Gall-stones and their surgical treatment

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1

m

'

Library of
L Dr. George E.Ebright

^imi^

^IfauAUpJiXiC

GALL-STONES

and their

SURGICAL TREATMENT

BY

B. G. A. MOYNIHAN, M^. (Lond.), F.R.C.S.

LEEDS

Fully Illustrated

PHILADELPHIA-NEW YORK— LONDON

W. B. SAUNDERS AND COMPANY

1906

Cop\Tight, 1904, by W. B. Saunders & Company.

Registered at Stationers' Hall, London, England.

PREFACE.

This book contains the material upon which I based
a course of lectures delivered at the ^Medical Gradu-
ates College in London during April and May, 1904.
It includes, I think, a detailed account of the etiology,
pathology, clinical manifestations and operative treat-
ment of gall-stones.

There can be no doubt that in the future surgical
treatment will be adopted more frequently and in an
earlier stage of gall-stone disease than has hitherto
been customar\\ The great and increasing importance
of the subject is, therefore, a sufficient warrant for the
publication of a work of this size.

I desire to tender mv thanks to the authorities in
charge of the museums at the Royal College of Surgeons
of England, at Guy's Hospital, University College
Hospital, King's College Hospital, and Charing Cross
Hospital, for permission to photograph the specimens
in their charge.

My friend, Dr. E. B. Hulbert, is responsible for the
selection of these photographs, and I am greatly in-
debted to him for the help he has afforded me.

The coloured and black and white drawings have
been made by Miss Ethel Wright. I consider myself
fortunate in having the assistance of so able an artist.

B. G. A. MOYNIHAN,
33 Park Square, Leeds.

August 16, 1904.

13

CONTENTS

CHAPTER I. PACK

Anatomy op the Gall-bladder and Ducts 17

CHAPTER II.
Varieties op Gall-stones 31

CHAPTER III.
The General Pathology of Gall-stone Diseask 57

CHAPTER IV.
The Symptoms and Signs of Gall-stone Disease 109

CHAPTER V.
The Special Symptoms of Gall-stone Disease 140

CHAPTER VI.
Remote Consequences of Gall-stone Disease 204

* CHAPTER VII.
Perforation of the Gall-bladder 226

CHAPTER VIII.
Intestinal Obstruction due to Gall-stones 252

CHAPTER IX.
Details of Preparation for Operations upon Patients Suf-
fering prom Gall-stones 270

CHAPTER X.
Operations upon the Gall-Bladder and Bile-ducts 293

CHAPTER XI.
Operations for Obstruction op the Common Duct . 339

Il^DEX 373

IS

(h^'

VOMJL UxaxJSJk ui^i^.

GALL-STONES

AND THKIR

SURGICAL TREATMENT.

CHAPTER I.

ANATOMY OF THE GALL-BLADDER AND DUCTS.

The gall-bladder in its normal condition is pear-shaped,

and measures approximately 3 to 4 inches in length and

1} inches to i^ inches in width at the fundus, having

an average capacity of iV ounces. It lies obliquely, the

fundus being directed downwards, slightly forwards,

and to the right, and touching the anterior abdominal

wall at the meeting of the outer border of the rectus

and the costal arch. This point corres])onds almost

exactly with the tip of the ninth rib. In the liver-edge

there is often a slight notch opposite the gall-bladder —

the i nets lira vesicalis. The neck of the gall-bladder is

directed upwards, backwards, and to the left. All the

fundus is covered by peritoneum, but above this there is

a bare, uncovered surface which lies in contact with the

liver in the fossa for the gall-bladder. The extent of the

peritoneal investment varies much in different individuals.

In approximately five per cent, of bodies examined a
2 17

Anatomy of the Gall-bladder and Ducts

FlO. I. — The gall-bladder, bilc-ducls, clc.. dissected from behind.
The upper small figure shows the reticulations o( the n
branc o( the gall-bladder.

Anatomy of the Gall-bladder and Ducts 19

distinct mesentery exists, so that the gall-bladder can
move, pendulum like, in the abdomen. The posterior rela-
tions of the gall-bladder are, from below upwards, the
transverse colon, the duodenum, and perhaps the pyloric
end of the stomach. As the gall-bladder narrows to the
cystic duct its walls become slightly thicker, and an S-

shaped curve is formed. Bevan has pointed out that this
curve can be entirely straightened out by dividing the
peritoneum and connective tissue around the neck of the
gall-bladder and the cystic duct. It is just beyond the
first turn of this curve that a stone may be impacted.
It is then a matter of great difficulty to force the stone
backwards into the gall-bladdt?r in order to remove it.

20 Anatomy of the Gall-bladder and Ducts

At the commencement of the cystic duct there is a valvular
projection of the mucous membrane which can be clearly
seen by looking into the duct from the opened gall-bladder.
There is a series of similar vaK-ular projections arranged
along the whole length of the cystic duct. The valves are
infoldings of the mucous membrane and are crescentic in
shape ; they are placed alternately upon the one side and
upon the other of the duct, It^s generally said that they

—Gall-bladder, bile-duels, hepatic and cystic artcrj', and portal
vein (after Cabot).

are arranged "in spiral fashion" in the duct, but this is
erroneous. The upper two, three, or four valves are con-
stant and well-marked. Below these the valves are often
imperfectly formed or irregularly placed. These are
known as "the valves of Heister." The cystic duct is
about ij inches in length, and it runs downwards and to
the left between the layers of the lesser omentum to
join the common hepatic duct in forming the common bile-
duct. The cystic arterj' lies close to the cystic duct,

The Common Bile-duct

being above and very slightly to the inner side. In
cutting across the cystic
duct, close to the com-
mon duct, other small
unnamed branches of the
hepatic artery may be
wounded. The average
diameter of the cystic
duct is given by Bevan
as I inch ; it is, therefore,
the narrowest of all the
bile-ducts. The common
hepatic duct formed by
the junction of the right
and left hepatic ducts is
about 2 inches in length
and one-sixth of an inch
indiameter, being slightly
wider below than above ;
it runs downwards and to
the right in front and to
the right of the portal
vein. The hepatic artery
lies to its left.

The common bile-duct
is slightly more than 3
inches in length, and ex-
tends from the point of
its formation at the junc-
tion of the cystic and
hepatic ducts downwards and slightl;

■The cystic, hepatic,
ducts (Testut),

y to the right, to

22 Anatomy of the Gall-bladder and Ducts

end \\-ith the canal of Wirsung in the ampulla or diver-
ticulum of Vater. The ampulla of Vater opens upon
a papilla, the ** papilla major" of Santorini, which
can be felt as a small shot in the mucous membrane
of the second portion of the duodenum, about 4 inches
from the pylorus. Examined from the opened duo-
denum, the termination of the common duct and of the
pancreatic duct is difficult to see. It is far more readily
recognised by touch. The papilla is, however, generally
placed upon a vertical ridge of mucous membrane,
the plica longitudinalis, which is readily distinguished
from the valvula? conniventes, whose folds run at right
angles to it. The lower part of this fold, that below the
papilla, is always l^etter marked than the upper part,
which may be entirely absent. This lower part is some-
times described as the **fra»num carunculae." The rela-
tions of the common duct are surgically of the greatest
importance.

Three portions of the duct may be described :

1. Supraduodenal.

2. Retroduodenal or pancreatic.

3. Transduodenal or interstitial.

The first, or siipraditoJcnaL portion is approximately
i\ inches to i^ inches in length. It extends from the
formation of the common duct by the junction of the cystic
and hepatic ducts to the posterior surface of the duodenum,
where it comes in contact with the pancreas. This portion
lies in the free edge of the gastro-hepatic omentum ; to its
left is the hepatic artery, and behind both lies the portal
vein. Along the tluct are two, three, or four lymphatic
glands. The gastro-hepatic t)nientum containing these

The Common Bile-duct

23

structures, in addition to lymphatic vessels and nerves,
forms the anterior boundary of the foramen of Winslow.
In a normal subject the foramen will permit the passage
of two fingers, but in patients who have suffered from

'cholelithiasis the foramen may be narrowed, or even en-
tirely obliterated by adhesions.

The second, or reiroduodenal. or pancreatic portion is about
I inch to I J inches in length. It lies in close contact with

34 Anatomy of the Gall-bladder and Ducts

the jHiiitTwis, being either in a groove or within a canal
in the Bubstfmce of the gland.

Tho exact relationship of the common bile-duct to the
head of the pancreas is of the greatest importance. Helty
huH Htudied the relationship in 40 cases. He finds that
the lower end of the duct is in contact with the gland for a
(liHliincc varying from 2 to 7 cm. In 15 cases (equivalent

I'm. 6. — The [lorlal fissure, showing the cystic and hepatic ducts,
the portal vein, the branches of the hepatic iirlcry, and lymphatic
dlands (Testul).

to 37.5 I'cr cent.) the duct was placed in a groove on the
posterior surface of the pancreas; in 25 cases (equivalent
to 63.5 per cent.) the duct was completely surrounded by
the substance of the gland.

Bunger (Beit. z. klin. Chir., Bd. 39, Heft i) has made
dissections in 58 subjects, In 55 he found that the com-
mon bile-duct ran through the substance of the pancreas,

L.

25

and in only 3 was it uncovered. The average length of
its course through the gland was 2 cm.

In so cases in which I dissected out the whole length of
the common duct I found in every instance that the pan-
creas, after dissection, hid some part of the common duct

Fig, 7.— Tho

1 frntn behind.

from view when looked at from behind. The separation
of the duct from the tissue of the pancreas could be effected
in 7 without any apparent damage to the structure of the
gland, the duct lying in a groove therein; in 13 the duct
was so embedded that the lobules of the gland had to
be divided before the common duct could be exposed.

26 Anatomy of the Gall-bladder and Ducts

It may, therefore, be stated that in two cases out of
three, on the average, this portion of the common duct
is surrounded completely by the tissue of the pancreas,
and that to reach the duct from behind, the substance of
the gland would have to be divided.

The third, or transduodenal, or interstitial portion in the
duct comprises that portion which, passing obliquely
through the wall
of the second part
of the duodenum.
on its inner and
posterior aspect,
endsin the divertic-
ulum of Vater. It
is about J inch to J
inch in length.

The common
duct at its termina-
tion is in relation-
ship with the duct
of Wirsung. As a
rule , both ducts end
in the base of a conical cavity whose apex opens into the
duodenum upon a papilla. The conical cavity is termed
the diverticulum of Vater. Its length varies, according
to Testut, from 6 to 7 mm., and its breadth from 4 to 5
mm. Opie measured the length of the diverticulum in
89 specimens. In 11 specimens in 100 no diverticulum
existed. It varied from zero to 1 1 mm. ; its average was
3.9 mm. In only 30 instances was the length of the
diverticulum 5 mm. The opening of the ampulla upon

Fig, 8.— The papilla of Vat
the duodenum. Note tho ■
fold and the vertical ridge, the frarium
carunculiC,

The Common Bile-duct 27

the surface of the papilla is narrow — narrower than any
portion of the duct. Opie found the average diameter of
the orifice to be 2.5 mm.

The actual size of the diverticulum and the relative
size of the diverticulum and of its opening upon the sur-
face of the duodenum are of great importance from a
surgical standpoint, for if the diameter of the opening,
for example, be 3 mm., and a calculus 4 mm. in diameter

Fio. Q. — Absence of ampiilla Fig, lu. — Ampulla of Vatcr

of Vater, showing separate open- with termination of commcjn duct

ings of common duct and duct and duct of Wirsung.
of Wirsung on the papilla.

reach the ampulla from the common duct, it may block
the duodenal orifice, being imable to pass, and will, there-
fore, convert the common bile-duct and the pancreatic duct
into a common closed channel. These are the conditions
which, as shown by Opie, determine the incidence of acute
pancreatitis by allowing a retrojection of bile from the
common duct into the canal of Wirsung.

28 Anatomy of the Gall-bladder and Ducts

The termination of the two ducts in the ampulla is
surrounded by circular muscular fibres — the so-called
** sphincter of Oddi.'* These fibres are continuous with
the longitudinal muscular fibres on the ducts.

Variations from this normal condition of the ampulla
are not common. The two ducts may open separately
into the duodeniim, or the canal of Wirsung may partially
surround the lower end of the duct, being gutter-shaped,
or the papilla may be absent, and in its place a depression
may be seen on the duodenal wall.

Diameter of the Duct, — The duct gradually narrows
from its beginning to its end. According to Padula (Brit.
Med. Joum. Supplement, Feb. 27, 1904, p. 34), the first
portion attains, with the distension which produces injec-
tion on the cadaver, a diameter of 7, 8, or even 8^ mm. ;
the second portion is never wider than 5 mm., and the
third portion than 3^ mm. A gradual lessening of the
dia*meter of the common duct is therefore one of the causes
of impaction. A stone which would pass along the first
inch of the duct would become wedged in the lower and
narrower portion.

Access to the common, cystic, and hepatic ducts can be
best obtained by freeing them from adhesions, introducing
the finger into the foramen of Winslow, and, by gentle
fon\'ard traction, fixing that part of the bile tract into
which an incision is to be made.

The lower part of the common duct can be reached in
one of two ways, retroduodenal and transduodenal. In the
former, the duct is opened from behind, access being
obtained by dividing the parietal peritoneum to the right
of the descending portion of the duodenum. The peri-

The Common Bile-duct 29

toneum to the left of this incision is stripped up until the
duodenum is reached, and it will then be found a simple
matter to turn the second portion of the duodenum over to
the left. It is possible, in fact, to mobilise this portion of
the gut, reproducing that condition of free duodenum which

mim duct seen from behind, showing lymphatic glands
along the cystic and common ducts.

is normal in foetal life. The posterior surface of the duct
is thus reached. The transduodenal route opens up the
second portion of the duodenum and exposes the papilla.
The lower end of the duct may be defined by passing a
director upwards along the duct, and by slitting the mucous
membrane upon this. If only the lower end of the duct —

30 Anatomy of the Gall-bladder and Ducts

that portion which lies within the wall of the duodenum —
is opened, there is no need for the introduction of stitches.

The walls of the gall-bladder and the ducts consist of
peritoneum, which forms only a partial investment of a
layer of fibrous and muscular tissue intermixed, and of an
inner layer of mucous membrane, covered with columnar
epitheliimi. The mucous membrane of the gall-bladder
presents a finely honeycombed appearance.

Lymphatic Glands. — The position of the lymphatic
glands around the bile tract is a matter of some importance.
Mascagni described a gland as being constantly present at
the neck of the gall-bladder where the S-shaped turn is
being made to the cystic duct. This gland is frequently
but not invariably present. Quenu describes two constant
glands, one larger, on the outer side of the common duct,
at its commencement, and one smaller, a little higher up, in
the angle between the cystic and hepatic ducts. A chain
of four or five glands lies along the common duct. These
glands by their enlargement may cause a blockage in the
ducts, or at the outlet from the gall-bladder, and they
may, when enlarged, be so firm and hard as to persuade
the operator that a stone is surely present in the duct.
Dr. Brewer has recorded a case of Hodgkin's disease in
which the enlargement of the glands along the common
duct caused all the symptoms of obstruction of the com-
mon duct, so that an erroneous diagnosis of malignant
disease was made.

CHAPTER II.
VARIETIES OF GALL-STONES,

Naiinyn has suggested the following classification of
gall-stones :

1. Pure Cholesterin Stones. — These are hard, oval or
spherical, smooth, pure white or yellowish, and trans-
lucent, rarely brown or green in colour. They are gener-
ally of the size of a cherry or larger. On section, they
appear white and crystalline throughout ; on fracture a
radiating striation is generally visible.

2. Laminated Cholesterin Stones. — These are generally
hard, but they become fissured and cracked on desiccation.
The surface may be variously coloured. In size and form
they resemble the first variety, but they are more often
distinctly facetted. On section they are laminated. They
consist of 90 per cent, cholesterin ; in addition they contain
small quantities of bilirubin-calcium and biliverdin-cal-
cium, and carbonate of soda.

3. Ordinary gall-bladder stones — of various sizes,
shapes, and colours. They rarely grow larger than a
cherry and are generally much smaller. They are facetted
and of a brown or yellow or rarely of a greenish colour.
When first removed, they are soft and compressible, but
as they dry they shrink and become hard. They have
a hard shell and a soft kernel. No crystalline structure
is visible.

31

32 Varieties of Gall-stones

4. Mixed Bilirubin Stoftes. — These are usually as large
as a cherry or even larger. They occur as solitary stones
or in numbers of two, three, or more, and are foimd in
either the gall-bladder or the ducts, generally in the
former. On drying, an outer layer or layers may peel
off like a rind. The nucleus, and sometimes the shell,
consists chiefly of cholesterin ; the rest of the stone con-
sists of bilirubin-calcium.

5. Pure Bilirubin-calcium Calculi, — Of these there are
two varieties:

(a) Solid black-brown concretions with a nodular sur-
face, generally compressible and conglomerate.

(fe) Harder stones, often spindle-shaped, showing a
metallic lustre on crushing.

6. Rarer Forms:

(a) Amorphous stones, resembling pearls.

(6) Chalk stones, ver\' hard and prickly or smooth

and often containing a hollow in the centre.
(c) Concretions formed around foreign bodies, such
as a worm of the species Anguillula (Lobstein), a
piece of Distoma hepaticum (Bouisson), a needle
(Nauche), the kernel of a plum (Frerichs), small
particles of mercur\^ (Frerichs), silk or catgut
sutures (Romans, Kehr).
{d) Casts of the bile passages.

Gall-stones may be single or multiple. A solitary-
calculus may be found in the gall-bladder, in the cystic
duct, or in any part of the hepatic or common ducts.
A single calculus, when discovered during operations,
is nearly always impacted at some part of the bile pass-
ages. As a rule, calculi are multiple, and the number

a

« ^

O a

Fio. 12.— Gall-stones.
I. Almost fri'c cholosterin; 2. tholestcrin and liilmxliin-calcium;
3, a stone rcmovfi fnim the amimlla of Vater; 4. a stono rfttinvcd
from tho common duct: 5, a stnnc removcil from the cystic duct.

Varieties of Gall-stones 33

of them is sometimes astonishing. The largest number
I have removed is 1885. The patient was a man aged
thirty-eight, who suffered also from duodenal ulcer, with

Fig, 13. — Small black tuberculated calculi of btle-pigment em-
bedded in mucus, the whole removed by operation from the gall-
bladder of a patient from whom a small ulcer of the stomach was ex-
cised. From a patient aged fifty-five, who had suffered for several
years from indigestion, and who then began to experience severe pain
about an hour after food, and to lose flesh. A doubtful tumour could
be felt, and during attacks of pain the stomach hardened under the
hand. Free HCl was found present after a test-mea!. On exploration
the swelling was found to be a greatly thickened pylorus, and along
the lesser curvature was a "tumour," which, on opening the stomach,
proved to be thickening due to a chronic ulcer. The latter was excised
and the edges closed by suture. Posterior gastro-enterosiomy was next
performed, and the gall-bladder emptied of the materia! shown in the
specimen and drained. Complete recovery. (Royal College of Sur-
geons' Museum, No, i8j Og.)

hiematemesis and mel^na. For this, gastro-enterostomy
was performed. As a matter of routine, I explored the
gall-bladder and found it packed with small stones, the
average size being equal to that of a mustard seed. There

34 Varieties of Gall-stones

had been no mention of symptoms of gall-stone colic
before the operation, and on subsequent enquiry nothing
that could not be accounted for by the duodenal ulcera-
tion was elicited. Larger numbers of stones have been
found on postmortem examination. Thus Frerichs, in
a woman sixty-one years of age, found 1950 stones, Dim-
lop (Lancet, 1878), in a woman of ninety-four, fotmd
201 1, Morgagni 3000, Hoffmann 3646, Langenbuch 4000,
Naunyn 5000, and Otto 7802. As a rule, it maybe said
that the fewer the stones, the larger their size, and the
more numerous the stones, the smaller are the v. Two or
three large stones may he present and smaller stones may
then be found witli them in hundreds. If many small
stones are ]>resent, lliey are generally rounded in shape
and smooth on tlie surface, but when the stones are larger
than mustard seeds, tlie ]^ressure of one against another
causes facetting.

The largest gall-stone I have removed had caused intes-
tinal obstnicticm. Its diameter was i\ inches. Stones of
a size far givater than this are sometimes found. Meckel
describes, in the Transiictions of the Berlin Academy, one
which was 15 cm. long and 6 cm. thick; it completely
filled an enlarged gall-bhuhler. Another large stone is
depicteil by Hutchinson in the Archives of Surgery,
lulv, iSgi. and bv Mavo Robson (Diseases of the Gall-
bladder and Hile-ducts. sectnid edition, page 151). It
weighed ^^ ounces 5 drams.

