has been ensured. The first of these alter-native measures consists in carefully suturing theopening in the gall bladder and returning it intothe abdominal cavity. This plan was first carriedout, I believe, by myself in 1883, but my patientunfortunately died. The procedure has latterly,however, been successfully effected by other oper-ators, and its adoption, in suitable instances, isfullyjustified, provided that means for drainage of the

9 lancet, April 19, 1890.

peritoneal cavity in the immediate neighborhoodof the sutured gall-bladder be taken.”

When this has been accomplished, we are en-abled to assure ourselves of the remaining portionof the duct. Other calculi may be present, or in-flammatory changes may have supervened whichrender it still impermeable. When we have as-certained that no further obstruction remains, weare then under the necessity of making at least apartial closure of the canal, since it is impossibleto attach the widely divided lips of the ductand bladder to the abdominal wall. In this in-stance, we may close the wound in part and usedrainage, as is more commonly recommended,or complete the operation as I did in Case 5.This latter method of complete closure of thegall-bladder was first suggested by Sir SpencerWells, and so far as I have ascertained it has beenattempted in only three instances, one of which,as reported by Mr, Tait, was followed by a fatalresult, because of escape of bile into the perito-neum.

To close so long a wound effectively wouldseem improbable by any method of interruptedsuturing. The use of silk, as the material forsuturing, no matter how prepared, would be like-ly to result disastrously, since it produces muchirritation in the wound, which would be especiallytrue if applied in repeated layers. The coapta-tion of the parts, as effected in Case 5, is simple,rapid, and makes a wound at once fluid proof; amethod which I have adopted for years, in allcases of intestinal suturing. When the edges ofthe duct and gall bladder have been thus coapted,the operation is finished by closure of the abdom-inal wound without drainage.

So far as I have been able to ascertain, how-ever, the attempt at incision of the duct to remove

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a calculus has not been made, except in Case 5,of ray series. Dr. Meredith suggests excisionin his recent paper. 10 “Failing of success by anyof these methods, (of removing a calculus withinthe duct) its removal by excision, followed bycareful and accurate suture of the duct might pos-sibly be performed with success.”

One of the serious, and I am constrained to be-lieve not seldom, dangers, resulting from biliarycalculi, while yet retained in the gall-bladder, re-sults from reflexive irritation as evinced by nau-sea and vomiting. It is now some years sincethe first case of this type came under my observa-tion, the sufferer being a physician of exceptionalwisdom. His diagnosis was perfectly correct,which he desired me to ascertain in the event ofhis death. The calculus which I here presentwas free in the gall-bladder, without obstructionof the biliary, or common duct. The immediatecause of death was from haemorrhage into thestomach, produced by continuous retching.

Some years later, a similar case came undermy observation, where the diagnosis was equallyclearly determined, and demonstrated by an au-topsy, and where operative measures were not fa-vorably considered by the patient and family, aswell as by the consulting physician.

In cases where the common duct is permanent-ly occluded from inflammatory or other changes,the cystic duct remaining open and the gall-blad-der not especially disorganized or adherent, itremains for consideration, if a permanent fistulousopening may not be effected between it and theduodenum. In a considerable number of cases onrecord nature has pointed out the possibility ofthis method by allowing to escape, through sucha fistulous tract, calculi from the gall-bladder in-

10 Lancet, April 19, 1890.

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to the intestine. In a most interesting case un-der my observation a few years since, I urged theopening of a distended gall-bladder, since thepatient was dying of extreme cholemia. Thepost-mortem examination showed a non-malig-nant, inflammatory, complete closure of the com-mon duct.

Winiwater successfully established a communi-cation between the gall-bladder and the transversecolon. However, in this situation, the physiolog-ical effects of the biliary secretion are lost. Dr.Gaston, 11 of Atlanta, Ga., reports a series of ex-periments upon dogs where he established a per-manent communication between the duodenumand the gall bladder. Winiwater advocates amodification of his operation, by selecting someportion ofthe small intestine whichcan be broughtmost conveniently into apposition with the gall-bladder, since the duodenum is not sufficientlymovable to be adjusted.

These are sutured by the peritoneal surfacesonly, and after five or six days adhesions shouldhave been formed sufficiently strong to admit ofa permanent opening being made. Althoughsuch an operation, as far as I know, has not beenattempted upon the human subject, conditionsmay arise in which it should be taken into seriousconsideration.

The technique of the operation in cholecysto-tomy is comparatively simple. Incision may bein varying direction. Mr. Tait advocates the di-vision parallel to the median line, just externalto the rectus muscle. In my own cases, the pa-rietal incision has been made parallel to the ribs.After having opened the abdominal cavity, thegall-bladder is examined by the finger. If thetumor is very large, its contents may at once be

“Atlanta Med. and Surg. Journal, September and October, 1882.