When a numlvr of sti^ies are present in the gall-blad-
iier ihev aiv, as a rule, of the s;une fi>rmation. Hein
found variations in the chemical constitution in 28 out
of o^j cases.

The Formation of Gall-stones 35

In 326 cases of gall-stones of which Riedel possessed
accurate information, in 56 there was i stone; in 29
there were 2 stones ; and in 1 7 there were 3 stones. The
stones were few in number, were generally large in size,
and vice versd.

THE FORHATION OF GALL-STONES*

From the days of Galen up to comparatively recent
times the belief was universal that gall-stones were the
result of the coagulation of bile, induced by the increase
of heat in the liver.

Morgagni, and, after him, Meckel von Hemsbach, at-
tributed a causative influence to a chronic catarrh of the
mucous lining of the gall-bladder and bile-ducts. The
recent investigations of Naunyn, Gilbert, Mignot, and
others have thrown light upon many of the circumstances
necessary to the formation of gall-stones in animals and
in men.

The two chief constituents of gall-stones are choles-
terin and bilirubin-calcium. The origin of these two
substances seems now to be definitely settled. Budd,
in 1845, was the first to suggest that the cholesterin of
gall-stones was derived from the mucosa of the gall-blad-
der. Bristowe, in 1887, supported this view, and Naunyn
gave it strenuous advocacy in 1892. It has now been
shown, by much careful work, that these two substances
are derived from the mucosa of the gall-bladder; that
for their production certain alterations are necessary,
such, for example, as slight inflammation with desqua-
mation of the epithelium (a condition which Meckel

36 Varieties of Gall-stones

called **lithogenous catarrh**), and that in all probability
this change is accompanied by an increased outpouring
of mucus from the glands.

In the great majority of cases, therefore, gall-stones
are formed in the gall-bladder. When fotmd in the
ducts, even in the hepatic ducts, or the intrahepatic
ducts, they are formed in the gall-bladder and have mi-
grated thence. Gall-stones may, however, without ques-
tion, form in the ducts primarily, as, for example, in the
intrahepatic ducts in cirrhosis of the liver.

The slight forms of cholecystitis necessary to the forma-
tion of gall-stones may be produced by the injection of
chemical irritants into the gall-bladder, or by the intro-
duction of micro-organisms.

Herter (Med. News, Sept., 1903) has found that the
injection of bichloride of mercury, carbolic acid, or ricin
into the gall-bladder resulted in a marked increase in
the cholesterin in the bile. The gall-bladder walls were
usually thickened (especially in the bichloride series)
and showed considerable proliferation and desquamation
of epithelium, together with congestion of the vessels of
the submucosa. The bile remained sterile.

Bacteria. — During the last few years much attention
has been given to the influence of bacteria in the pro-
duction of gall-stones. The microbial origin of biliary
and other calculi was first suggested in 1886 by Galippe.
In 1890 Welch found the bacillus coli and the staphylo-
coccus pyogenes in gall-stones, and in 1896 Hanot and
Milan discovered the bacillus typhosus.

It was formerly thought that the bile possessed a
mild, though perhaps an important, antiseptic action.

Bacteria 37

L6tienne (Arch, de Med. Exp., 1891), Mieczkowski (Mitt,
aus den Grenzgeb., Bd. 6), and others, however, found
that micro-organisms could be readily cultivated in
normal bile, though their rate of growth was not so rapid
as in broth. The bile of all animals and of man is said,
under normal circumstances, to be sterile. Rettger,
working under the direction of Herter, made cultures
from the bile of six healthy dogs, with negative re-
sults in every instance. Erhardt divided the common
or hepatic ducts in several animals and allowed the bile
to flow freely into the peritoneal cavity. No signs of
peritoneal sepsis resulted; the animals died after a few
days of cholaemia. If, however, the bile was first in-
fected by the bacillus coli, a septic peritonitis rapidly
developed and proved fatal. Fraenkel and Krause
(Zeit. f. Hygiene, Bd. 32) opened the gall-bladder in
guinea-pigs and rabbits, and allowed the bile to flow freely
into the peritoneal cavity, without causing infection.
Miyake found no organisms in the bile, in the gall-blad-
der, cystic and hepatic ducts, in 75 animals out of 76.
He further showed that the lower portion of the common
duct, and the ampulla Vateri in particular, invariably
contained organisms, especially the bacillus coli. In
dogs and in rabbits Netter and Uuclaux foimd the lower
part of the common duct to be inhabited by bacteria,
the rest of the bile passages being sterile. Naunyn and
Gilbert found the bile from the gall-bladder removed
after death to be sterile. These results, however, have
not been invariably confirmed by other investigators.
Ehret and Stolz (Mitt. a. den Grenz., Bd. 7), using large
quantities of bile, so as to increase the likelihood of the

38 Varieties of Gall-stones

discovery of organisms, found that the bile was sterile
in only about one-half of the cases examined. Fraenkel
and Krause examined the bile in 125 autopsies. In 105
cases the bile was sterile. Of these 128, 36 patients were
tuberculous. In 34 of these the bile was sterile on ex-
amination by ordinary culture methods. Eleven guinea-
pigs were injected with the bile from these patients,
and five well-marked tuberculous lesions were excited. It
is, therefore, possible that though the usual culture tests
may fail to reveal the presence of micro-organisms, they
may, nevertheless, be present, though they are probably
few in nximber and of very slight virulence. Very few
investigations have been made from the healthy human
bile removed during life. Mieczkowski collected the
bile from 1 5 cases operated upon for diseases other than
cholelithiasis. In all it was sterile. In 23 cases operated
upon for gall-stones the bile was infected in 18. Petersen
also found that in 50 operations for gall-stones bacteria
were present 44 times; in 36 the bacillus coli alone was
found ; in 6 it was found in association with the staphylo-
coccus aureus, and in 4 with the streptococcus pyogenes.
Hartmann (Deut. Zeit. f. Chir., Bd. 68, p. 207) ex-
amined the bile in 46 cases of cholelithiasis treated by
operation. In 36 bacteria were found; in 10 the fluid
was sterile. In 23 the bacillus coli alone was found; in
3 the staphylococcus pyogenes albus and aureus; in 2
streptococci; in i the staphylococcus pyogenes albus;
in 2 the bacillus coli with staphylococcus; in 3 strepto-
cocci, with other organisms. Bacteria were fotmd in
larger nximbers in the bile removed from the common
duct in cases of calculus in the duct. These investiga-

Bacteria 39

tions refer to the micro-organisms found in the bile, not
to those fotmd in the gall-stones. The absence of the
bacillus typhosus is, therefore, not so remarkable as it
might seem.

In ordinary health it is probable, therefore, that the
human bile is sterile, but, as Herter says, *' Bacteria are
likely to be present in human bile when there exist patho-
logical conditions in parts remote from the gall-bladder.'*
He points out, further, the difficulty of discovering such
organisms as the pneumococcus and the tubercle bacil-
lus, which renders it possible that the bile may appear
to be sterile when in reality it is infected. The bile re-
mains sterile, however, only so long as it flows unhindered
through the ducts. Charcot and Gombault first showed
that as soon as the outward flow of bile was hindered by
ligature of the common duct the bile above the obstruc-
tion became infected. Sherrington showed that when
the bile is not escaping freely from the common duct an
ascending infection from the duodenum speedily occurs.

The connexion between typhoid fever and biliary
infection has been closely studied since Bemheim, in
1880, first called attention to it. Hanot and Milan, in
1896, found the bacillus typhosus in the centre of gall-
stones of recent formation in the gall-bladder. Chiari, in
1893, found the typhoid bacillus in the gall-bladder in 19
out of 22 cases of enteric fever, and Gushing, in 1898, found
that in 50 per cent, of patients who died of typhoid fever
the organism could be found in the bile removed from the
gall-bladder. Ehret and Stolz compiled a table of 32 cases
of typhoid cholecystitis which were treated by opera-
tion or recognised at an autopsy. Of this number in no

40 Varieties of Gall-stones

less than 20 were gall-stones present. Chauffard found
that 20 per cent, of cases of cholelithiasis gave a history
of a previous attack of typhoid fever, and Gushing found
that 30 per cent, of the patients operated upon at the
Johns Hopkins Hospital had previously suffered from
this disease. Gushing further called attention to the
fact that in typhoid fever there may be an active ag-
glutinative serum reaction towards the bacillus typhosus
and the colon bacillus isolated from the gall-bladder.
The bile may share the agglutinative properties of the
serum.

Richardson, in a case of cholecystitis, found the typhoid
bacillus clumped "as if a gigantic serum reaction had
taken place in the gall-bladder." In examining the bile
in fatal cases of typhoid fever he found large clumps of
bacilli in five cases out of six ; in the sixth case the blood
serum had no agglutinative property. He injected 0.5
c.c. of typhoid bouillon culture, in which clumping had
been produced by the addition of typhoid serum, into
the gall-bladder of one rabbit; into the gall-bladder of
a second rabbit he injected two drops of ordinary bouillon
culture of typhoid bacilli; a third rabbit was used as a
** control." Four months later all the animals died. In
the first rabbit the gall-bladder was contracted and a
rounded concretion was found within it; in the second
nothing was found; in the third there were a nximber
of round bodies arranged in concentric rings.

The extraordinary endurance of typhoid organisms
in the gall-bladder and bile-ducts is shown by cases re-
corded by Droba (Wien. klin. Woch., 1899, No. 46) and
Hunner (Johns Hopkins Hosp. Bulletin, 1899). In the

Bacteria 4 1

former the bacillus was found seventeen years after
typhoid fever, and in the latter a purulent collection
beneath the right costal margin contained the bacillus
of Eberth eighteen years after the occurrence of typhoid.

Successful attempts to cause gall-stone formation in
animals have now been made in a large number of cases.
The priority in this matter belongs to Gilbert, though
Mignot, in 1897, preceded him in the publication of re-
sults. In 1893 Gilbert and Domenici had noticed in
the gall-bladder of a rabbit in which cholecystitis and
cholangitis had been produced the presence of **petites
concretions verdatres/' but it was not until January 29,
1897, that they obtained a small stone from the gall-
bladder of a dog that had been infected with the bacillus
coli. Gilbert and Domenici had discovered, in 1894, the
presence of organisms, both living and dead, in one-third
of the gall-stones examined by them. Their obser-
vations were confirmed by Hanot, Lctienne, and others.
The possibility of the penetration by organisms of stones
already formed was mentioned by Gilbert and Fournier.
Gilbert in a later communication has said that the forma-
tion of gall-stones may be protective in character, an
offending and irritating organism being encapsulated and
embedded in an innocuous material.

The injection of virulent micro-organisms into the
gall-bladder is not sufficient to induce the formation of
gall-stones in the great majority of experiments. As a
rule, an acute cholecystitis is aroused, and the mucosa is
so damaged by inflammation and ulceration that the
overproduction of cholesterin is entirely prevented. In
purulent cholecystitis occurring in man and produced

42 Varieties of Gall-stones

experimentally in animals bile and the pigments of bile
are entirely absent. Mignot first pointed out the neces-
sity of using attenuated cultures. An attenuated culture
when injected produces a mild, subacute cholecystitis
which is peculiarly favourable to the overproduction of
cholesterin, and, therefore, to the formation of calculi.
It is fotmd to be of great advantage in making the attempt
to produce cholelithiasis, to use an organism that has
been ctdtivated for several weeks in diluted bile. Mignot
in his work obtained the following results (see Epitome,
Brit. Med. Joum., 1898, p. 92, article 431) :

1 . Foreign bodies when introduced into the gall-bladder
can stay there for an indefinite time, provided they are
aseptic, without causing inflammation or precipitating
the solids from the bile.

2. Foreign bodies previously impregnated with virulent
micro-organisms cause a more or less intense cholecystitis
and precipitate the solids from the bile. As long as the
bacteria retain their virulence, however, they cannot form
a calculus, but only a sediment mixed with pus. This
precipitate has no tendency to cohere or to adhere to
foreign bodies.

3. The bacteria must be attenuated, not virulent.
This is best attained by growing them for some months in
bile to which constantly decreasing amounts of broth are
added. When sufficiently attenuated they are no longer
pathogenic when injected into the cellular tissue of ani-
mals. By injecting these into the gall-bladder, stones
are occasionally formed, but more often the bacteria are
washed out into the intestine. If, however, a foreign
body, especially if porous, such as cotton wool, be placed

Bacteria 43

in the bladder and fixed to its wall to prevent expulsion,
a stone is formed round it with the greatest certainty.
Five or six months are required for formation of a per-
fect calculus.

Gilbert and Foumier injected into the gall-bladder of a
rabbit a culture of the typhoid bacillus attenuated by
heating a bouillon culture for ten minutes at a temperature
of 50 per cent. Three drops of this attenuated culture
were injected ; six weeks later the rabbit died. In the gall-
bladder two concretions were found adherent to the mu-
cous membrane. Sections of these showed a central whit-
ish portion from which typhoid bacilli were obtained in
pure culture ; the shell was pigmented.

The organisms capable of giving rise to stones are, ac-
cording to Mignot, the bacillus coli, the bacillus typhosus,
the staphylococcus pyogenes, the streptococcus pyogenes,
and the bacillus subtilis. More important than the indi-
viduality of the organism is its degree of attenuation.

The retention or stasis of bile is a very important factor
in assisting in the formation of gall-stones. If the bile
can escape freely from the gall-bladder, any organisms
injected speedily find an exit. If, however, the cystic
duct be tied or a foreign body placed in the gall-
bladder, the organisms find a foothold. Miyake and
others, in their experiments w4th the colon bacillus,
failed to produce the formation of calculi if no other
factor than the presence of microbes was in evidence.
Before stones could be produced it was necessary to
impede the flow of bile through the cystic duct. Ehret
and Stolz also showed that a diminution of the motility of
the gall-bladder, or anything tending to retard the dis-

44 Varieties of Gall-stones

charge of bile, favoured the growth of organisms in the
gall-bladder. Mignot. in a series of experiments, intro-
duced foreign bodies impregnated with the bacteria whose
action was to be tested into the gall-bladder, and left
them there. Gall-stones were found to have formed
around them in the course of a few months. In another
series the foreign bodies were removed at the end of four
weeks by operation. In these, also, calculi were found at
the end of four and five months. The stones formed in
both series were comparable, * ' chemically, physically, and
bacteriologically, ' ' with those found in man.

Foreign Bodies. -The influence of foreign bodies in
the formation of gall-stones was first recognised in man
by Homans. In a patient upon whom cholecystotomy
had been performed seventeen months before a second
operation became necessary on account of a return of symp-
toms. Seven stones were found, and five of these had
formed around silk ligatures. Similar instances have
been met with in the practice of other surgeons. Jacques
Meyer, experimenting upon dogs, introduced small sterile
ivory balls into the gall-bladder. At the end of a year
a small amount of sediment was noticed in the gall-blad-
der, but no stone. Even when hollow balls were used
there was no deposit on the inner side of the globes. Mig-
not combined the introduction of sterile foreign bodies
with the injection of attenuated organisms. The injections
were made first, and after a time the sterile bodies were
introduced. After two months thev were found covered
with a deposit of cholesterin. In a series of 19 animals
the foreign body, coated with cholesterin, was removed
and the gall-bladder closed. At the end of six months,

;

Fig. 14— Gall-s

t-'stnllbtcd around sutures (Homans, in "Annals
of Surgery").

Foreign Bodies 45

in 7 out of 19 of the animals, fine stratified cholesterin
stones were found.

Italia (Riforma Medica, 1901), after a series of experi-
ments with various organisms, stated his results in the
following manner:

1. The bacillus coli and the bacillus typhosus are the

specific organisms concerned in the formation of
cholesterin calculi.

2. The streptococcus pyogenes and the staphylococcus

pyogenes aureus are rarely the causes of gall-stone
formation. When they are, the stone consists
solely of calcium salts.

3. If the bacillus coli and the streptococcus or sta-

phylococcus are present, the stone is of mixed for-
mation, consisting of cholesterin, calcium salts, and
bile pigment.

4. The bacillus subtilis grows well in bile but does not

alter it in any way.

The following conclusions may be accepted :

1. The chief constituents of gall-stone, cholesterin and

bilirubin calcium, are produced by subacute inflam-
matory changes in the mucous membrane of the
gall-bladder, which result in desquamation of epi-
thelium and in increased production of mucus.

2. The injection of a virulent culture of micro-organisms

produces an acute cholecystitis, without the forma-
tion of gall-stones.

3. The injection of attenuated cultures causes no change

if drainage from the gall-bladder is free.

4. Retention of bile, brought about by the introduction

of sterile foreign bodies, does not cause the forma-
tion of stone.

5. If retention of bile be caused by ligature of the

46 Varietiies of Gall-stones

cystic duct or by the introduction of foreign bodies
(which cause a stasis of the bile adhering to them
and between them), and an attenuated culture
be injected, stone formation will occur.

6. The gall-bladder is the chief seat of the formation of

gall-stones.

7. The clumping of typhoid bacilli within the gall-blad-

der may possibly furnish an explanation of the
occurrence of cholelithiasis after typhoid fever.

All these researches seem to assume that the gall-bladder
is the seat of the formation of stones, and not merely the
storehouse. Doubtless tliis is true in great measure,
but the question as to the formation of stones and as to
the origin of bile of altered quality which may make the
stone-building easier within the intrahepatic ducts, is
worthy of closer investigation than it has, so far, received.
In the smaller bile-ducts no epithelial lining is present,
and therefore no overproduction of cholesterin is possible.

It is interesting to remember that gall-stones are found
in the foetus, and that the intestinal canal of the foetus is
sterile. The stones in the foetus are, however, softer, and
seem to consist of bilirubin calcium chiefly.

An interesting case, bearing upon the question as to the
time needed for the formation of gall-stones, has been
recorded by Rokitisky (Cent. f. Chir., 1899, p. 616).
The patient was a woman, twenty-three years of age,
who, at the end of the third week, in an attack of typhoid
fever, showed all the signs of a suppurative cholecystitis.
Six days later the gall-bladder was opened. It contained
58 cholesterin calculi. On section the stones showed a
radiate arrangement and seemed to be of recent forma-

Entrance of Micro-organisms to Bile Passages 47

tion. The bacillus typhosus was found in the centre of the
calculi and in the fluid contained in the gall-bladder. There
had been no symptoms of any kind referable to the gall-
bladder or to the stomach before the onset of the typhoid
fever.

ENTRANCE OF MICRO-ORGANISMS TO THE BILE PASSAGES-

The organisms necessary'- to the formation of gall-stones
in man obtain access to the gall-bladder and bile passages
chiefly in two ways :

1. Along the common duct, from the duodenum.

2. By the blood current, chiefly from the portal vein.

1. Along the Common Duct. — The first route is prob-
ably more frequent. The fact that the bacillus coli is the
most common bacterial inhabitant of the gall-bladder and
of gall-stones suggests that an intestinal origin is the most
likely, for this organism abounds in the intestine, though
it is not, as a rule, present in large numbers in the duo-
denum when in a normal condition. The bacteria are
normally present, as has been mentioned, in the lower
part of the common duct ; chiefly in the ampulla of Vater
in animals; and in man, when gall-stones are present, the
bacilli are more numerous in the common duct than else-
where. Sherrington has shown (Joum. Path, and Bact.,
1893) that no germs can enter the bile-duct from the
duodenum so long as the bile remains normal and is ex-
pelled at regular intervals. If, however, there should be
any obstruction to the flow of bile, and therefore stag-
nation, there is an instant invasion of organisms.

2. The Portal Circulation, — The view that the most

48 Varieties of Gall-stones

frequent route of infection is through the portal vein
has recently been advocated by Lartigan (New York Acad-
emy of Medicine, 1902, quoted by Herter, Med. News,
Sept. 26, 1903, p. 592). He produced inflammation of the
intestine of dogs by means of various irritants. The ani-
mals were then fed on pathogenic bacteria, which were
soon discovered in the bile. In some instances the cystic,
in others the common, duct was ligatured previous to the
feeding with bacteria.

On the other hand, Carmichael (Joum. Path, and Bact.,
vol. 8, No. 3, p. 276) has failed to find any evidence of
infection after the injection of the bacillus typhosus, bacil-
lus coli, and streptococci into the portal circulation of rab-
bits. He considers that the liver destroys the micro-organ-
isms that reach it in this way, and that, therefore, the
occurrence of biliar>^ infection from the intestine along
this path is highly improbable.

Adami, writing upon this subject, says that we may
assume: (i) '* That the colon bacilli in small numbers are
in the healthy individual constantly finding their way
into the finer branches of the portal circulation; and (2)
that one of the functions of the liver is to arrest the fur-
ther passage of these bacilli into the general circulation
and to destroy them through the agency of the specific
cells of the organ. Then if the action of the liver cells
has been disabled by the toxic products of the bacteria
these may reach the bile and spread through the gall-
bladder and ducts.''

Blackstein (Johns Hopkins Hospital Bulletin, vol. 2,
p. 121, 1 891) injected bacteria into the general venous sys-
tem and recovered them from the bile. In these circum-

Entrance of Micro-organisms to Bile Passages 49

stances the organisms may have reached the liver either by
the portal vein or by the cystic artery. Dr. Welch, in a
footnote to this paper, expresses the opinion that the bile
was not often infective in these experiments, owing to the
bactericidal action of the liver cells. The infection of the
bile through the portal vein, however, is not only possible
in experimental work in animals, but is also probable in
man, especially with the bacillus typhosus and with the
bacillus coli. The importance of inflammatory or ulcer-
ative lesions of the intestinal tract, in opening up a path
for the entrance of organisms, is probably of great impor-
tance. During recent years attention has been called
to the association of gall-stones and appendicitis. Ochs-
ner, for example, has found that a little more than 35
per cent, of his patients operated upon for gall-stones
had suffered from appendicitis (Annals of Surgery, vol.
35, p. 708). I have on several occasions simultaneously
removed the appendix and performed cholecystotomy
or cholecystectomy. The destructive lesions in the ap-
pendix doubtless allow of an infection of the blood in the
portal system.

Gall-stones when once formed may increase in size in
any part of the biliary tract in which they may chance
to lie. Stones formed in the gall-bladder which have
migrated into the hepatic or cystic or common ducts may
there undergo a very considerable enlargement. Stones
may be found in the common duct of so great a size that
it is impossible for them to have passed through the cystic
duct. Large calculi found in the ducts have, therefore, in
all cases grown after their passage has been arrested.

The general circumstances determining the formation of
4

50 Varieties of Gall-stones

gall-stones in man are but little understood. There has
been a considerable, and, so far, an xinprofitable, dis-
cussion as to the part played in the causation of gall-stones
by certain constitutional conditions. Herter, after a
recapitulation of the evidences 50 far adduced, writes:

* * It is plain from what has been said that there is at
present no unequivocal evidence that gall-stones arise from
constitutional derangements unconnected with micro-
organic invasions of the gall-bladder. On the other hand,
it is certain that the cholesterin of the bile can be consid-
erably increased by local irritants unconnected with in-
fection, and it is likely that the requisite local conditions
for such increase sometimes arise through purely meta-
bolic disorders. While gall-stones are commonly the result
of local infections, we should carefully guard against the
conclusion that they can never have a diathetic origin.
It is at least highly probable that diathetic conditions
are capable of so altering the composition of the bile as to
favour materially the production of calculi in the presence
of suitable local bacterial activities. ' '

And again :

• ' Derangements in general metabolism are not essen-
tial factors in the production of gall-stones. This, how-
ever, is no evidence that disturbances of metabolism
which modify the composition of the bile may not, under
certain conditions, play an important part in bringing on
cholelithiasis. ' '

The stagnation of bile, the importance of which, as a
factor in causing the formation of calculi, was first pointed
out by Femelius in 1554, has been attributed to a great
variety of causes. Tight lacing, the production of the
so-called ** corset-liver, ' * sedentar>" habits, pregnancy, tu-

The Age and Sex of the Patient 51

mours, or looseness of the kidney or of the liver, enterop-
tosis, growths in the pancreas and stomach, heart disease,
are some among many that are named. Certain alter-
ations in metabolism are also credited with influence —
such, for example, as gout, rheumatism, diabetes, and
arteriosclerosis. Frerichs supposed that long intervals
between meals caused an infrequent emptying of the
gall-bladder and therefore a stasis of bile; and Charcot
finds an atrophy of the muscle of the gall-bladder in the
aged — a fact to which he attributes some value.

Ehret has found gall-stones in four generations, and

m

some physicians are disposed to think that heredity
must be considered as playing a part. The number of
suggestions that have been put forward are remarkable
for their number and for their worthlessness. Much has
been written, but little is known. It is in surgery'' as in
finance — much poverty and much paper may coexist.

The age and sex of the patient have doubtless great
influence upon the formation of gall-stones. The following
statistics have been published by Schroder. They are
based upon all the cases examined postmortem by v.
Recklinghausen, at Strassburg, in the years 1880-1887.
The patients were of all ages, the hospital including a
children's department:

I

NlTMBRR OK ' PKRCKNTAGB OF

AcR OF Patirnts Number of , casks with I ^^*'^* Examinbd in

AGB of f ATIBNTS. PoSTMORTBMS. r A t «J« JJl WHICH GALL-STONES

I UALL-STONKS. WKRE PRESENT.

0-20 82 ' 2 I 2.4

21-30 188 I 6 ' 3.2

31-40 209 24 I 1 1. 5

41-50 252 ' 28 I II. I

51-60 161 ! 16 I 9.9

60 and over 258 65 | 25.2

52 Varieties of Gall-stones

Schroder also found that gall-stones were present in 4.4
per cent, of the male bodies examined and in 20.6 of the
female. There were 115 adult women, and of these 99
had certainly borne one or more children, and in 5 the
question of antecedent pregnancy was doubtful ; in 1 1 only
was there undoubted evidence that the women had never
been pregnant.

Fiedler found gall-stones in 1 5 per cent, of female bodies
examined and in 4 per cent, of male bodies ; Roth in 1 1.7
per cent, and 4.7 per cent.; Rother in 9.9 per cent, and
3.9 per cent., respectively.

Information obtained from postmortem experience is,
however, almost worthless. We learn from it nothing
whatever as to the length of time a patient may have
suffered from gall-stones, and therefore nothing as to the
period of their incidence. More reliable information can be
obtained from operation records which give the age of the
patient at the time of the operation, and, approximately,
the duration of symptoms.

O. Hartmann (Zeit. f. klin. Chir., vol. 68, p. 230) found
the average of his male patients, who earned their liv-
ing by manual labour, to be at the time of operation forty
years, and the period of duration of symptoms to be six
years. Of the leisure class, the average age was thirty-
seven, and the period of duration of symptoms nine years.
In women of the working class the average age was thirty-
five and one-half, and the duration of symptoms seven
years ; of the better class the age was thirty -seven and the
duration of symptoms nine years. The time of the onset
of stone was, therefore, in all classes before the age of
thirty-five. In my own cases the average age of the

The Age and Sex of the Patient 53

patients in the last 50 cases was forty-five, and the dtira-
tion of symptoms five and one-half years. The time of
onset, therefore, on the average was at or near the age of
forty. At the Leeds Infirmary, including the cases, male
and female, of all the staff, the average age of the last 50
patients was forty-nine, and the duration of symptoms
six and one-quarter years.

There may, however, be an increased frequency of stone
in older people which cannot be represented in any list of
operations, for the occurrence of cholelithiasis in the aged
may be devoid of symptoms. There are observations by
Becquerel and others which go to show that cholesterin is
present in the blood in larger quantities in older people
than in those in the prime of life. Moreover, the in-
creased production of cholesterin by the epithelial lining
of the gall-bladder may well be a specially marked attri-
bute of advanced age, occurring as a natural stage in the
period of decadence. It is then not due to any such con-
dition as the * ' lithogenous catarrh'' already described,
but rather to a degenerative condition, comparable, per-
haps, with atheroma. When stones are formed under
these circumstances their presence causes no symptoms,
and therefore treatment, either by the physician or by the
surgeon, is never sought. The fact, however, is undoubted,
that the age of patients who seek relief from gall-stone dis-
ease by operation is nearer forty than fifty years, and that
in them the onset of symptoms occurs, approximately,
before the age of forty.

The occurrence of gall-stones in the new-bom has been
observed by Lieutaud and Valleix. The latter authority
indeed is quoted by Naunyn as saying that * * concretions

54 Varieties of Gall-stones

are somewhat frequently found in the gall-bladders of
new-bom infants. ' '

.\n interesting paper upon * * Biliary Calculi in Children, * '
by Dr. G. F. Still, is published in the Trans. Path. Soc.,
vol. 50, p. 151. The following details are extracted there-
from: Dr. Still finds that, including three cases of his
own, there are 23 cases recorded in which gall-stones were
found, either in the faeces during life or at an autopsy.
Of the 23 cases 10 were infants who were stillborn or
died within a few weeks of birth ; i was * ' an infant, ' ' 4
were between three months and nine months of age, and 8
were children fn^m three to fourteen years of age. Of
the 10 cases which (KTurred in newborn children, 7 are
stated to ha\'e been jaundiced, and in most of these the
jaxmdice was present at birth. Abdominal pain, appar-
ently of the nature of colic, was present in some cases,
but not in all.

In one case (Bouisson) some narrowing of the ductus
choledochus was also found ; in another (Cuffer) the gall-
bladder appeared to be shrunken. A tendency to haemor-
rhage was also associated with the latter case ; haematuria
and haemorrhage from the bowel were present during
life, and haemorrhage into the psoas muscle was found after
death. The jaundice in these newborn infants was very
intense, and in five of the cases was showTi, postmortem,
to be due to impaction of calculi in the bile-ducts. It is
exident, therefore, that biliar\' calculus must be reckoned
amongst the causes of icterus neonatorum of a severe and
persistent variety, which in some cases, at least, ends
fatally.

The presence of gall-stones in later infancy and in child-
hood has rarely been associated with any distinctive
SNTnptoms during life. The occurrence of jaundice with

The Age and Sex of the Patient 55

colic was recorded only in one (Walker) of the 13 cases,
while in another (Case 3) it was especially stated that the
child had screamed much and drawn up its legs as if in
pain. In the remaining 1 1 cases no special symptom of
calculus was recorded.

The existence of pain of a special type in the abdomen
is difficult to ascertain in infants and young children.
Colic and intestinal disturbances are so common that any
special observ^ance of them by the mother is not likely.
Pain, therefore, may have been present in other cases
besides the two in which it was mentioned. The passage
of calculi along the bile-duct is, Dr. Still says, * ' certainly
an occasional cause, perhaps a more common one than
we suspect, of colic in infants.

Dr. John Thomson and Dr. Still are both of opinion
that in many, if not in all of the newborn cases the cal-
culi have actually been formed during intra-uterine life.
The condition present before birth which favours the pro-
duction of biliary'' concretions is probably stagnation of
bile, and Dr. Still and other writers have commented upon
the peculiarly viscid character of the bile in infancy.

These theories are of interest as bearing upon the ques-
tion of the formation of calculi in general. In the adult
and in animals, as shown by repeated experiment, the
stones are always microbic in orgin. In the newborn
the alimentary canal is sterile. Investigation as to the
presence of organisms in the bile in these cases of gall-
stones is desirable.

Dr. Still's three cases arc briefly epitomised :

Case I. — C. B., female, aged nine months, was admitted

56 Varieties of Gall-stones

for vomiting and wasting; there were ptirpiiric patches,
but no jaundice. No symptom of colic, abdominal pain,
or jaundice was noticed dtuing the time the child was in
the hospital. At the autopsy the gall-bladder was filled
with golden-yellow bile; it contained ii small calculi,
angular, dull, black, and friable. The stones were sur-
rounded by inspissated bile. Three calculi were impacted
in the common duct, 1.5 cm. above the duodenal opening.
The calculi consisted mainly of bile pigment.

Case 2.— -M. T., female, aged eight months, died of
acute miliar}^ tuberculosis. There was no history of
jaundice or abdominal pain. The gall-bladder contained
some golden-yellow bile ; near its neck there was a small
area about 3 mm. in diameter where the mucous membrane
showed superficial erosion, and adherent to this was
some thick mucus, entangled in which was one of the
minute calculi shown. Onlv three of these minute con-
cretions were present, and inasmuch as they are barely
the size of a pin's head, they are hardly worth calling cal-
culi, but are of importance only as showing the tendency
to formation of calculus. They were too minute to
allow of anv satisfactorv chemical examination.

Case 3. — H. C, male, aged five months, died from ma-
rasmus and broncho-pneumonia. The gall-bladder was
moderately full of rather dark, amber-coloured bile, and in
the fundus of the bladder were three small calculi, the larg-
est being about the size of a millet seed, measuring nearly
3 mm. by 2 mm., and being roughly oval in shape, with
rounded contour, not angular. The colour was a dingy
black, the consistence was very hard, but they were friable
under considerable pressure. No calculi were found in
the liver substance. Examination of one of these calculi
showed no trace of cholesterin; the stone seemed to be
made up almost entirely of bile pigment associated appar-
ently with some carbonate, as a few bubbles of gas escaped
on adding an acid.

CHAPTER III.

THE GENERAL PATHOLOGY OF GALL-STONE

DISEASE*

The pathological results which follow upon gall-stone
disease are of great diversity.

Cholecystitis. — In the gall-bladder their evidences are
most commonly and most deeply imprinted. In the early
stages there may be very slight evidences of catarrh of the
mucosa, and it is said by Janowski that in this stage a
hypertrophy of the muscle is recognizable. This, however,
must be only in the earliest stages and must be only tran-
sitory ; it is not to be discovered in any of the specimens
removed by me in the performance of cholecystectomy.
The existence of speciraens of hypertrophy of the muscu-
lar wall of the gall-bladder to such a degree as to cause
fascination is authenticated. The condition is compar-
able to that found in the urinar\^ bladder. Upstanding
bands of hypertrophied muscle are found, and between
them there is a condition of sacculation. I can find
no museum specimens showing this condition in man,
though a specimen from an ox is in the Royal College of
Surgeons. Schuppel describes a specimen in his possession,
and Gilbert and Foumier make mention of the condition.
In one specimen, which I removed by cholecystectomy,
the wall of the gall-bladder, which to the naked eye was
but little altered, showed microscopically a decided hyper-

57

58 General Pathology of Gall-stone Disease

trophy of the muscular layer. This condition can, how-
ever, only be fugitive, sorm giving place tn lesions of degen-
eracy.

Brockbank has met with two cases in which the mucous

Fig. 15.— Parts at the liver and gall-liladder of an ox. No cystic
duct can be traced; the coals of the gall-bladder are } inch thick and
show marked sacculation, such as that seen in cases of long -continued
distension of the urinary bladder (Royal College rjf Surgeons' Museum,
No. »8o4).

membrane of the gall-bladder was seen with the naked
eye to be dotted with many small dark specks which
couldbeeasilypickedoutwith a sharp-pointed instrument.
Microscopical preparations of these specimens showed

Cholecystitis

59

that the black specks were small gall-stones consisting of
beautiful clear crystals of cholesterin of the ordinary
type collected together in large numbers and covered in
places with biliary pigment. These small cholesterin

Fig. i6,— a gall-l)Uddur lillfd with jjall-sluncs which was removeil
by pperation, during which tht muscular coat was extensively stripped
from the mucous membrane, the latter being tijjhlly stretched over
the small gall-stones with which the bladder was packed. A single
large stone occupied the neck of th* gall-bladder, the mucous mem-
brane of which was smooth, opaque, and thickened.

From a woman aged sixty-two. The operation was performed in
June, i8go, Thiee yeara before the patient had an attack of jaun-
dice, with pain below the shoulder-blades; this was followed by symp-
tonis of chronic dyspepsia, and in October, iSgS, by irregular vomiting,
The patient very slowly but completely recovered from the dyspeptic
symptoms (University College Museum. N», 1570).

gall-stones were lying in spaces in the mucous membrane
which looked like retention cysts, -Brockbank calls
these calculi ' ' intramucous gall-stones, ' ' A specimen
(No. 1570) in the museum of University College Hospital
shows a gall-bladder filled with gall-stones which was

6o General Pathology of Gall-stone Disease

removed by operation, rluring which the muscular coat
was extensively stripped from the mucous membrane, the
latter being tightly stretched over the small gall-stones
with which the bladder was packed. A similar embedding
of stones in the mucous membrane may be seen in the com-
mon, and rarely in the hepatic, duct.

Fic, 17. — Showing uluuration of the gall-bladder aiirl thickening
more marked at the pelvis and along the cystic duct; "hypertrophic
sclerosis of the gall-bladder."

It is not long before inflammatory changes are recog-
nisable in all the coats of the gall-bladder. The mucosa
becomes thickened, mottled; in parts it has shed its
epithelium, and patches of ulceration are to be seen. The
muscular layer disappears and is replaced by dense bun-
dles of fibrous tissue, varying greatly in thickness. The

^ Cholecystitis

_

_

1

Rl

4*i^<

^

^^V live calculi emb
^^M filty-five who h
^^M bilious vomiting
^^H increasing in siz
^1 anasarca and an:
^K No.

dilated gall-blnddcr «ilh tliiokcm-d
edded in its mucous membrane. F

d long had fixed pain in the right
and occasional jaundice; after two

, appeared over the site of the gall-b
ites preceded death {King's College H

vuUs, containing ^^^^^^^^
rom a man aged
hypochondritim,

years a tumour. i
adder. General
ospital Museum,

62 General Pathology of Gall-stone Disease

mucous coat at the first shows a thickening of the natural
nigx and microscopically an infiltration of small round
cells ; a hypertrophy of the glands and a vascular disten-
sion are obser\'ed. There is an abundant desquamation of
epithelial cells, which, according to Gilbert and Foumier,
can often be found singly or in masses in a state of degen-

roini'iil.ril Inuclhtr hy
(C'lmrlTiK I'

, H<u,>ltKl Ht

criition in the Huid within the gall-bladder. The lesions
in tha muciiHti iin- rapidly pn>gressive. The epithelium
|iiii<>M lU ntiriiml tipjwiinince. the celts become cubical in
Hhiint', ftiiil, iii'i'iinliiig In (iilbert, a transition into pave-
iliriil ci'ltliclium is fuuiid. The rugLe now begin to wither
mill lllKiIh' dioHl'l't'iir c.>ni]>li'tciy. the lining of the gall-

J

Cholecystitis

63

bladder being perfectly smooth. In a later stage a divi-
sion of the gall-bladder wall into its normal layers is no
longer possible ; all that can be seen on the microscopical

Fig. la. — Showing the wall of the gall-bladder considerably, but
not uniformly, thickened, to } inch in parts, and composed of dense
fibrous tissue, with opaque whitish, areas of necrosis. There are
adhesions between the thin margin uf the liver and the gall-bladder,
the former being there invaded by new growth. From a man aged
forty-four, who had suffered from pain in the fpigastrium off and on
since the age of seventeen. At the age of forty-four he was jaundiced
for one month after an attack of pain i for two or three months before
operation he had l>een losing flesh and tailing in health. The gall-
bladder and the adjacent portion of the liver were removed hy an
clastic toumi'juet. The patient made a good recovery from the
operation, but death took place three months afterwards, owing to
secondary growths in the lower part of the abdomen (Royal College
of Surgeons' Museum, No, 1800 a),

examination is a fibrous tissue, but little vascular, which
is sometimes excessively dense, thick, and ligamentous.
Such cicatricial tissue soon hastens to contract, and sclero-

64 General Pathology of Gall-stone Disease

sis of the gall-bladder is the final result. In the earliest
stages of cholecystitis there is, according to Langenbuch,
some oedema of the wall of the gall-bladder and an in-
creased activity of secretion of the mucosa. A thin mucous
fluid is poured out into the gall-bladder and then mixes
with the bile If the cystic duct be blocked, the bile, after

Fig, 3 1. — A thickened gall-bLaddtr closely contracted upon a stone
measuring 1} inches in diamtter (Royal College of Surgeons' Museum,
No. 18 ig).

a time, can no longer be discovered in the fluid, the thin
mucous exudate alone being present. The serous coat is
turbid, it loses its polish, and contracts adhesions with
the surrounding structures. The thickness of the gall-
bladder wall is sometimes remarkable, and this is more es-
pecially the case in the pelvis of the gall-bladder and at the
commencement of the cystic duct. In one of my speci-

Cholecystitis 65

mens the section of the wall is here i^ inches in thick-
ness, and the tissue is dense, white, and fibrous. Before
its removal it was thought to be a malignant growth of
the gall-bladder, and the whole of the gall-bladder with
the adjacent portion of the liver was removed. As adhe-
sions form to the serous coat of the gall-bladder, that sur-
face which lies in contact with the liver becomes more
firmly welded to it, and the liver substance itself becomes
infiltrated with a fibrous deposit. In some cases a fatty
degeneration of the liver substance is found. The changes
in the liver substance in immediate contact with the gall-
bladder are more marked near the cvstic duct than near
the fundus. In some cases the fibrous gall-bladder can be
separated with little difficulty from the liver, at or near
the fundus. The separation near the pelvis is, in my
experience, always a matter of difficulty. When stones
are placed irregularly in the gall-bladder the contour of
the viscus may be greatly altered. The gall-bladder often
shrinks onto the stones and fits accurately into all the ir-
regularities of their surfaces. One of the forms not infre-
quently assumed by the gall-bladder is that of an hour-
glass. The isthmus which separates the two compartments
may be nearer the fundus or nearer the cystic duct, most
frequently the latter. There may be a channel connecting
the two cavities or they may be quite separate; if so,
the contents of the two may be different — bile may be
found in the one and pus in another.