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evacuated with an ordinary trocar. Oftentimesthe walls of the greatly distended gall bladder arevery thin. In such instances it may be wise tomake use of a small aspirating needle, instead ofthe trocar. The puncture should be made in themost dependant portion of the tumor. The ab-dominal cavity must be carefully protected byaseptic sponges to prevent the escape of any ofthe fluid into it. It may be a wise precaution,which I adopted in Cases 3 and 5, to unite theedges of the peritoneum to the gall-bladder care-fully, by a running suture, prior to opening it.If the tumor is not very large, and the emptyingof its contents with drainage is all thatis required,suturing in this manner before opening is to begenerally advised. It is easier effected with thegall-bladder tense, and gives more accurate coap-tation than can be secured by uniting the gall-bladder when flaccid and empty.

The incision is now made into the gall-bladdersufficiently large to admit the finger and an ex-amination of the contents is carefully made. Cal-culi may be removed by forceps, or scoop, carebeing exercised not to injure the delicate struc-tures. If a stone is impacted in the neck of thegall-bladder, or the cystic duct, its removal willbe attended with exceptional difficulty. Theright fore-finger within the abdominal cavity mayaid in its dislodgraent, assisted by gentle proced-ure of operative measures, from within the dxict.This failing, crushing by forceps carefully padded,or protected by rubber may be attempted. Aftercrushing, the fragments should be removedthrough the wound if possible. If crushingproves impracticable, division of the parts, untilthe stone is reached, should be made, followed byclosure, as already described.

If, as may be found expedient in a great ma-

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jority of cases, a fistulous opening is determinedupon, a soft rubber drainage-tube should be in-serted, and the wound dressed with absorbentmaterial. I have used with advantage a soft-rubber double drainage-tube, inserted into a dia-phragm about the size of a half dollar. Thesehave been especially made for me in one piece.

If the common duct is patent, the fistula willvoluntarily close in a few weeks. It has beenused, as an argument in favor of suturing anddrainage, that adhesions are formed which wouldrender easy the division, in the line of the old ci-catrix, in case of subsequent obstruction, a con-tingency worthy of consideration.

Cholecystotomy may be accepted as an opera-tion already established, worthy of adoption bythe surgical profession. Present experienceabundantly warrants this conclusion. More bril-liant triumphs await its future development, whenoperative interference will be advised much ear-lier than at present. The more serious complica-tions which render the operation especially diffi-cult arise from previous inflammatory attackswith their resultant pathological changes.

In the American Journal of the Medical Sci-ences, for October, 1884, Drs. Musser and Keentabulate all the hitherto recorded cases of chole-cystotomy. They number thirty-five, by sixteendifferent operators, with ten deaths. Three fatalcases from haemorrhage, one from peritonitis, theremaining cases death probably due to the pre-vious condition of the patient. Since 1884, thehistories of about one hundred cases of cholecys-totomy, have been published by more than one-third as many different operators. It is safe topredict that the future history of operative meas-ures, for therelief of biliary obstruction, will fur-nish one of the most brilliant chapters in surgery.

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One of the most serious of all the abdominaldiseases, as evinced by acute pain, prolonged suf-fering, and great mortality, confessedly withoutremedy from medicine, cholecystotomy offers helpto the hopeless with an attendant danger in thehands of the experienced surgeon, of as small apercentage as in ovariotomy. By present dem-onstration, the closure of intestinal wounds bysuture, or even resection, is to be preferredover an artificial anus. If operations upon thegall-bladder are undertaken, at a time when theorgan itself is not materially changed, remainingfree from adhesions to the surrounding parts, itwould seem a safe conclusion that an opening,made into this viscus, should be closed with asgreat safety and as good reason as in that of theintestinal canal. If attempted, it should be com-pleted with as much care and exactitude as in thelatter instance.

It has been clearly shown that an aseptic ani-mal suture is not only far safer when properly ap-plied than silk, but that it also possesses thegreat advantage of causing an abundant prolifer-ation of connective tissue along the tract of theburied suture. It may also be safely applied inrepeated layers in order to coapt broad surfaces, ina manner unsafe to attempt with silk. A-fter aconsiderable period it disappears to be replaced byvitalized tissue. Such a suture, itself aseptic,

aseptically applied, in an aseptic woitnd, furnishesan important aid in dealing safely with * woundsof the gall-bladder. There can be no doubt butthat its proper use adds another factor of thehighest importance in aseptic surgery, addingmuch to the safety and subsequent resultinggood.

We cannot but believe that the animal suture,especially that from the tendon, properly preserved

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and prepared, furnishes the surgeon with an aidof the highest importance. By means of its use,the tissues in nearly all the varieties of operativewounds, can at once be coapted and retained inposition withoutfurther disturbance.