The gall-bladder may be divided into two compartments
by a septum, an hour-glass form resulting. Hotchkiss
(Annals of Surgery, vol. 19, p. 200) gives the following

5

66 General Pathology of Gall-stone Disease

description of a gall-bladder that was found to be in a con-
dition of gangrene :

The interior of the bladder presented a remarkable
condition in that it was almost completely di\ided by a
thick transverse septimi, which was found about i J inches
from the end of the fundus. This septum was complete
cxce])t for a small aperture about \ inch in diameter near
its centre. The appearance of this curious partition gave
rise to the question as to whether it really was a true
septum or whether the apparent cavity of the fimdus
might not be a diverticulum. With a view to determining
this ]H)int, sections were made through the septum and
throuj^li the thin walls. Mucous membrane was found ab-
sent in both sections, but the muscularis, though thinner
than elsewhere, and with its bimdles spread apart, was
found continuous with that of the gall-bladder. This
|)n)vt»(l the lower gangrenous end of the tumor to be the
fiin(his of the gall-bladder and not a diverticulum. The
walls of the gall-bladder, as shown in both sections, but
c*s|H'i'ially the walls of the middle portion, were found infil-
IrattMl with fibrin and pus. The amount of this fibrinous
«*xn<late was so great as easily to account for the great
thickness of the walls of the gall-bladder, and quite suffi-
i'u*ui to determine gangrene of the fundus.

< )r there may be three compartments, or even more.
Miockbank and others have described a multilocular ap-
|»«*in-a!u*c of the gall-bladder, due to the inward projection
ill id fusion of immenms sepUi. By this means the gall-
I'liiddtT is divided into many compartments, in each one
"1 which a stone mav be fcmnd. Such incomplete septa
'lie ui'rw (|nitc commonly in cases of chronic cholecystitis.
All l\\vi,r changes in the gall-bladder are inflammatory

Cholecystitis

67

in origin. The appearances described therefore vary- ac-
cording to the acuteness or the chronicity of any infection
and according to the relative duration of each process,
when both are present. In
rare instances the thickened
and inflamed wall of the gall-
bladder may show an abun-
dant deposit of fat, evenly
distributed throughout, or
placed irregularly in larger or
smaller masses. In a speci-
men (No. 1403) in Guy's Hos-
pital Museum the infiltration
with fat measures a third of
an inch in thickness, being
placed between the serous
and submucous coats. A
similar, though shghter, con-
dition was foimd in one of my
own specimens of cholecy.stec-
tomy.

In acute inflammation the
catarrhal condition of the
mucosa may go on to sup-
puration. The whole of the
wall is swollen and thickened.
Patches of ulceration are

numerous, and in some of the deeper ulcers a stone
may be seen to be resting. If the ulcer deepens, the
stone may eventually perforate the gall-bladder wall,
escaping into the peritoneal cavity, into a mass of

Fin. 12. — An adipost gall-
bladder. The infihration with
lat measures a third of an inch
in thickness, being placed be-
tween the serous and submu-
cous coats. From a man aged
sixty-sLx, who died on the day
after admission to hospital.
The cellular tissue throughout
the body was loaded with fat;
the kidneys were granular, the
liver cirrhotic (Guy's Hospital

y

68 General Pathology of Gall-stone Disease

adhesions, or into the liver substance; or if a viscus
be adherent to the outer side, an internal biliary fis-
tula may form, through which gall-stones may escape.
In the more acute forms of inflammation there may be
patches of gangrene in the wall of the gall-bladder, or
the whole viscus may be in a condition of phlegmonous
ulceration. Many such examples are quoted in the chap-
ter on perforation of the gall-bladder. When the cystic
duct is blocked, and even, rarely, when it is patent, and
there is an acute virulent infection of the gall-bladder, a
purulent collection speedily forms. The gall-bladder is
greatly dilated, its walls are thickened, deep red in colour,
sodden with inflammatory exudate, and the characteristic
condition of empyema of the gall-bladder develops. This
may lead to ulceration and perforation of the gall-bladder,
to a general i)urulent peritonitis, or the whole condition
may slowly subside. The gall-bladder lessens, the acute
symptoms disappear, and the fluid contents are either
passed into the ducts or in part absorbed. Many
weeks after such an acute outburst the gall-bladder may
be found to contain pus, though it is shrunken from its
former size. The cystic duct is still found blocked
with a calculus which all efforts may fail to dislodge.

Hydrops and Empyema. — The more chronic forms of in-
flammation may be associated with distension or shrinkage
of the gall-bladder when the cystic duct is blocked. At
the first a hydrops of the gall-bladder forms, the bile
within the gall-bladder being absorbed. In hydrops
the physical conditions resemble those which are found
in empyema; the difference between them is due to the
different degrees of virulence in the invading micro-organ-

r

d

/

Hydrops and Empyema

69

ism. In hydrops the wall of the gall-bladder may be grossly
thickened or it may be paper-thin and almost translucent.
There is both an atrophic and a hypertrophic sclerosis of the
gall-bladder. The epithelium is lost in patches and has
unrlergone a process
of flattening, being
transformed, ac-
cording to Gilbert
and Fournier, into
the semblance of a
squamous epithe-
lium. It has indeed
undergone such an
alteration as to be
scarcely or not at
all recognisable as
having any relation-
ship with that norm-
ally found, A dis-
tended, easily palp-
able gall-bladder
may remain un-
altereil for many
months, even, it
may be, for years.
But the patient who

bears it is in a condition of constant peril, for rupture,
ulceration, or acute infection may at any moment be
aroused.

The following examples give some idea of the enormous
size to which the gall-bladder m:iy attain :

.^Stone in the cystic duct,
drops of thi; gall-Haddcr.

7© General Pathology of Gall-stone Disease

Lawson Tait (Lancet, 1889, vol. i, p. 1394) reports a
case of distended gall-bladder which he mistook for a
parovarian cyst. The patient was a woman forty years
of age. The cyst contained eleven pints of a clear, gluey
fluid, and was emptied through an incision made between
the umbilicus and the
pubes. A stone was
found obstructing the
cystic duct.

Erdmann (Virch. Ar-
chiv, Bd. 43) relates the
case of a man twenty-
four years of age who
suffered from an enor-
mous abdominal tumour
from which 60 to 80
pounds of fluid were as-
pirated. The analysis of
the fluid shewed it to be
albuminous and to con-
tain a trace of bile. The
tumour was regarded as
a hydrops of the gall-
bladder, due to blockage
of the cystic duct.

Vincent (Rev. de Chir., 1888, viii, 753) reports the
following very interesting case :

A girl, eight and one-half years old, with a good family
history, came to him complaining of an abdominal tumour.
Six months previously her mother had noticed that the
child's abdomen was larger, but the patient had com-
plained for only three months of discomfort from the size
of the tumour and the pain in it. Tlie pain had never
been acute and was rather a feeling of soreness than actual

Hydrops and Empyema 71

pain. She had suffered with constipation alternating
with diarrhcea. Nothing resembling gall-stones had ever
been seen in the stools, and the latter had not been ob-
served to be clay-coloured. The child was anremic,
poorly nourished, and slightly jaundiced. There was a
continuous elevation of temperature of ioo.5''-io2'' F.
The stools were hard and blackish in colour. The urine,
300-400 C.C., was albuminous and contained bile.

Examination of the abdomen showed it to be fairly
uniformly distended, but rather more prominent on
the right side. A ridge extended from the right hypo-
chondriac to the left iliac region. The tumour was fluc-
tuating, flat on percussion, and extended two finger-
breadths to the left of the median line and within three
fingerbreadths of the symphysis.

The child was kept under observation some time and
after aspirating the cyst, when 160 c.c. of bile were ob-
tained, a cholecystotomy was finally done. Three litres
of fluid were obtained.

The operation and the autopsy (for the child died ten
days after operation) showed that the galhbladder was
tremendously dilated and hypertrophied, its walls being
I mm. in thickness. The cystic duct was obliterated,
forming a part of the cyst wall. The hepatic duct was in
the same condition and likewise helped to form the cyst ;
the openings of its two branches admitted the thumb.
Most of the ductus choledochus also took part in the form-
ation of the cyst, the duct being represented by a portion
15-20 mm. long, its opening into the cyst being closed
by a valve-like projection of mucous membrane. While
this fold of mucosa closed the duct above, a probe could
be passed from below into the cyst. The pancreatic duct
was ligated. The pancreas and spleen were enlarged.

Vincent considered that the trouble had arisen from
the presence of a stone or lumbricoid worm in the common
duct, and that after its presence had caused the dilatation

72 General Paiholog)' of Gall-stone Disease

of the gall-bladder and ducts the body had passed into
the duodenum. The valve-like fold of mucous membrane
in the common duct had caused the continued damming
Ixick of bile.

Similar enlargements of the gall-bladder are seen in
empyema— thus Berger (Bull. et Mem. Soc. de Paris, vol.
1 6, p. 472^ operated upon a pus-containing gall-bladder
which filled the right iliac fossa and measured 16 cm. by
12 cm., and Temier. from a ** slightly inflamed" gall-
bladdor, removeii 24 litres of fluid.

If the hydn^ps be infected, a condition of empyema
n^sults; if it Ix^ not infected, then the gall-bladder grad-
ually dwindles in size ami eventuallv becomes sclerosed.
In the latter case the cavity of the gall-bladder may at
the last be so small as to be dillicult of recognition, or it
may certainly W entirely obliterated. In one example of
stricture o( the cystic duct the gall-bladder had become
reiluced to a mass (^f fibrous tissue less than an inch in
length, and on minute examination no eWdence of a
ca\itv could be disan*ereil.

Pericholecystitis. The extension to the outer surface
of the ^all bhulder and the manifestations thereon are
^icncrally pn>iH>rtioned to the conditions existing \\-ithin
lht» ^all Madder. It ther^^ is acute inflammation of the
^(ill hladiler, a local acute |vritonitis results and adhesions
arc h^lt heliintl. If then" an.^ chnMiic indurative conditions,
llin adhesiiM\s aiv numennis and intensely difficult to
hi lip; Ihcv are tonned nuietly and without any e\*idence
nl aiMitc inlcctioM. In raiv cases the {X'ritonitis resulting
ImiM an aculciv it\llanu\I iT-dl-bladder may Ix^ purulent

Pericholecystitis 73

wliLTi no rupture of the gall-bladder is discoverable. In-
stances are recorded by Dilger, Jacobs, anil BilHnger.

Fig, 28, — A gall-hladder with thickenuil and calcareous walls
which contained, pus. From a case of typhoid fever, in the fourth
or fifth week of which tht^ suppuration is believed to have occurred
(Royal College of Surgeons' Museum, No. j8o6).

When the gall-stones have become quiescent in the gall-
bladder the pericholecystitis which they have caused

74 General Pathology of Gall-stone Disease

may be the one condition which demands surgical inter-
ference, by reason of the adhesions crippling the stomach
or the dutxknium and thereby causing symptoms of pyloric
obstruction.
Calcification.— In certain cases of long-enduring chole-
cystitis a calcification
(it is sometimes incor-
rectly called ossifica-
tion) of the gall-blad-
der may be found. In
the fibrous wall of the
gall-bladder smaller
and larger plates of
calcification are recog-
nisable, the whole \'is-
cus seeming to be
turned into a twisted
mass of bone. In the
earliest stages small
deposits of lime salts
are found only in the
mucosa. In a later
stage the fibrous wall
of the gall-bladder is
encrusted with a de-
"'" "■ ""*"""■ '^"- '*'-" ix)sitof calcium phos-

phate. Pilliet. who
liHH iiKiiiulimd nmny sivcinicns. remarks upon the striking
hlnillmlty Unit Iht- proces.s of calcification of the gall-blad-
ili'l- ipniwuiiU Li' Ihiil iif iithoroma occurring in the walls of
(ll'lt'l'lf'lti t'tllritii'iilion is ivcognised as following a suppu-

I'ki <ij a ('uk'iiri'ciiiii )iiilM>)iid(li.'r,
l)i« ciwU mmtiiiriiiii a qiiuncr to onc-
llilril "f «" I'luh '" Hiickncim its In-
trrlor WH* MM with a $nlt Bulid sub-
ilaiina I'riilHluliiH H lurno (juantiiy of
tiliiilwKliTln. TKiTK woro prncticully no
i<IImI>'I>1 «VI">|'Ii'I"« (KiiyHl College of

i

d

Formation of Diverticula 75

rative cholecystitis in the great majority of cases. Com-
plete calcification of the gall-bladder is rare, though
examples are to be found in a few of the museums. Riedel
records a very remarkable case in which the calcification
of a gall-bladder was of such density as to require the use
of a chisel and mallet before removal could be effected.

Formation of Diverticula. — One of the most remarkable
of the later results of gall-stone irritation is the formation
of diverticula in connexion with any part of the biliary
passages. The mucous membrane is worn through by
ulceration, the stone which lies in contact with it pushes
the outer wall of the gall-bladder before it, and finally

•

comes to lie in a separate compartment, which is shut off
completely from the gall-bladder in some instances, but
more commonly communicates with it by a narrow and
often tortuous channel. The commonest site of these di-
verticula is in the pelvis of the gall-bladder or in the cystic
duct, but the fundus, or indeed any part of the gall-bladder,
may be affected. A very remarkable example of diver-
ticulum occurring from the fundus is recorded by Staub
(Corresp. f. schw. Aerzt., 1896). The diverticulum was
opened and stones removed therefrom. Behind this was
felt a tumour which was supposed to be a movable kidney,
but which proved to be a distended gall-bladder. In
some specimens which I have examined there was a con-
dition seemingly of diverticulum at the outlet of the gall-
bladder which, on closer examination, proved to be noth-
ing more than the lodgment of the stone in the first part
of the sigmoid turn of the cystic duct. Two of such
specimens I have removed by operation. A close examin-

76 General Pathology of Gall-stone Disease

ation of them is necessary to distinguish them from those
in which true diverticula have been formed.

If the stone ulcerate more deeply into the wall of the
gall-bladder or of the ducts, a protective peritonitis may
occur around the area which is being eroded from within.
If, in such circumstances, the destruction of the gall-blad-
der continues, the stone may finally pass through the wall
and come to lie in a cavity outside the gall-bladder. Such
cavities are often described as ** secondary gall-bladders.
Very good examples of them are referred to in the article
upon perforation of the gall-bladder.

In some cases the gall-bladder may adhere to the abdom-
inal wall and stones may ulcerate through ; or a tumour,
resembling a malignant growth in the muscles of the ab-
dominal wall, may be formed. Mordret records (Bull, et
Mem. Soc. de Chir., vol. 29, p. 1 189) a case where a tumour
of the abdominal wall, not adherent to the skin, was
formed in this way, and Michaux refers to a precisely
similar case which was under his own observation. In
the former case cholecystotomy, in the latter cholecys-
tectomy, was performed.

These diverticula may be found also burrowing in the
liver substance, but in such cases it is hard to distin-
guish them from an actual i)erf oration of the gall-bladder
and the formation of a secondary cavity in the liver.
Diverticula, which form from the cystic duct, may contain
stones of large size, stones which, by their pressure,
may have iproduced obstruction of the portal vein, of the
common duct, or of the duodenum. Many examples of
mistaken diagnosis, resulting from this condition, are
quoted in this book. If the ])ortal vein is obstructed.

Formation of Diverticula 77

there may be thrombosis, and ascites will result, which,
if pressure also is exerted upon the common duct, will
be associated with jaundice. A diagnosis of malignant
disease will then be made, as recorded by McArthur, Barrs,
and others. If pressure be made upon the duodenum, the
signs and symptoms of pyloric stenosis will be manifest,
and an operation for that condition vnll be undertaken.
Examples of this are related by Mikulicz and Maclagan.
In one of his cases Mikulicz performed gastro-enteros-
tomy, and only six months later, on performing chole-
cystotomy, discovered the cause of the duodenal obstruc-
tion. In another, a patient aged twenty-nine had
suffered for six months from great dilatation of the
stomach and excessive wasting. Stenosis of the pylorus
from simple ulcer was diagnosed and an operation under-
taken. After opening the stomach Mikulicz found, at
the base of the pyloric ulcer, a gall-stone * * larger than a
thumb joint. * '

Diverticula are also, though less frequently, found in
connexion with the common duct. They spring almost
invariably from the tipper part of the duct and do not
necessarily cause any impediment to the onward flow
of bile ; jaundice, therefore, may be absent.

A case in which a diverticulum had formed from the
pancreatic portion of the duct is recorded by Thienhaus
(Annals of Surgery, vol. 36, p. 927). The description of
the operation upon this case is reproduced in the chapter
dealing with operations upon the common duct.

In contradistinction to all the foregoing there are
changes in the wall of the gall-bladder and of the ducts,
especially in the former, which lead, not to thickening.

Mngt <f S-Jmntr Disease

; Ak ^^fe b sane mstanoes the
' fas cfasehr en to a

ra«idoaw><<s>'

,^«t a^ kt a anO

Changes Seen in the Common Duct 79

may contain only a few drams of a thin and watery
fluid.

When a great part of the wall of the gall-bladder seems
healthy, there may be local thickening and puckering at
the site of an old ulcer. These scars are commonly seen
in cases of old-standing cholecystitis, and may be single
or multiple. If the cholecystitis has been acute, or
has been chronic, adhesions on the outer surface of the
gall-bladder vAll almost certainly be seen. When the
inflammation is of recent date, the adhesions are thin,
filmy, and easily detached; when the disease is of old
standing the adhesions are so complex that half an hour
may be spent in detaching them before the landmarks
can be recognised. The gall-bladder then is often shrunken
and may be contracted and withered almost beyond recog-
nition. Such adhesions, the result of a pericholecystitis,
may affect all the adjacent structures, the liver, colon,
duodenum, and stomach being all gathered up into a mass
of the densest complexity.

When ulceration extends deeply into the wall of the gall-
bladder the peritonitis which results upon the outer sur-
face may result in the adhesion of the stomach, the duode-
num, the colon, or any jjart of the intestine. If, then,
a perforation of the gall-bladder occurs, an opening is
made into these hollow viscera and a fistula results.

Changes Seen in the Common Duct. — When gall-stones
are for any length of time fixed in the common duct they
give rise to a great variety of altered conditions. The
absolute fixity of a stone is rare. As has been shewn by
Fenger, the stone soon comes to act as a ' * ball valve. ' *
The duct behind the stone becomes dilated, and within

So General Pathology of Gall-slone Disease

this larger duct the stone is free tu move. The dilatation
of the duct is chiefly due to two factors: first, inflam-
mation, softening the duct wall and causing it to yield :
and second, the pressure of the bile. The secretion pres-

FlC. 31, — Chronic cholecystitis (calculous disease). The gall-
bladder is represented by a mass of tough inflammatory tissue, sur-
rounding a small cavity in which lay a number of small gall-stones.
The common bile-duct O^'i^ open) is much dilated. In it lay three
large ova! stones; two removed during life by operation through the
opening seen in its anterior wall, the remaining stone, which blocked
tho duodenal end of the duct, being found in the wound at the autopsy.
The bile-ducts and the liver were greatly dilated, and the liver was
deeply jaundiced. From a woman aged sixty. At the operation
much difficulty was experienced from matting of the tissues around
the bile-ducts in the hilum of the liver (Charing Cross Hospital Museum,
No, 1305).

sure of the bile lias been shewn by Noel I'aton and Bal-
four to be no more than 24 mm. of mercury; but this
low pressiu^e acting constantly upon the wall of a weak-
ened duct is ample to produce a high degree of dilatation.
The distension of the common duct is sometimes remark-

Changes Seen in the Common Duct

Fic. 32. ^Dilatation of the common bile-duct; cholecystotomy;
drainage. On the under surface of the liver is a thick-walled cyst
about six inches in diameter the interior of which is smooth and
presents three openings, communicating respectively with the dilated
hepatic and cystic ducts and with the distal portion of the common.
■ duct. The last i inch of the common duct is of less than normal
calibre, and shews a valvular fold so far obstructing its lumen that
after death fluid could not be forced from the cyst through the biliary
papilla. From a woman aged twenty-one, who for two and one-halt
years suffered from persistent jaundice the onset of which was not
preceded by pain. A tumour in the hepatic region extending to
the level of the umbilicus was twice aspirated, three and a half pints
being removed on each occasion. Immediately after the second
aspiration the gall-bladder was laid open and stitched to the abdom-
□ days later. No calculus was found

inat wall. Death took pla
(Guy's Hospital Mu

No.

I-O).

82 General Pathology of Gall-stone Disease

able. Terrier records three cases in which the common
duct was dilated to such a size that a palpable tumour
was observed ; in one a diagnosis of pancreatic cyst was*
made; in another a diagnosis of distended gall-bladder,
and in a third a diagnosis of hydatid cyst of the liver.
Several instances are recorded where the last mistake has
been made. In cases recorded by Swain and Mayo Rob-
son the common duct has been dilated to a degree permit-
ting its anastomosis with the small intestine.

Edgcworth (Lancet, 1895, i, 1180) reports the following
instance of dilatation of the common duct :

The patient, a girl of four and one-half years, had been
quite well until six months of age, when she became jaun-
diced. This lasted two or three weeks. Since that time
she had slight recurrent attacks of jaundice every six
months or so. Otherwise she had been well and devel-
oped normally. About one year before admission, how-
ever, when three and one-half years old, "the child^s
stomach began to grow big, •' and this enlargement slowly
increased, though none the less the girl appeared to be in
good health until about four weeks before, when she
bec(mie thinner in body and face. On examination, the
patient was found to be well grown for her age and moder-
ately well nourished. There was a slightly yellow tint to
till! conjunctivae and skin. The urine contained a small
amount of bile jMgments and no albumin. The stools
wcri^ bile-stained. The liver was enlarged, the upi^er
limit of dulness extending to the upper border of the
fourth rib in the nij^ple line, and its lower edge in the epi-
^{/iHtric notch being lower than normal. The surface of
l.lir liver in tlu» latter situation felt smooth and firm. Im-
mediaU'lv beneath the abdominal wall, in portions of the
e|ii^r/iHt.rie, tnnbilii'al, right hyi)ochondriac, and lumbar

Changes Seen in the Common Duct 83

regions, an intra-abdominal tumour was found measur-
ing about three inches in transverse and three and one-half
inches in longitudinal diameter, with the lower edge one
inch below the level of the umbilicus. The tumour was
slightly movable laterally, of rounded shape and smooth
surface, with an elastic feel like a tightly distended bladder.
Fluctuation was doubtful. The tumour was dull on per-
cussion and the dulness was continuous with the liver
above. Spleen enlarged; no ascites. It was considered
to be a distended gall-bladder. The tumour was incised,
twenty -nine ounces of normal bile were evacuated, and
a drainage-tube inserted. The child died in one week and
at autopsy the gall-bladder was found very small and con-
tained a little inspissated bile. The cystic duct was oblit-
erated, a fibrous cord representing it. The lower end
of the common duct was stenosed ; its lumen admitted a
hair-pin. The middle portion of the common duct was
so distended as to form the sac, which had a thick wall
consisting of layers of fibrous tissue. The common duct
above this and the hepatic duct were somewhat dilated,
as were also the biliary ducts. The liver was enlarged and
was in a state of biliary cirrhosis. The cause of the condi-
tion was not clear, but he thought it due to repeated
attacks of catarrh of the ducts.

Barlach (Deut. med. Woch., 1876, No. 31) observed a
thick-walled cyst almost as large as a child's head formed
by a dilatation of the common duct. The cyst was adherent
to the stomach above and communicated with it by a
perforation 6 cm. long. The gall-bladder formed an ap-
pendage to the upper part of the cyst, with which it com-
municated by a small opening ; the hepatic duct opened
into the cyst. The cyst was formed by the upper part of
the common duct, the lower part being blocked by ' * a
fleshy tumour."

Frerichs (Klinik d. Leberkrankheitcn, vol. 2, p. 433)
describes a specimen in the museum at Breslau removed

84 General Pathology of Gall-stone Disease

from a woman who died as a result of obstruction of the
common duct. The cystic and upper parts of the duct
were dilated to form a cyst eight inches long and five inches
wide.

In Guy's Hospital Museum is a specimen (No. 1429)
shewing a papilliferous cyst of the common bile-duct,
the cyst communicating by several perforations with the
first part of the duodenum. The patient was a boy aged
four, the right half of whose abdomen was occupied by a
fluctuating swelling from which five pints of greenish,
purulent fluid were withdrawTi. After death, eleven days
later, the cyst was found to communicate with the cystic,
hei)atic, and common bile-ducts and with the fundus of
the gall-bladder.

The fluid contained in these dilated ducts is generally
bile, for the obstruction is almost always intermittent
and of the * * ball valve ' ' type. Rarely, however, when the
obstruction is impassable, the fluid is clear, as was first
shewn by Moxon. The mimicry of a gall-bladder whose
outlet is blocked by a stone in the cystic duct is then
complete. Complete block of the cystic duct or of the
common duct results in the retention behind them of a
clear or slightly turbid fluid containing mucus. Be-
hind an incomplete or intermittent block bile is re-
tained.

The interior of the duct mav not seldom shew evidence
of ulceration, which may lead to the formation, in the last
stage, of diverticula or of fistulae. Fistula between the
termination of the common duct and the duodenum is
l)r()bably a very common condition. Many examples are
rc»f()r(le(l under the name of '* wide-mouthed opening'* of
the common duct. In Courvoisier's records ulcerative

Changes Seen in the Common Duct

perforation into the duodenum occurred in six cases, into
the general peritoneal cavity in eight cases.

Fig 33, — Papillitevous cyst of the common bile-duct, the cavity of
the cyst communicating by several perforatioiiB with the first part of
the duodenum. The patient, a boy aged four, was admitted for en-
largement of the abdomen, emaciation, and vomiting of seven months'
duration. The right half of the abdomen was occupied by a fluctuating
swelling from which five pints ot greenish, purulent fluid were with-
drawn. After death, eleven days later, the cyst was found to com-
municate with the cystic, hepatic, and common bile-ducts and with the
fundus of the gall-bladder (Guy's Hospital Museum, No. 1439).

The ulceration in its healing causes a stricture, and
the points of narrowing, like the points of ulceration,
may be single or may be many.

86 General Pathology of Gall-stone Disease

A pericholangitis, a peritonitis surrounding the common
duct at its upper end, may be one of the results of inflam-
mation within the duct, and by its means so great a nar-
rowing of the calibre may be produced that jaundice may
be present as an enduring symptom.

Suppurative Cholangitis. — When infection of the gall-
bladder and bile-ducts occurs, every stage of inflamma-
tion of the mucosa, from the slightest form of catarrh up
to the most extensive suppuration, may be witnessed.
In the gall-bladder the conditions already described are
found. In the common and hepatic ducts, cholangitis,
ulceration, perforation with the formation of fistula,
and widespread suppuration, extending upwards to the
smallest of the ducts within the liver, may be found.
The inflammation may at times resemble that found in
membranous cholecystitis, and casts of the duct of larger
or smaller size may be found. Thudichum, in his work on
gall-stones, asserted that the nucleus of many of the stones
found in the gall-bladder could be shewn to consist of a
cast of the finest hepatic ducts, but his observation has
lacked confirmation. When inflammation and obstruction
coexist, the walls of the common and hepatic ducts give
way. In chronic cases a marked thickening of the duct,
due to a deposit of fibrous tissue, is found. When the
duct is incised for the removal of a stone, its walls are seen
to be thick, tough, and yellowish white in colour. The
duct beyond the calculus, between the stone and the duo-
denum, is often softened and dilated also so as readily to
allow of the passage of the forefinger. When the inflam-
mation is virulent, the suppuration extending into the
liver may give rise to the condition which Leonard Rogers

Suppurative Cholangitis 87

has aptly termed * * biliary abscess. * * There is a general
suppurative cholangitis, and the liver has been likened to
a sponge whose interstices are filled with pus. By enlarging
and causing disintegration of the intervening liver sub-
stance a large hepatic abscess may be formed, which may
reach the surface of the liver and then burrow upwards into
the chest, downwards into the abdomen, or, in the most
happy event, reach the surface of the body. The contents
of such abscesses are not uncommonly tinged with bile,
and when there is a general purulent disintegration of the
liver, hei)atic cells may be found on examination of the
fluid. The offending organisms formed in the pus are
the bacillus coli, most frequently, and the staphylococcus
pyogenes aureus and albus, and various streptococci.

Suppurative cholangitis in the majority of instances is
found as a result of occlusion of the common duct by a
stone or other foreign body, a hydatid for example, as in
two cases under my care. The condition, however, may
result from typhoid fever, and the typhoid bacillus alone,
or in a mixed infection, is then found in the pus.

Another organism found, either with or without the
presence of stones, is the pneumococcus. This has been
found alone or in company with the bacillus coli. Do-
menici, in exj^erimenting upon animals, injected bacillus
coli, typhoid bacilli, and pneumococci into the gall-bladder
and into the bile-ducts. When injected into the former
the results were always negative; when into the latter,
the results were always positive, acute cholangitis result-
ing. In some instances, when the bacillus of typhoid
and the pneumococcus were injected, endocarditis also
resulted.

88 General Pathology of Gall-stone Disease

In several records and in museum specimens the impor-
tance of a secondary infection upon an old-standing disease
of the common duct is shewn. In cases where there is
gall-stone disease in any of its various forms the onset
of enteric fever adds a serious risk to the patient's condi-
tion, and may be the determining cause in an acute sup-
puration in any part or in the whole of the bile passages.
Hepatic abscesses depending upon cholelithiasis may, as
shewn by Naunyn, be formed in several ways :

1. An empyema of tlie gall-bladder may burst into the
liver.

2. Purulent cholangitis of the intrahepatic bile-ducts
leads to ulceration of the mucous membrane, and the
ulcerative i)roeess s])rea(ls from the duct walls to the
neighbouring i)arenchyma of the liver. The bile-ducts,
around which the sui)puration occurs, are often filled with
inspissated pus, or, more frequently still, with dark-
coloured pultaceous deposits of bilirubin calcium.

3. Necrosis of the liver cells at the periphery of the
lobule, suppuration, and the casting off of the necrosed
tissue; the process of " hepatitis sequestrans.* '

4. Hepatic abscess occurring with cholelithiasis may
be embolic.

Pylephlebitis may be set up by the pressure of a stone
in the common or cystic ducts, causing thrombosis in the
disorganization .

The suppurative process extending from the liver may
give rise to a subphrenic abscess, to pleurisy, or to empy-
ema. In one case, related by Simmons (Amer. Joum.
Med. Sci., Oct., 1877, p. 463), an abscess burrowed upwards
into the anterior mediastinum, and finally burst into the

Membranous Cholecystitis and Cholangitis 89

right bronchus. Two cases are recorded by Vissering and
Colv^e, in which gall-stones have been coughed up with
pus and bile.

Biliary abscess of the liver, general suppurative cho-
langitis, is due in the majority of instances to gall-stone
obstruction in the common or hepatic ducts. I-^eonard
Rogers found gall-stones in eighteen out of twenty cases
whose records he studied. In the seventy-four cases
collected by Courvoisier gall-stones were the cause, di-
rectly or indirectly, in fifty-seven.

Membranous cholecystitis and cholangitis are rare
sequelae of gall-stone irritation. But few cases of this
disease are recorded; in some, gall-stones were present;
in some, gall-stones had been passed, but could not be
found at the autopsy ; and in others no gall-stones were at
any time perceptible. The following case is recorded by
Fenwick (Brit. Med. Joum., vol. i, 1898, p. 1072) :

The patient, a male, aged twenty-nine, had nine attacks
of biliary colic in the last fourteen months, accompanied
by more or less severe jaundice. During the first two
attacks he passed on each occasion a fairly large facetted
gall-stone. The faeces had not been examined during the
later illnesses, but from his severe pain and symptoms,
exactly resembling his earlier attacks, he feels sure that
he has passed a stone on each occasion. Fourteen days
ago he had a severe colic, necessitating the use of mor-
phine, and next day passed a large ''j^ece of flesh,"
which was examined by his doctor, who described it as an
oblong sac, with moderately thick walls, stained green,
about two inches long and one inch broad, resembling the
gall-bladder in shape. Ten days later he was again seized
with severe pain, similar to that experienced in all the

90 General Pathology of Gall-stone Disease

former illnesses, and after some hours of agony he was re-
lieved and next day passed another cast which I examined.
It is two inches long, one and one-half inches in breadth,
its walls are one-tenth of an inch thick, it is a closed sac
with a distinct neck, and is stained bright green in parts,
especially towards the neck. When laid out, it appears
to resemble a gall-bladder. The accompanying faeces
were clay-colored, and had been so for a long period of
time. There was no microscopic appearance of hydatid
structure, and I do not think that it was an intestinal cast.
We came to the conclusion that both these casts were
derived from the gall-bladder, as the patient had suffered
from typical biliary colic many times before the passage of
the casts exactlv similar to that he had felt before he
passed the gall-stones.

It does not seem improbable that the presence of the
stones has set up a chronic inflammation in the bladder,
which has resulted in the formation of a false membrane,
which has itself been exi)elled after the last stone had been
passed.

In one case, related by Malmsten, the gall-bladder of a
patient who had died of general peritonitis was found to
contain a croupous exudation.

Rolleston (Path. Soc. Trans., vol. 53, p. 405) records a
case in which a fibrinous cast of the gall-bladder was asso-
ciated with a gall-stone. The following is his account :

The patient, a woman, aged fifty-two, who had never
had jaundice or biliary colic previously, was suddenly
seized with pain on the right side of the abdomen and
vomiting. On admission to St. George's Hospital two
weeks later a tumour of stony hardness was found in the
right iliac fossa, separated from the liver dulness by a zone
of resonance. Laparotomy was ])erf()rmed by Mr. Ailing-

Membranous Cholecystitis and Cholangitis 91

ham, and revealed a greatly enlarged gall-bladder, united
by adhesions to adjacent parts. On opening the gall-
bladder a single calculus, rather larger than a walnut,
enclosed in a membranous sac, was removed. This mem-
brane was easily detached from the walls of the gall-blad-
der and was brown in colour and not unlike a dysmenor-
rhoeal cast of the uterus. Its walls were from a quarter
to one-sixth of an inch thick, varying in different parts.

Microscopically, the walls of the cast were composed of
fibrin enclosing bile pigment and hexagonal and quadri-
lateral crj'stals. The crystals were soluble, without effer-
vescence in dilute nitric acid, but not in acetic acid. On
the outer layer of the cast there were a number of small
round cells, and scattered through the fibrinous network
there were a few nuclei. There was no trace of the mucous
membrane of the gall-bladder in this membranous cast.
No micro-organisms could be seen in specially stained
specimens.

In the present case the fibrinous structure of the mem-
brane is quite different from the histological appearance
of the intestinal casts of mucous colitis, and the process
cannot be considered to be comparable to that of mucous
colitis. Its structure suggests a comparison to acute
membranous inflammations of mucous surfaces, such as
have been found to be due to pneumococcal infection,
but pneumococci were not found in this case.

The association of attacks of a nature precisely similar
to that in which a gall-stone is passed, with the passage of
membranous casts in the faeces, was first observed by
Richard Powell: "On Certain Painful Affections of the
Intestinal Canal*' (Medical Transactions of the R. C. P.,
vol. 6, p. 106, 1820). These casts were due to the disease
now regarded as "membranous colitis." There is noth-

92 General Pathology of Gall-stone Disease

ing in Dr. Poweirs account to suggest that any part of the
casts came from the gall-bladder or bile-ducts. The asso-
ciation of cholelithiasis with membranous colitis has
since been observ^ed by Mayo Robson, myself, and others.
The following case of membranous cholecystitis was
under my care :

History. — Mrs. A., aged forty-three. Seen August 21,
1902, with Dr. Carlton Oldfield. The patient had suf-
fered all her life '*from spasms." Pain was felt in the
right hypochondrium, shooting thence through to the back
and all over the abdomen; it was attended by vomit-
ing and collapse. There has never been any jaundice.
Seven weeks ago a tumour was noticed on the right side of
the abdomen, a little above and internal to the anterior
superior spine. Constipation has latterly been a marked
feature, and distinct intermittent intestinal coiling has
been seen, the caecum rising up very prominently and
loud borborygmi have been heard. On several occasions
an abundance of thick, blood-stained mucus or unstained
mucus has been passed in the motions. The tumour is
densely hard, irregular in outline, very slightly movable
laterally and vertically during respiration ; it is not tender
to the touch. A diagnosis of growth of the ascending colon
was made and laparotomy advised.

Operation. — The abdomen was opened on August 28th.
A hard tumour, adherent to the abdominal wall and as-
cending colon, was found. On first examination it was
thought that the diagnosis was accurate, but a gradual
separation of adhesions revealed the gall-bladder lying
buried in a trough made by the colon and adherent by
strong bands to the colon and abdominal wall. The caecum
was large and very much hypertrophied, feeling tough and
leathery. There was very dense thickening and stiffening
of the ascending colon at the part where lay the distended

Stricture of Ducts 93

gall-bladder. The much-thickened gall-bladder was laid
open and 368 stones were removed. The gall-bladder
was then seen to be lined with a thick, membranous coat-
ing, which peeled off the mucous membrane very readily.
The condition was one of membranous cholecystitis. The
gall-bladder was therefore removed with a portion of the
cystic duct, and the abdominal wound closed without
drainage. The patient made a perfect recovery and is
now in good health, doing her ordinary household duties.

Stricture of Ducts. —The ulceration caused by gall-
stones in the hepatic or common ducts may, in the healing
which ensues upon the passage of the stone, give rise to a
stricture of the duct. Hoffmann (Virch. Archiv, Bd. 39,
p. 206) found a stricture which involved the common he-
patic duct for I cm., the left hepatic duct for 1.4 cm., and
the right for 0.8 cm. The finest bristle could not be passed
through it ; the walls of the stricture were thick and cica-
tricial. Merbach (Schmidt's Jahrb., 141, p. 107) records a
somewhat similar example. Moxon found a stricture of
the hepatic duct in a man of thirty-one years of age who
had suffered from cholelithiasis. It was situated about
one inch above the point of junction with the cystic duct.
The walls were irregularly thickened and fibrous. No gall-
stone was found in the duct, nor any ulceration. Bris-
towe (Path. Soc. Trans., vol. 9) and Holmes (vol. 10)
relate cases of stricture of the hepatic duct. The latter
calls attention to the resemblance of the appearances to
those found in stricture of the urethra.

Stenosis of the common duct may be produced in a sim-
ilar manner, or the duct may be compressed, twisted,
kinked, or otherwise warped by the action of adhesions

94 General Pathology of Gall-stone Disease

which surround it. Cases in which a stricture of the
common duct, dependent on gall-stone ulceration, has
\^en excised, are recorded by Kehr and Mayo.

Hsemorrhage. — Haemorrhage from the gall-bladder and
bile-ducts, as the result of calculous disease, is sometimes
seen, and may be a symptom of dire significance. In old-
standing jaundice a tendency to haemorrhage is one of the
most remarkable clinical features. Operations upon these
patients is attended by the risk of continued bleeding,
which may end fatally. This tendency is decidedly more
frequently present when the jaundice is dependent upon
pancreatic disease, as was first shewn by Mayo Robson.
The haemorrhage from the vessels of the abdominal wall
may, in such circumstances, be so profuse and so long-con-
tinued as to be the immediate cause of death. In patients
so affected there may be large haemorrhages into the sub-
peritoneal tissue, or, indeed, into any part of the body, as
the result of the most trivial injury. When pressure is ex-
erted by a stone, in the cystic or common ducts, upon the
portal vein, there may be submucous haemorrhages in any
part of the intestinal canal, and the bleeding from the con-
gested surface into the bowel may be profuse. A case is
related by Naunyn of a woman, aged fifty, who had suf-
fered from jaundice for six months; ascites developed
rapidly, and about three weeks later there was a profuse
haematemesis, with melaena, and coma developed. At the
autopsy a stone in the cystic duct was found to be press-
ing upon the portal vein, which contained a clot. The mu-
cous membrane of the intestine and of the stomach exhib-
ited haemorrhagic areas but was nowhere ulcerated.

Quinquaud — quoted by Hoppe-Seyler and Schiippel —

Hemorrhage

Fio. 34. — Shewing tht gall-bladdtr and bile-ducts distended by
blood; Cholccystotoiny Thi'ro was a laceration two and one-half
inches long in the anterior wall of the gall-bladder. The cystic duct
and lower part of the common bile-duct are slightly dilated, the re-
mainder of the latter and thf hepatic ducts enormously so. Below are
seen the clots removed from the gall-hladder (measuring two and one-
half inches transversely) and the hepatic duct (one and one-quarter
inches). From a woman, aged iittj'-four, who, while suffering from
jaundice of two months' duration, was suddenly Ecizcd with acute ab-
dominal pain and collapse, together with a rapidly increasing tumour of
the gall-bladder. Much blood was passed per rectum. Laparotomy
was performed Hve days after the onset of the acute symptoms and
almost a pint of blood-clot was removed from the gall-bladder. Death
look place a few hours later (Guy's Hospital Museum, No. 13S9),

96 General Pathology of Gall-stone Disease

described a case of haemorrhagic cholangitis in which so
large a quantity of blood was poured into the bile-ducts
and into the intestine that death followed from haemor-
rhage.

The following case is recorded by W. Arbuthnot Lane
(Clin. Soc. Trans., vol. 28, p. 160) :

The patient, a female, aged fifty-four, was admitted to
St. John's Hospital, Lewisham, on December 20, 1894.
Two months previously she had developed jaundice, which
became very deep. There was no history of a previous
attack or of any pain or discomfort in the region of the
gall-bladder. The liver was enlarged and she had pain
about the gall-bladder. On December 16, owing to the
taking of a strong purgative, she was seized with profuse
diarrhoea, with severe straining. During a severe bearing-
down effort she suddenly exclaimed that she had felt a
very sharp pain in the region of the gall-bladder, as if
something had given way. A surgeon was sent for, who
found a rounded tumour in the position of the gall-bladder.
The diarrhoea continued in a lesser degree and the motions
consisted chiefly of blood. Next day the tumour was
larger, but the pain was not so intense. On December 21
she was much worse, and the temperature rose to 100°.
Mr. Lane was called in consultation. He decided on oper-
ation and exposed the gall-bladder by an incision over it.
The tumour protruded at once through the wound, when it
was found to be firm and inelastic, like a soft growth. It
was incised and three-quarters of a pint of blood-clot
turned out. The cystic, hepatic, and common ducts were
also enormously distended with clot. No stone could be
felt. The patient died the same night.

Postmortem. — The gall-bladder was distended to about
twice its normal size and was filled \\4th clotted blood.
The common duct was greatly distended and was com-

Hs

o rrhage

97

pletely filled with finn_ blood-clot, which extended into
the main hepatic duct and into the branches of the ducts
within the liver.

The mucous membrane of the gall-bladder was lacerated
for a distance of about one inch and a half in the anterior
wall, and the rent extended for a small distance into the
substance of the liver. In the absence of any other dis-
covered cause, it appears probable that this laceration of
the mucosa was the source of the hemorrhage. No gall-
bladder stone was found nor any other cause for the jaun-
dice than the obstruction of the ducts by the blood-clot.

It is possible that the stone which produced the obstruc-
tive jaundice was forced into the bowel by the pressure of
the blood behind it, and that it escaped unobserved in
the evacuations which were thrown away by the friends.
(Guy's Hospital Museum, Specimen, No. 1389.)

Many cases are recorded of haemorrhage from the stom-
ach or from the bowels during the formation of fistuUe be-
tween the gall-bladder and the alimentary canal. Fatal
hfemorrhage from the biliary passages as the result of
cholelithiasis is recorded by several writers, Naunyn,
Chiari, and others. In some of these false aneurysms
of the hepatic or of the cystic arteries have been found to
have ruptured. The following case is recorded by Cahn
and quoted by Naunyn :

An elderly woman had long suffered from epigastric
pain and vomiting after food. The diagnosis lay between
round ulcer of the stomach or duodenum and cholelithiasis.
No gall-stones could ever be found in the stools. Five
weeks before her death there occurred a copious gastric and
intestinal hjemorrhage, and a few days later a more severe
one, with the passage of bright red blood from the bowel.

98 General Pathology of Gall-stone Disease

Then followed slight jaundice, without discolouration of
the stools, and this repeatedly recurred in a transitory
manner. A similar haemorrhage occurred three weeks
before death, and finally a rapidly fatal intestinal haemor-
rhage. At the postmortem there was found a false
aneurysm of the right hepatic artery ** which lay in con-
tact with that part of the hepatic duct which was over
against the point of a gall-stone which had penetrated
into it from the cystic duct.** This aneurysm had rup-
tured into the hepatic duct. There were, in addition,
three perforations from the gall-bladder into the duo-
denum.

Many fatal cases of haemorrhage into the gall-bladder
and ducts after operation are recorded by Riedel, Qu6nu,
and others.

Schwartz relates (Bull, et Mem. Soc. de Chir., vol. 29,
p. 677) the case of a man of forty-three who was operated
upon in April, 1901, for cholelithiasis. The gall-bladder
contained a litre of bile. The common duct was ex-
plored with a negative result. The head of the pancreas
was found increased in size and indurated. Cholecystot-
omy was performed. A biliary fistula persisted until
January, 1903, when he became jaundiced and died
from profuse and incoercible haemorrhage from the
fistula.

Malignant Disease. — One of the most serious of the se-
quelae of cholelithiasis is malignant disease of the gall-
bladder or of the ducts. The close connexion between gall-
stones and malignant disease has never lacked recognition,
though opinions have differed as to which is the cause and
which the effect. Opinion is now universally in favour of
the view that it is the irritation of the gall-stones

Malignant Disease 99

that determines the incidence of cancer, the view that
was first supported by Klebs, In his record of cases
Courvoisier found the follow-
ing results :

Of 84 cases of primary can-
cer of the gall-bladder, there,
were 72 in which stone were
found ; in twoothers stone had
been passed in the motions.
In the remaining 10 no men-
tion of stones is made; in
four of these there were cer-
tain pathological changes :
scarring of the duodenal pa-
pilla, stricture thereof, and
dilatation of all the bile pass-
ages, which indicated . un-
questionably, the former
presence of calcuh.

Janowski quotes Brodow-
ski as having examined 40
cases of primary cancer and
finding gall-stones in all.

Siegert (Virchow's Archiv,
Bd. 132. H. 2, 1893) investi-
gated cases both of primary
and of secondary cancer. In
primary cancer gatl-stones
are present in 15 per cent.

Musser, writing in 1889, had collected the notes of
TOO cases of primary cancer of the gall-bladder, verified

Fig. 35, — I'apillomata of
gall-bladder. From a woman
aged fifty-nine who died from
phthisis. Two large facetted
calculi and some fragments of
a third were found in the gall-
bladder (Guv'a Hospital Mus-
eum, No. .404).

36.-Primar>-c..luni
bile-duct shews, at
which i

lar-cfllfd cancer of tht bilc-Oiicls. Tht
its junction with the cystic Ouct. a. tight
ivoives also the latter. The bile-ducts
above are extremely dilated and the liver deeply jaundiced. The
gall-bladder presents a deep-red inflammatory appearance (following
on operation). From a woman, aged forty- live, who experienced
severe epigastric pain, jaundice, and vomiting about two months
before admission. A lump had been noticed in the abdomen for five
weeks and the lower edge of the enlarged liver reached nearly to the
umbilicus. The liver surface was irregular, but presented no nodules.
The gall-bladder was opened and thirty-two stones were removed,
some embedded in solid material connected with the wail; seven
more were extracted from a pouch at the exit of the cystic duct. A
hard lump was felt in the common duct, and a second similar lump
in the cystic duct. The opening in the gall-bladder was sewn to
the parietal peritoneum and a tube inserted. After operation there
were progressive weakness, increasing jaundice, and slight but per-
sistent pyrexia (Charing Cross Hospital Museum, Mo. 1,131).

Malignant Disease loi

postmortem. Gail-stones were present in 6g. Jayle. in 30
cases collected entirely from French records, found that
stones were present in 23 cases.

Fic. 37. — Carcinoma of Rail-bladder, with gall-stones, Sccondarj-
deposits in the liver (London Hospital Museum, No. tn).

Primary carcinoma of the bile-ducts is far less commonly
seen than in cancer of the gall-bladder, and the association
between gall-stones and growth is not so clearly shewn in

I02 General Pathology of Gall-stone Disease

postmortem records. A specimen of primary columnar-
celled carcinoma of the bile-ducts due to gall-stone irrita-
tion is in the Museum of Charing Cross Hospital(No. 1332).
Rolleston, writing in 1896, found that stones were present
in only four cases out of 1 1. He considers that calculi are
less commonly associated with cancer of the bile-duct
than with cancer of the gall-bladder, but' he admits the
i:)ossibility of the passage of gall-stones after the develop-
ment of the growth and before the death of the patient.
Courvoisier gives two cases of cancer of the common duct
due to the irritation of stones.

Ingelrans found that in cancer of the hepatic duct the
association with gall-stones was unusual.

In some of the museum examples the implantation of
the malignant change upon a chronic ulcer of the gall-blad-
der is well seen. The condition is exactly similar to that
of '* ulcus carcinomatosum** seen in chronic ulcer of the
stomach.

i\n examination into the records of a number of cases of
cancer due to gall-stones shews that in many, certainly in
a majority, jaundice had never been present. The symp-
tom most commonly recorded is cramp in the stomach,
followed by sickness and vomiting. The symptoms, that
is to say, are in the greater number of cases those due to
stone contained within the gall-bladder. Though gall-
stones are present and are the cause of the malignant dis-
ease, they may never have been suspected.

In very rare instances malignant disease of the gall-blad-
der may occur after cholecystotomy. The following case
was under the care of my colleague, Mr. Lawford Knaggs,
to whom I am greatly indebted for the notes :

Malignant Disease

103

Sarah D., aged sixty-nine, a spare old woman, who
looked and expressed herself as being very healthy, was
admitted on September 8, 1902. She had never had any
trouble with her digestion or her bowels except some slight
diarrhcEa two years before. Seven weeks before admission
she felt pain in the right hypochondrium which wore her
down when she walked. The pain gradually mounted
higher till it was felt over the lower ribs, and her doctor
discovered a tumoiu' in the right loin.

She had never been jaundiced or had any attack of
severe abdominal pain and she had lost no flesh. She
had a goitre of long duration which caused no trouble.

On examination, a smooth, rounded swelling was found
in the right loin. It was evidently attached to the liver and
was regarded as a distended gall-bladder, which, from its
mobility, was free from adhesions. A tender spot was al-
ways to be found on pressure at a point midway between
the umbihcus and the tip of the ninth rib, and a gall-stone
impacted in the cystic duct was diagnosed.

The urine was normal.

On September 11 the patient was anaesthetised and an
incision was made over the gall-bladder. This, much elon-
gated and distended to the size of a fist, was drawn out of
the wound and a quantity of foul-smelling fluid with some
pus was drawn off by the aspirator. A single stone was
felt in the cystic duct and was squeezed back into the gall-
bladder and removed. It was about the size of a nutmeg,
oval, and not facetted.

The gall-bladder was very long and supple, not notice-
ably thickened, and no suspicion of anything abnormal
was raised by the examination of the cystic and common
ducts which was made in the routine manner. An india-
rubber tube was now fixed in the "gall-bladder, which was
then attached to the aponeurosis, but, owing to its length,
a portion of the gall-bladder wall was allowed to lie above
the opening and between the lipsof the skin incision. From

I04 General Pathology of Gall-stone Disease

this circumstance the fistulous opening refused to close,
but the amount of bile that came from it steadily dimin-
ished and became so trivial that it proved to be no discom-
fort to the patient. Consequently, no thought of doing
anything to close it was entertained. The following report
of the fluid removed from the gall-bladder was made by
J. A. C. Forsyth, M. B. :

** On agar there was an active growth in five hours. At
the end of three days culture examined. Foul odour
noticed on withdrawing plug from tube. Film prepara-
tions show bacillus coli communis in pure culture. '*

The patient left the hospital on October 19, 1902. She
was seen from time to time as an out-patient and, except
for the fistulous opening discharging a ver\' little bile, she
was quite well.

About the end of 1903 she came complaining of pain in
the right hypochondrium. She stated that the fistula had
closed and that the pain began as soon as it ceased to dis-
charge. Some thickening under the skin around the cica-
trix of the fistula was to be felt, but this was attributed to
the redundant portion of the gall-bladder which had been
allowed to remain in the wound above the aponeurosis.
For two or three weeks she continued to attend as an out-
patient, but the pain then became so continuous and so
distressing that she was very glad to consent to the fistula
being reestablished. During this time she lost flesh and
was readmitted on January 23, 1904. The urine was nor-
mal. On the 26th she was anaesthetized and a small in-
cision was made into the gall-bladder over the closed
sinus, and the mucous membrane was sutured to the skin.
A considerable quantity of mucus with some purulent
dregs escaped, but no stone could be felt with a probe.
The intense pain was relieved by the operation, but the
patient did not seem to recover her spirits. On January
28 she had a rigor and the temperature rose to 105°.
She had another rigor on the 29th (temperature 102°),

Malignant Disease

105

and on February 4 the temperature rose to 103° and gradu-
ally fell ; but with these exceptions the temperature kept
about the normal throughout. The pulse varied from 72
to 100, but it averaged from 80 to po. Two or three days
after the first rigor jaundice was first noticed and marked
tenderness on pressure was present in the middle line
above the umbilicus. The jaundice increased and was
evidently due to obstruction. The left lobe of the liver
enlarged and reached almost to the umbilicus, and all
over it was very tender. There was also much pain in the
right hypochondrium and around the right lower ribs. The
mucus coming from the gall-bladder became bile-stained.

The patient complained of feeling very ill, was listless,
and often drowsy. Albumin appeared in the iirine and
there was cedema of the legs and abdominal wall. Grad-
ually ^e passed into a semi-conscious state. Petechial
vesicles appeared over the body and she died on February
17. 1904-

Mr. Gruner, the pathologist, examined the blood on
February 8, and reported as follows :

" Red cells, 480,000 per c.mm. White cells, 10.000 per
c.mm. The neutrophile leucocytes predominated. This
result is quitP in accordance with the blood-find in cases
of malignant disease."

Necropsy. — -4 bdonien . — The liver was somewhat en-
larged. On laying open the gall-bladder through the
fistulous opening it was found to be the seat of malignant
disease. The walls of the gall-bladder were infiltrated
with growth to the thickness of nearly one-half inch, and
the growth extended to and involved the cystic duct, prac-
tically occluding it. No growth involved the common he-
patic or the common bile-ducts, but the growth involving
the cystic duct had pressed upon and partially obstructed
the commencement of the common duct. Above this
stricture the ducts were markedly dilated and were the
seat of suppurative cholangitis.

io6 General Pathology of Gall-stone Disease

The surface of the liver showed numerous cystic eleva-
tions due to the dilated terminal ducts, and on section
the dilated bile-ducts were found filled with pus. A small
secondary nodule of growth was present in the left lobe
near its anterior margin. No gall-stones were found.
The pancreas was normal. The kidneys were small and
slightly granular — other organs normal.

Chest. — There were some adhesions in both pleural
cavities and both lungs were the seat of chronic bron-
chitis.

A microscopic examination of the growth of the gall-
bladder showed it to be a columnar carcinoma.

Changes in the Liver. — In cases of obstruction of the
common or hepatic ducts the liver, when examined during
life, is found in the early stages to have undergone a con-
siderable enlargement, reaching perhaps down to the um-
bilicus ; in the later stages the liver gradually shrinks and
eventually may become very much smaller than the nor-
mal. The condition of enlargement of the liver or hyper-
trophy, as it is often called, may persist for many months.
During each successive attack of inflammation in the
ducts, as shewn by an elevation of temperature and rigor,
and an increase in the depth of the jaundice, a slight fur-
ther increase in the size of the liver is commonly observed,
and palpation shews that the liver is also tender upon
pressure. If a liver be examined in this stage, after death,
it is seen that the hepatic ducts have undergone a consid-
erable dilatation, so that a series of cysts, as it were, are
formed in the liver. The outer surface of the liver mav
also be irregularly raised, the dilated ducts forming
smooth, spherical protuberances upon its surface. These
cysts contain bile almost always; in some cases fine

Riedel's Lobe

107

calculi; or a biliary sand, or mud, consisting chiefly of
bilirubin calcium, may be found therein. In cases of
complete obstruction of the common duct, supervening
upon an incomplete obstruction, the fluid may consist
of mucus alone, or of mucus faintly tinged with bile.
In the worst examples the absence of bile, acholia, may
be due to a profound alteration in the hepatic cells.

In the condition of atrophy of the liver a section of
the organ shews the same dilatation of the hepatic ducts,
but the liver tissue is in greater or less measure replaced
by fibrous tissue. The histological changes in all cases
consists of a biliary cirrhosis on the dilatation of the
hepatic ducts. Many of the bile channels may at the
last be so thoroughly strangled by the abundant deposit
of fibrous tissue that they lose their epithelium and
finally disappear altogether. The vessels of the liver
similarly undergo constriction, and the hepatic cells are
in parts strangled out of existence.

If these conditions are associated with a virulent in-
fection, the condition of biliary abscess already described
will result.

Riedel's Lobe. — One remarkable change, which though
commonly is not invariably associated with the pres-
ence in the gall-bladder of a number of calculi, is the
formation of a tongue-shaped process which projects
downwards from the right lobe of the liver. This process
may have many forms and may take its origin from the
margin of the liver to the right or to the left of the gall-
bladder. It was first descr lied by Cruveilhier, and in
the instance given by him the gall-bladder contained
manv stones. It is to Riedel that we are indebted for

io8 General Pathology of Gall-stone Disease

the fullest and most accurate description of this " lingui-
form process," as he termed it. He describes (Beriin.
klin. Woch., 1888, Nos. 29 and 30) and figures eight
forms of the process, and emphasises its dependence
upon gall-stone disease. He expresses the opinion that
the gall-bladder in its enlargement gradually drags down-
wards this tongue-shaped "lobe of the liver. In recogni-
tion of his work the process is generally described as
** Rtcdcrs lobe.*' Riedel, Terrier, and other observers
have asserted that after cholecystotomy the projecting
lobe gradually shrinks, and the liver then assumes its
normal outline. In a ver\' thin woman, upon whom I
])erformed cholecystectomy, a lobe, at least three inches
in length, has almost disappeared in the course of eighteen
months. The lobe may be long or short, its pedicle
may be thick or thin, it may overlie the gall-bladder
or be placed to its inner or outer side. As a rule, the liver
substance in the lobe is greatly altered from the normal,
being ])aler in colour and more fibrous in texture. The
tumour is often recognisable, clinically, as a smooth,
S(^lid, elastic tumour, sometimes very freely movable
("floating lobe"), sometimes fixed by adhesion. It
has been mistaken for a distended gall-bladder, a mov-
able kidney a hydatid cvst of the liver, a tumour of
the omentum, or an abscess.

I have, on one or two occasions, seen a well-marked
Riedel's lobe when operating uj^on other abdominal
conditions, in the absence of gall-stones.

CHAPTER IV.

THE SYMPTOHS AND SIGNS OF GALL-STONE

DISEASE*

Gall-stones are present in approximately lo per cent,
of all bodies examined on the postmortem table. The
exact percentages given by various writers are as fol-
lows :

Riedel lo per cent.

Kehr lo

Brewer 12

Recklinghausen 12.2

Reports of the Johns Hopkins Hospital

(Mosher) 6.94

Herter (Presbyterian Hospital, New York) ... 7.6

1 1

i t

1 1

I «

<i

And Xaunyn writes: *'0n an average every tenth human

being, and of elderly women, perhaps every fourth, has

gall-stones.'' Djakanow, on the other hand, states that

gall-stones are very rare in Russia. In the very great

majority of these cases the stones have never given rise

to symptoms of sufficient severity to have caused them

to be recognised during life. In probably nine persons

out of ten who carry gall-stones the disease is never

recognised. Gall-stones have been passed, being found

in the faeces when no symptoms of their presence have

been elicited within a recent period. In such cases,

probably without exception, there have been previous

attacks of gall-stone trouble, and a fistula has formed

109

I lo Sjinptoms and Signs of Gall-stone Disease

between the biliar\' passages and the bowel. It is through
the fistula and not along the ducts that the stones have
r«as5ed. In one patient, a woman of seventy, I saw several
stones almost unaltered in appearance in the faeces.
They were passed without any warning symptoms of gall-
st/iTie ccJic. or pain, or temperature, or jaundice, though
al] these symptoms had been present over thirty years
ear::er. About four years after I saw her she died from
other causes, and a fistula between the gall-bladder and
cc-k'n was found.

This rx^-int. as to the infrequency of the recognition
of gall-stones, requires emphasis, for it shews clearly
er-otigh that if gall-stones can bo brought to lie quietly
in the ^all-r/adcer. there may be a complete immunity
frorr. all sunerlng. There is need, however, for some
cua3incat:on in the statement so terselv made, for, in
the f.rst ti'lace. it is an undoubteti fact that the com-
n:'nest rr.ar.ifestation of the presence of gall-stones is
n^vfrr referre^: by the patient, and rarely by the medical
rr-ar.- \r, the gall-bladder or bile-ducts. The most cursor}'
exan::nat:on into the histor\' of a long series of cases
tr*3at/r': hv oixrration will show that, in almost all, the
ear'ffrst svntr^tom. that which has for vears caused in-
t/rnv: vifrenng at times, is "indigestion." The variety
'f. narT/es given to the symptoms of epigastric pain,
r-i.-iv?a. an'! vomiting is infinite: ** indigestion." **gas-
tn'. ^;at/arrh- ' "neuralgia of the stomach," "spasms."
rlat'.:>mt 'distension of the stomach." are a few of those
•^jO'it rr'r^'.-i'rnt-v encountered. They all. as can be seen.
r^-''r' t!v: \rry'jz to the stomach, auii not to the liver.
Jt r<;'.-::r^r-: \':jz unn::5takable evidence of iaundice to

Pain

associate the suffering with gall-stones in the minds of
all patients, and of not a few medical men, yet jatmdice
is an infrequent and an inconstant symptom of gall-
stone disease.

In the second place, it must not be assumed that,
though no momentous symptoms of gall-stone irrita-
tion are present, all is yet well with the patient. In
cases which come to operation, where the most obvious
undoubted symptoms have been present for only a
few weeks, there will often, one dare venture to say
always, be found abundant evidence of chronic inflamma-
tory processes that have taken years in the accomplish-
ing, or of malignant disease that is but the expression
of long-persisting local irritation. It is not accurate,
therefore, to say that gall-stones, in the vast majority
of cases, cause no symptoms. They cause symptoms
in a great many cases where the true nature of the dis-
ease is never recognised; and gall-stones found at an
autopsy upon a patient who has suffered for years from
gastric disorders may explain all the symptoms. This
fact, of the want of recognition of gall-stone disease, in
its earliest stages, must be insisted upon, for it is in this
stage that surgical treatment should, if possible, be
advised.

The symptoms and signs of gall-stone disease that
require discussion are pain and colic, nausea and vomit-
ing, jaundice, fever, and tumour.

I. Pain (tn be distinguished from colic, of which
later mention will be made) elicited by the presence of
gall-stones is either local or referred. Localised pain is
of two types: a dull aching pain, due to increased ten-

112 Symptoms and Signs of Gall-stone Disease

sion and inflammation, limited to the gall-bladder; and
an acute, almost intolerable, pain which results from
more intense infection and a more widespread inflamma-
tion The dull, localised pain is generally due to a
slight degree of irritation and inflammation, with a
gradually increasing tension in the gall-bladder or cystic
ducts, due to the impaction of a stone in its attempt to
pass out of the gall-bladder. The pain is diffused over
a large area along and below the margin of the liver.
Tenderness is not specially marked; the area can be
examined by gentle pressure of the open hand without
hurting the patient. If, however, a sudden pressure
be made, there is an instant tightening of the muscles,
which, by their contraction and rigidity, protect the
underlying parts from injury. The best method of
eliciting tenderness in such conditions is that which is
mentioned by Xaunyn and emphasised by Dr. T. B.
Murphy, of Chicago, who writes (Med. News, vol. i, 1903,
p. 825): **The most characteristic and constant sign of
gall-bladder hypersensitiveness is the inability of the
patient to take a full inspiration when the physician's
fingers are hooked up deep beneath the right costal arch
below the hepatic margin. The diaphragm forces the
liver down until the sensitive gall-bladder reaches the
examining fingers, when the inspiration suddenly ceases
as though it had been shut off. I have never found
this sign absent in a case of calculus or in infectious cases
of gall-bladder or duct disease."

Naunyn writes (p. 79) : ** If the liver is swollen as the
result of the attack (that is, recently), the organ is always
more or less tender, and often very acutely so; but

Pain 1 1 3

frequently it is tender without being swollen. In such
cases it is found that pain is induced when, during a
deep inspiration, pressure is made with the hand as far
upwards as possible beneath the right costal border.
At the moment when the liver impinges upon the tips

I
I

[Itrness of gnll-blaiider.

of the fingers the patient experiences a deep-seated pain
which sometimes radiates over the entire hepatic region
and on to the epigastrium."

By no means rarely, however, the tenderness of the
liver is only manifested by tension of the muscles of the
anterior alxlominal wall on the right siile, and in such

J

1 14 Symptoms and Signs of Gall-stone Disease

cases the difference in tension of the right and left side
is best obser\*ed in the upper part of the rectus. I have
found the simplest method of eliciting the pressure signs
to be this: ^^^lile the surgeon sits on the edge of the
couch, to the right of the patient, the left hand is laid
over the lower part of the right side of the patient's chest,
so that the thumb lies along the rib-margin; as a deep
breath is take!i the thumb is pressed upwards towards
the uuilor surface of the liver. Figure 38 shews the
pi^ition,

This variety o( pain is apt to be confounded with that
vhio Iv^ vlisoasos of the stomach. It is a dull, rather diffuse
aohit\>:» which is often worse after food, and is almost
without exception relieved by vomiting. The pain is
vluo io the impaction of a stone and the gradual increase
in tensivu\ within the gall-bladder. As soon as the stone
lulls back iiiti> the gall-bladder, as it often does alter the
act of vomiting, the pain is relieved. It is readily under-
wlood. tluMvfoiv. that the act of emptying the stomach is
mipposcd to have given relief to that organ. The pain,
liowcvtM'. is sometimes moiv acute than that described, and
in thr c\pn*ssiot\ of a higher degree of irritation and of
cohmMMitive iutlammation in the gall-bladder and ducts,
(Uul pnhaps also of the ]H>ritoneum surrounding them.
TliP |»(Un. whether mild or grave, is certainly due to in-
llainiuatorv action, atul i»n>bably indicates that the peri-
lohiMiiu \n involved. When the irritation caused by the
i\\\^\\v lunlij^ht, \vluM\ its impaction is but of brief duration,
Ihr lull(Unm<Uiot\ which is set uj^ is trivial and evanescent;
wlu^u liupiU'lion is ttuMV pi-olonged, a cholecystitis or a
» holiumlllM \u \\\\\ \o\\\i delayed, and the pain becomes.

Pain

IIS

^H pain is refer

therefore, more acute, and the peritoneal investment
of the bladder and ducts becomes more widely impli-
cated. That inflammation is the cause of the pain,
and that the inflammation is the result of an infection
due to the irritation of a stone, there can be no doubt.
When the dull, aching, constant pain has been present for
years and the gall-bladder be examined, its walls are
found thickened, toughened, and fibrous; there may be
little or no evidence of surrounding peritonitis. When,
however, the pain has been more severe, and especially
when there has been a marked rigidity of the muscles
overlying the gall-bladder, evidence of peritonitis in the
form of adhesions, more or less complex, will be found.
The dull, aching pain, elicited by thumb pressure, and the
acute, more wide-spread pain, w^th muscular rigidity, are,
therefore, both due to an infection and inflammation.
In the former the inflammation is limited to the gall-blad-
der, producing gross degeneration of its coats ; in the lat-
ter the inflammation spreads to the surrounding peri-
toneum and causes the outpouring of lymph, and, at the
last, a complex entanglement of the gall-bladder and its
surroundings in dense and tough adhesions. The local-
ised pain of cholelithiasis is almost always made easier by
steady, even pressure ; the radiating pains are unaffected.

The referred pain is almost always, though not in-
variably, associated with one or the other of the foregoing.
The pain radiates to the right subscapula ■ region, rarely
to the left; to the neck, or down the arm, and to the
epigastric region. According to Murphy, in obstructions
to the pelvis of the gall-bladder or to the cystic duct, the
pain is referred, on an average, in seven cases out of ten,

f 1 6 Symptoms and Signs of Gall-stone

tr> the riffht subscapular region; in one case, to the left
Huhncapular region; and in two cases out of ten, to the
front of the chest as high as the neck. This computation
jH based uix:>n repeated soundings and irritations after
<!holecyHtf)tfjmy.

The existence of an area of referred tenderness in gall-
nUtnc disease is described by Boas. He finds that in a
majority ^>f patients suffering from cholelithiasis there is
an area of increased tenderness, on pressure, on the right
Hide behind, on a level with the twelfth thoracic vertebra,
two or three fingersbreadth from the spine. At a cor-
n'HfKmding j)oint on the left side no tenderness is found.
This symi)U>m may be present even when there is no ten-
diTtiess over the gall-V)ladder or beneath the margin of
the liver.

Hoas writes (Munch, med. Woch., April 15, p. 604):

" Least recognised as a symptom of cholelithiasis is
li*nd<*nu*ss over the posterior surface of the liver. When
well marked it extends laterallv from about an inch exter-
nal U) the s])ines of the vertebrae to the posterior axillary
liiu*, and vertically from the eleventh dorsal to the first
himbar spines. To demonstrate it the finger should be
presst'd against a jxnnt to the right side of the tenth
dorsal spine; then against successive points in lines run-
ning horizontiilly outwards, opposite the other spinous pro-
rt'sses, down to ihe first lumbar spine, first on one side,
tlu*n on the other. It s then evident which side is the
more tender. This symptom, if present during the acute
attack, is also invariably present in the intervals; that is,
if ouci* present, it is always present, and is therefore of
special diagnostic value in the latent stages. Occasionally
il. may be found vears after the last attack of colic. Con-

Pain 117

versely, if absent in the acute attack, it is not found in the
intervals. It is usually sufficient to map out the areas of
tenderness with the finger ; but when there is a doubt as to
whether the right side is the more tender, greater accuracy
may be obtained with the faradic or galvanic current.
When, as often occurs, the lower edges of the liver and the
gall-bladder are not tender, the discovery of the second
or third areas of tenderness may, in conjunction with
other symptoms, often decide the diagnosis. The pres-
ence of one or more of these areas indicates also that
though no attack of colic may have occurred for some
time, the patient still requires supervision and treat-
ment. ''

I consider the search for this tender area a necessary
part of the examination of all patients who suffer from
gall-stone disease, or in whom the existence of this dis-
ease is suspected. It is undoubtedly a sign of great value.

Colic. — The pain experienced as a result of the irri-
tation of gall-stones is often colicky in character. The
exact cause of the colic has been much debated, and at the
present time there seems to be no likelihood of general
agreement upon the question. Kehr, Riedel, and others
take the view that the colic is often or solely due to an
inflammatory response to irritation in the gall-bladder
or in some part of the ducts. They consider that the
cholangitis so aroused lessens the calibre of the ducts,
impedes the onward passage of their contents, causes an
increased pressure behind the obstruction, and so gives
rise to the colic.

Riedel tabulates the following as causes of gall-stone
colic :

1 1 8 Symptoms and Signs of Gall-stone Disease

1. Adhesions of a gall-bladder no longer containing

stones. There is a ciroimscribed peritoneal irri-
tation, with abdominal distension, more or less
severe vomiting, and pain.

2. Adhesions when large stones are present in the gall-

bladder and the cystic duct is patent.

3. Inflammatory processes in a gall-bladder distended

by fluid or stones, when the cystic duct is occluded
by inflammation or by the presence of a stone in the
neck of the gall-bladder.

4. The transit of a stone through the bile passages.

5. The inflammation of a dilated, calculous common

duct, or its tributaries, without impaction of the
stone.

Riedd is of the opinion that a hydrops of the gall-blad-
der is i>roscnt in (ill cases where the onset of the attack
is suddcMi, as it is when a stone is about to be passed. If
closure of the eystie duet is not present, the sudden onset
of gall-stone eolie is rare. The absence of symptoms
in so manv patients whose gall-bladders contain stones
is due to the fael that the cystic duct remains patent.

On the other hand, many surgeons consider that the
(M)lie is alwavs and inevitably due to spasm of the duct;
that it is in the attempt of the duct, by overcontraction
(»f its tntiscle. to expel an impacted body, that the cause
i»f the eohc is to he found. The characteristics of the
eohekv pain are the abruptness of its onset and the
p\uldennr'iM ol relief. These are incompatible with any-
thlnr. wl»irh jm inlliiinmatory in character, and can only
|te eNplaineil l»v the sudden entrance and the equally
Mudileu eMt ol a jorei^ru body. The colic is due, therefore,
jit the |«.i'j'i,i)i:e ol a stone or a foreign body of some kind

Pain

119

(a hydatid cyst, for example, I have once seen) down
the ducts. The pain endures just so long as the body
is moving. If impaction and fixity of the stone occur,
the pain gradually lessens, and at length, probably
after a few hours, disappears entirely, to be roused
afresh when a further movement occurs.

Many surgeons have remarked that a high degree of
infection of the gall-bladder and of the ducts may be
present when no colic is or has ever been noticed. Both
Riedel and Kehr, indeed, have given exemplary instances
of both; of cases, that ts to say, in which inflammation
has been present without colic.

An attack of colic or of spasm is caused, therefore,
only by an overexertion, of the nature of cramp, of the
muscular wall of the gall-bladder or ducts in the onward
passage of a foreign body. It is never found as the result
of a gradually increasing distension of the gall-bladder or
ducts; it is not aroused by inflammation, whether acute
or chronic, in any part of the bile-tract; it is not foimd
in cicatricial stenosis, nor in those cases in which a grad-
ually increasing pressure is made upon the ducts from
without. It is due to the sudden blockage of the ducts and
to their exaggerated muscular efforts to rid themselves
of the foreign body. It occurs only when this foreign
body is in transit. As soon as the body becomes fixed
the muscular efforts slacken and cease, and the ducts
proceed to adapt themselves to the intruder. Small stones
may pass along the cystic and common ducts without
exciting pain. During operations for the removal of
stones from the gall-bladder I have occasionally demon-
strated the presence of small pebbles in the common

I

1 20 Symptoms and Signs of Gall-stone Disease

duct which have lain there without producing symptoms.
The colic, when severe, is probably as terrible a suffering
as a patient is ever called upon to endure. It comes
on with absolute suddenness, produces a degree of col-
lapse that may be profound, and soon induces faintness,
sickness, and vomiting. The patient has terror written in
every line of an anxious face. He is cold, and yet sweats
profusely. His general condition, indeed, is at times
alarming. The pain is often said by patients to " double
them up.** In their agony some slight relief seems to
be gained by bending from the waist over a chair or
couch, or, when sitting, by folding the arms across the
epigastrium and by forcible flexion of the trunk. To
see such a patient in the utmost extremity of his suffer-
ing is enough to convince one that a spasm, similar to
the spasm of the intestine or of the ureter, is the cause
of the intolerable pain.

This hepatic colic is the most characteristic and the
most commonly recognised form of pain associated with
gall-stones. It is present, however, in those cases only
in which a stone is recently impacted or is in transit in
the ducts. Since in the vast majority of patients a stone
never enters on its travels from the gall-bladder, it is
quite clear that hepatic colic is a far less frequently ob-
served symptom than the dull, or the more acute, localised
pains which have been previously mentioned.

If the stone while in passage through the ducts becomes
for any reason arrested, the colic gradually ceases and
in a few hours disappears. The stone may rest in its
position for many years without causing spasm, but the
moment it attempts to resume its journey the pain will

Pain

surely return and the colic will be as severe as before.
Murphy has called attention to the fact that pain of the
same character may be caused by the backward move-
ment of a stone, as, for example, after a cholecystotomy,
when a stone, impacted in the cystic duct, works its
way backwards into the gall-bladder. Vermicular con-
tractions of the gall-bladder or of the bile-ducts have
never, so far as I am aware, been observed in man;
but spasmodic muscular contractions of the wall of
the gall-bladder and bile-ducts were observed by Haller
and Miiller in pigeons. Doyen and Oddi have observed
them in rabbits, dogs, and cats. Simanowski was able
to recognise spasm in the common bile-duct in animals,
when foreign bodies were introduced into its lumen,
A muscular hypertrophy has, howtver, been not infre-
quently found in the gali-bladder, and in some cases this
may be so exaggerated as to cause the upraising of
muscular bundles in the wall. Schiippel has described
a specimen in which a fasciculation , similar to that seen
in the urinary bladder, is found.

Gall-stones, it will be seen, cause pain, and therefore
elicit recognition in one or two ways. Firstly, by causing
irritation, infection, and inflammation as a result of
their impaction in the neck of the gall-bladder or in any
part of the ducts. Secondly, by traversing the ducts
for a shorter or a longer distance, and in their movement
setting up a spasm of the muscular wall, behind the stone.
The pain caused in the former manner is, in some cases,
a dull, in other cases an acute, pain, limited generally to
the gall-bladder area. The pain caused in the latter
manner is a spasmodic, colicky pain. In both there are

122 Symptoms and Signs of Gall-stone Disease

radiating pains, spreading away from the gall-bladder
region, sometimes to the right shotdder-blade, some-
times to the left, sometimes to the front of the abdomen

and chest.

There has been a prolonged and a somewhat heated
discussion as to the exact cause of the colicky pains in
gall-stone disease. It is held by Riedel, Kehr, and others
that the colic is due, as a rule, to infection and inflam-
mation in the gall-bladder or the bile-ducts; by others,
chief among whom is Murphy, it is asserted that colic is
due to spasm of the gall-bladder or ducts, and is an
indication of the fact that a stone or other foreign body
is in transit through the ducts. Kehr writes : ** The gall-
stone colic depends almost always upon an inflammation
of the gall-bladder,'* and, again, **The inflammation
causes pain since the secretion collecting in the hollow
organ stretches its walls.'' There can be no doubt
whatever that in the great majority, if not in all, opera-
tions upon patients who have suffered from attacks of
gall-stone colic there is evidence of old, often wide-spread,
inflammation. But, although this must be allowed, it
does not explain why an acute or subacute inflammation,
even when leading to distension, should cause colic. The
distension of other hollow viscera, as the result of inflam-
mation, does not cause colic. With them, colic signifies
an excessive, ill-regulated, spasmodic muscular action.
In cases of dilatation of the stomach, as the result of
pyloric obstruction, and in cases of intestinal obstruction
of slow onset, a visible peristalsis can be recognised. It
is always found that the onset of a colicky pain coincides
with, and by the patient is recognised as being due to.

Nausea and Vomiting

123

I

a well-marked spasmodic muscular contraction of the
wall of the viscus. In the passage of a stone down the
xireter the pain is always colicky in character. In fact,
so far as we know, colic is never due to an increased
tension alone ; there must be added a spasmodic muscular
contraction in the walls of the cavity. In cases of gall-
stones it is universally admitted that it is the inflamma-
tion to which they give rise that in the vast majority of
cases causes their recognition : and it is the inflammation
which causes all pains other than the colic. Inflamma-
tion, by causing an increased secretion from the walls of
the gall-bladder, or by altering the physical properties of
the fluid contained therein, may indirectly be responsible
for the excitation of a spasm. For the thickened, ropy,
tenacious, or semi-solid bile, or mixture of bile and mucus,
may, and almost certainly does, act as a foreign body.
In the transit of this thickened material a spasm is excited
and colic is experienced. My own view is that, though
full allowance must be made for the supreme importance
of inflammation in cholelithiasis, there is no evidence
that cohc is ever due to any other cause than spasm
of the muscular wall of the gall-bladder or ducts; a
spasm that is excited by the entrance into, or the at-
tempted passage through, some part of the ducts of a
stone, of altered bile, or mucus, or other irritating
foreign body.

2. Nausea and Vomiting. ^These are among the com-
monest of the manifestations of cholehthiasis. It is,
indeed, their frequency which is responsible for the un-
just and heavy burden which is laid upon the stomach.
If one wished to frame an epigram it could be said, with

k

J

\ 24 Symptoms and Signs of Gall-stone Disease

*
truth, that the most common symptom of gall-stones is

indigestion. The indigestion has, as its natiiral and
expected sequence, an attack of nausea and vomiting,
which brings relief. The nausea and vomiting are partly
reflex in origin and are partly due to the direct irritation
of the stomach. In the majority of cases the feeling of
deadly sickness and the vomiting which follows it are
due to the impaction, momentary or enduring, of a stone
in the cystic duct. Just as the passage of a renal stone
from the pelvis of the kidney to the ureter is attended
by the sudden feeling of intense prostration and sickness,
8() is the passage of a stone into the orifice of the cystic
duct. It is the obstruction which reflexly produces the
nausea and the vomiting. The vomiting when pro-
longed produces a general muscular relaxation and sweat-
ing, and in this flaccid and enfeebled condition of the
patient the impacted stone falls back.

I have, in one patient, seen on tw^o occasions the grad-
ual filling up of the gall-bladder attended by persistent
vomiting. The patient was a woman, thirty-four years
of age, whom I saw with Dr. Carlton Oldfield. She
complained of attacks of sickness and constant vomit-
ing, and during these attacks a lump gradually formed
in the abdomen. When the lump vanished, as it did
almost suddenly, the vomiting ceased. The patient was
admitted to the hospital and her story verified by obser-
vation. She began, quite suddenly, to suffer from faint-
ness, nausea, and vomiting, and within a few hours the
gall-bladder became palpable. Vomiting and enlarge-
ment of the gall-bladder continued for three days on
one occasion, for five days on another, when the gall-

Jaundice 125

bladder disappeared almost suddenly and the vomiting
and nausea instantly ceased. At the operation no gall-
stone was found. The gall-bladder was very large, thick,
and flaccid. The obstruction at its neck was due to a
sharp kink, aided very probably by a large gland lying
close to the cystic duct.

In all patients who suffer from constant attacks of

nausea and vomiting it is desirable that the possibility of

«

the existence of gall-stones should be borne in mind.
The examination of such patients should include an
attempt to elicit the pressure sign to which reference
has already been made.

3. Jaundice. — Jaundice is a rare symptom of gall-ston^
disease, unhappily. If jaundice occurred more frequently
than it does, there would be an earlier and more frequent
recognition of the disease. It is, however, an inconstant,
and often an inconspicuous, symptom. Murphy, whose
experience of the surgery of gall-stones is very consider-
able, found that jaundice was present in only 14 per
cent, of his patients at any time during the course of
their disease.

Wolff stated that jaundice was present in 50 per cent,
of the patients in whom a diagnosis of gall-stones was
warranted by a discovery of stones in the faeces. Fiir-
bringer found jaundice is only 25 per cent, of his cases.

In some patients, owing to a natural sallowness of the
skin, the presence of jaundice may be difficult to deter-
mine. I have found a suggestion made by Hamel to
be of great value in this and in like circumstances. A
capillary tube is taken and blood allowed to flow into it
from a puncture made in the lobe of the ear. After

1 26 Symptoms and Signs of Gall-stone Disease

st4ituiitvjr f^T^ a few hours the serum should collect in the
xip|vr jxirt of this tube; normally it is quite colourless,
but if even the faintest tinge of jaundice be present, a
Yx^Uow dolour will be readily perceived in the serum.

jiumilice in cholelithiasis depends upon one or other of
two factors: impaction of a stone in the hepatic or com-
inoi\ ducts, or, rarely, of a large stone in the cystic duct,
ottusing pressure on the common duct; or infection of
these ducts. The impaction of a stone in the cystic duct
(Uh^s not cause jaundice unless the hepatic or common
ducts are also involved. If they remain intact, jaundice
does not occur.

Jaundice varies greatly in the character of its appear-
ances and of its vanishing. When jaundice is due to
gall-stones it is, almost without exception, preceded by
colic. The pain comes a few hours or a few days before
the tinge of jaundice is noticed, and a rough proportion
holds between the intensity of the colic and the depth
of the jaundice. The jaundice, as a rule, appears grad-
ually and deepens more or less rapidly, according to the
completeness of the obstruction to the onflow of the bile.
If. after attaining a certain depth, it passes gradually
away, the obstruction to the duct has been relieved.
If, however, a stone becomes impacted in the duct and
the duct dilates behind it, a ball-valve action results,
as she\vn by Fenger, and the jaundice is remittent. It
varies, — that is, in depth of tinge, — but never clears
completely away. There is always a perceptible yellow-
ness of the conjunctivae and of the skin of the abdomen.
The degree of discolouration may vary not only from day
to day, but from morning to night, being slighter on

Jaundic

127

^K reco

rising in the morning and deepening slowly during the
day.

If a stone be impacted in the cystic duct it may give
rise to jaundice by arousing an acute inflammation which
spreads down to the common duct, and there causing a
swelling and thickening of the mucosa, resulting in an
incomplete block to the downward passage of the bile. If
a stone be impacted just as its tip is entering the common
duct, similar attacks of cholangitis are caused. In both
these instances, howe\'er, the jaundice clears off entirely
in the intervals between the recurring attacks of inflam-
mation ; that is, the jaundice is intermittent, not remittent.

By contrast with this the form of jaundice met with
in malignant disease may be mentioned. If there be a
cancer of the head of the pancreas, and obstruction to the
common duct result from the presstire of the enlarging
growth, jaundice will be a symptom of the gradually in-
creasing difficulty that the bile experiences in passing
down a narrowed channel. The jaimdice will appear quite
gradually and painlessly; it will deepen day by day by
almost imperceptible degrees, until the colour of the skin
is a deep greenish yellow. There will be neither remissions
nor intermissions, but a steady and progressive deepening.
Pain is never present. I am of opinion that there is a
decided difference in the colour of the jaundice in simple
and in malignant cases. In the former the golden-yellow
colour, in the latter, the green, predominates.

The importance of the association of distension of the
gall-bladder with jaundice was pointed out many years
by Courvoisier. In the large series of cases whose
records were examined by Courvoisier, it was found that

1

128 Symptoms and Signs of Gall-stone Disease

in a little over 80 per cent, of cases of gall-stones in
which persisting jaundice was present, the gall-bladder
was contracted. The inflammatory changes, due to long-
standing and oft-repeated attacks of infection of the gall-
bladder in the cases of impacted stone, result in a thicken-
ing of its walls and in a marked contraction of its cavity.
In many cases the gall-bladder is no thicker than a lead
pencil ; in others its cavity will barely contain the ordi-
nary probe. Distension of such a gall-bladder is a
physical impossibility. When, therefore, a distended gall-
bladder is found in association with jaundice, there is a very
strong probability that gall-stones are not the cause of the
symptoms. In a certain number of such cases the disten-
sion of the gall-bladder may be due to a stone impacted
in the cystic duct, which causes recurring waves
of inflammation to spread along the cystic to the com-
mon duct, or the stone may project by its tip from the
cystic into the common duct. In one case I have seen
the gall-bladder enormously distended by hydatids which
had burst into it from a large hydatid cyst in the right
lobe of the liver ; other hydatids blocked the common duct
from end to end, distending it to a diameter of about one
and one-half inches. Jaundice was, of course, persistent.
The case, indeed, was diagnosed as one of malignant dis-
ease of the pancreas; no operation was performed, as the
patient # became maniacal and died within a few days of
her admission to the Infirmary.

Courvoisier further pointed out that when persisting
jaundice was associated with distension of the gall-bladder,
the cause was, in over 90 per cent, of cases, an obstruc-
tion of the common duct by pressure from without.

Jaundice

12$

The most frequent cause in. such circumstances was
malignant disease of the head of the pancreas. The
exact figures given by Courvoisier were as follows:

There were 187 cases of ob-
struction of the common duct
from all causes. Of these, 100
were due to obstruction from
causes other than stone, and
87 were due to obstruction by
stone. Of 100 cases in which
the obstruction was due to
causes other than stone, in
92 cases there was dilatation
of the gall-bladder; in eight
cases there was a normal gall-
bladder or an atrophy of the
gall-bladder.

Of 87 cases in which the ob-
struction was due to stone, in
70 cases the gall-bladder was
small and atrophied; in 17
cases the gall-bladder was
dilated.

All these eases were col-
lected from the literature. Of
the cases that came to oper-
ation and were recorded by
Courvoisier. 35 in number,
due to causes other than stone, and in i() of these there
: dilatation of the gall-bladtler; in 17 the obstruction
I due to stone, and in 13 of these the gall-bladder was

Via. 30- — A dilated gaU-
bladdcr measuring eight by six
inches due to cancer of the
head of the pancreas [Guy's
Hospital Museum, No, 1391).

18 the obstruction was

ij;o Symptoms and Signs of Gall-stone Disease

c\>ntracted. In several cases I have seen a chronic indu-
rative i>ancreatitis produce jaundice with an enlarged
jrall-bladder. These obser\'ations of Courvoisier's were
formulated by him in the following statement, which is
now generally referred to as " Coitrvoisiers Law *';

" In cases of chronic jaundice due to blockage of the
ci^mmon duct, a contraction of the gall-bladder signifies
tliat the obstruction is due to stone: a dilatation of the
g:ill-bladder, that the obstruction is due to causes other
than stone.*'

The validity of this law has been closely investigated
and its truth has been affirmed by almost every writer.
The earliest confirmation of it was afforded by the inde-
pendent observations of Mayo Robson, published in 1892.
Ho wrote: ** Distension of the gall-bladder, accompanied
by jaundice, has in all the cases which I have observed,
and in those cases where I have operated, turned out to
be dependent on cancer, either of the head of the pancreas
or of the common duct."

Ecklin, in 172 cases of common duct obstruction, due
to calculus, found that 28, or 16 per cent., had dilatation
of the gall-bladder; 144, or 84 per cent., had contraction
of the gall-bladder. In 139 cases of obstruction due to
other causes 121, or 87 per cent., had dilatation of the
gall-bladder.

A further examination of the question has been made
by Dr. A. Cabot, of Boston, who collected the records
of the Massachusetts Hospital. There were 86 cases of
obstruction of the common duct. Of these, 5 7 were due to
obstruction by stone ; in 47 the gall-bladder was atrophied.

Jaundice 131

in eight it was normal, and in two enlarged. Twenty-
nine cases were due to causes other than stone; in 27 the
gall-bladder was distended ; in one the gall-bladder was
empty, and in one contracted around three stones. Only
four cases, therefore, in this series did not fall in with
Cour\'oisier*s law. Cabot writes: **With the exception
of these four cases, which constitute only 5 per cent, of
the total number examined, every record of the Massa-
chusetts Hospital series in which definite statements are
to be found concerning the points at issue goes to confirm
Courv'oisier's law.'*

The explanation given by Courvoisier of the occurrence
of sclerosis of the gall-bladder in cases of stone was that
the presence of calculi in the gall-bladder, and their pas-
sage or attempted passage down the ducts, had caused
irritation and inflammation in and around the bile
passage. Cholecystitis and peritonitis were the result
and had resulted in the cicatricial cramping and compres-
sion of the gall-bladder.

Fenger, criticising this statement, offers the explana-
tion that ** the atrophy in these cases, hitherto incom-
prehensible, is easily explained by the ball- valve action
of a floating choledochus-stone at the distal end of the
cystic duct.** This, however, leaves out of considera-
tion the numerous cases where the stone is not found
at the spot mentioned. Elsewhere Fenger attributes
the emptiness of the gall-bladder to a floating stone
**in or near the cystic duct.**

The great probability is that the explanation of Cour-
voisier is entirely correct. The sclerosis of the gall-
bladder is a matter of old standing and is present long

132 Symptoms and Signs of Gall-stone Disease

before the impaction of the stone. Fenger's explana-
tion would account for the emptiness of the gall-bladder
in a few cases, but not for the cicatricial contraction
present in the great majority.

4. Fever. — The elevations of temperature caused by
infection due to gall-stones are characterised by their
abruptness. The temperature rises rapidly, attains its
maximum, and then, with almost equal speed, returns
to the normal. Between the attacks of infection the
temperature remains approximately normal. When the
infection is limited to, or chiefly affects, the gall-bladder,
there is a rise of temperature up to ioi°-i04°, accord-
ing to the severity of the infection. In the slighter
cases the temperature rises to 101°, and some local ten-
derness is developed, but within two or three days all
returns to the normal. In the severer cases a rigor
may occur, and the infection may be so severe that an
acute cholecystitis, or a phlegmonous cholecystitis, may
develop, and the plight of the patient is serious indeed.

In many cases it is found that the elevation of tem-
perature or the occurrence of a rigor precedes the on-
set of pain. The acute inflammation in the gall-blad-
der causes a rise to 101° or higher, and is responsible
for the increased effusion from the mucosa into the
gall-bladder; and it is this which, in its turn, causes
an increase of tension and pain. If there are repeated
attacks of cholecystitis, the temperature does not re-
main high in the intervals, but rises abruptly at each
fresh infection and soon returns to the normal. If,
however, suppuration occurs, then a continuous eleva-
tion of temperature to 101° or 102° may be found.

Fever 133

Budd, Schmidt, Schuppel, and others of the earHer
writers spoke of the rigors and the elevations of tem-
perature as ** nervous*' in origin and as comparable
with the rigors of urethral fever. We now recognise
that both this fever and urethral fever are bacterial
in origin, the result of an undoubted infection.

When there is stone in the common duct, an attack
of colic is followed by or accompanies a rigor, some-
times severe, sometimes in miniature. The tempera-
ture again rises abruptly and again quickly descends.
Between such attacks the temperature may be nor-
mal.

A temperature chart, shewing these attacks of in-
fection, represented by an abrupt, peak-like elevation
with the normal interspace is most characteristic. In
describing the chart to students I am accustomed to
falling it. the *' steeple*' chart.

The occurrence of these angular elevations in the
chart recording the temperature is quite pathognomonic
of gall-stone disease. I am not aware that any other
charts, except perhaps those of malarial fever, resemble
these to a degree which can cause a doubt in the mind
of the surgeon. Murphy speaks of the ** temperature
angle of cholangic infections." He writes (Med. News,
vol. I, 1903, p. 830): *'The temperature in an hour will
rise to 104° or 105°, remain stationary for a few hours,
and then drop as suddenly to normal, and remain nor-
mal for hours, days, or even weeks, when it will go
through the same rapid variation and continue to repeat
itself at irregular intervals." And again: ** These tem-
perature changes are so characteristic that I have given

134 Symptoms and Signs of Gall-stone Disease

them the name of *the temperature angle of cholangic
infection.' '*

These characteristic charts are reproduced by both
Charcot and Naunyn, though their perfectly charac-
teristic appearance does not seem to have been remarked
by either. Charcot, in his original account of ** inter-
mittent hepatic fever/' depicted a most excellent
** steeple*' chart, a part of which is reproduced in Fig. 46.

In later stages of acute disease, when the intense
infection has spread throughout the finer bile channels
in the liver, the temperature may show no remissions,
but remain persistently high. In such cases the tem-
perature may range from 103° to 105°, and never return
to the normal. As a rule, fever of this type follows
the intermittent fever previously described, and is a
sign of a more generalised and more intense infection.

5. Tumour. — A tumour of the gall-bladder in chole-
lithiasis occurs as a result of a block in the cystic duct,
by a stone, by the enlargement of a lymphatic gland,
or by torsion or flexion at the neck of the gall-bladder.
It occurs also when there is obstruction to the common
duct by enlargement, simple or malignant, of the head
of the pancreas. In rare cases an enlargement of the
gall-bladder, due solely to its being crowded with stones,
may be recognised on palpation of the abdomen. Sev-
eral observers have been able to grasp the gall-bladder
and to feel the stones therein rubbing together. Petit,
in 1743, speaks of a gall-bladder feeling **like a ba^ of
nuts" when distended with stones. Lessdorf was able
to invaginate his hand within the abdomen through
the neck of a large umbilical hernia and to grasp a

Tumour 135

stone-containing gall-bladder. I have once, in the lax
and pendulous abdomen of a multipara, been able to
feel a 'gall-bladder filled with stones, to recognise that
its shape was hour-glass, and at the operation, a few
days later, to verify my observ^ation.

When a stone is impacted in the pelvis of the gall-
bladder or in the cystic duct, the gall-bladder distends
behind the block. The fluid contained within it may
at first be deeply tinged with bile, but soon all trace
of colouring matter disappears, and a condition of
hydrops exists in which a clear or opalescent mucoid
fluid is found. If there is infection, the fluid becomes
purulent and a condition of empyema of the gall-bladder
is recognised.

A distended gall-bladder which contains bile is due
to pressure upon the common duct by growths or chronic
inflammation in the pancreas, or by growths originating
in closely adjacent structures.

A tumour of the gall-bladder may be due to malig-
nant disease, which, in the majority of instances, is a
late result of gall-stone irritation.

The tumour formed by the enlarged gall-bladder is
generally easy to recognise. It forms a prominence
visible on inspection of the abdomen in some instances,
and in many is readily appreciated as lying just beneath
the abdominal wall. It is generally pear-shaped or
like a banana in form, smooth in contour, and may
sometimes possess a range of considerable mobility,
swinging pendulum-like from side to side, reaching,
in some cases, as far as the left hypochondrium. As
a rule, the swelling is tender, and a feeling of nausea

136 Symptoms and Signs of Gall-stone Disease

is excited upon handling it. Immediately above the
tumour can be felt the edge of the liver. The colon
on inflation is found to lie below it, or; rarely, beneath
it, though in one case I have found the colon to be
adherent to the edge of the liver above the gall-bladder,
so that on inflation the swelling was recognised as being
below the colon and made less easily palpable. Law-
son Tait and Liicke have described cases in which
the small intestine was adherent in this position. A
large mass of thick omentum over the gall-bladder may

blur the outline of the tumour, so that its character-

•

istic shape is not recognisable. Inflation of the stomach
is often a useful aid to diagnosis. A gall-bladder tumour
in this way is displaced to the right and a little upward,
and, as Naunyn has pointed out, it may become pushed
against the abdominal wall and therefore be more dis-
tinctly palpable. The attachments of the tumour to
the liver may be recognised by their simultaneous de-
scent when the patient breathes deeply. The tumour
cannot be held down during respiration, but moves
upward and under the hand at precisely the moment
when the ascent of the liver begins. Other tumours,
those, for example, of the kidney, or stomach, or colon,
or omentum, can be held downwards when grasped at
the end of a full inspiration. In some cases the extent
of the projection of a gall-bladder beyond the margin of
the liver is no criterion as to the size of the gall-bladder
or as to its capacity, for in several instances where
little more than the rounded fundus can be felt, or seen
after the abdomen is opened, there may be a consider-
able dilatation of the part concealed by the liver, and on

Tumour 137

aspiration 15 to 20 ounces of fluid may be removed.
In many cases of old-standing cholelithiasis, the lower
edge of the liver is dragged down to the right and in
front of the gall-bladder into a tongue-shaped lobe
which is generally known as the "linguiform lobe of
Riedel."

Further reference to the characters of a distended
gall-bladder will be made in discussing the condition
of "hydrops"

A tumour found in the neighbourhood of the gall-
bladder may be caused by an adhesion of an enlarged
gall-bladder to the abdominal wall. Stones therein
contained may then ulcerate through into the abdominal
wall. In such cases a tumour which closely resembles,
in its physical characters, a growth in the muscles of
the abdominal wall may form. The tumour is hard,
rounded, smooth, and fixed, but it is not adherent to
the skin. Mordret and Michaux record examples of
this kind. (Bull, et Mem. Soc. de Chir. . vol. 29, p.
1189.)

Enlargement of the liver may be noticed in many
cases where gall-stones are passing down the ducts or
attempting to do so. As a rule, in all gall-stone attacks
the liver enlarges and becomes tender In some cases
the increase in size is remarkable. Naunyn remarks:
'*I have seen a previously normal liver examined by
myself so to increase in size in the course of a few days
as to extend as far as the hypogastrium as a quite mas-
sive tumour, and this not by any means only in cases
with severe colic, but even in those with slight pain
and hardly perceptible jaundice.'' The recession of the

i^S Symptoms and Signs of Gall-stone Disease

hepatic enlargement is generally rapid and complete
ur.less further attacks follow or there is abscess or
:gnant disease.

THE DIFFERENTIAL DIAGNOSIS OF GALL-STONE DISEASE*
To discriminate between gall-stone disease and many
v>ther affections producing pain, localised or general,
within the abdomen, and radiating to the chest and
Kick, with vomiting and perhaps collapse, is often a
matter of difficulty, and is sometimes impossible of
achievement. Nevertheless, it is a fact that the diag-
tu^is of gall-stones is often made readily and with cer-
tainty. This has been more apparent during recent
years since the earliest stages of the disease have been
iXHX-ignised and dealt with by the surgeon. The **pro-
dn^mal stage" of cholelithiasis described by Kraus,
\\]xn\ which Xaunyn threw doubts, is not the stage, as
lie thought, of the formation of gall-stones; it is the
stage in which gall-stones insidiously formed are begin-
ning to cause discomfort. Nothing is more certain
than this, that in the majority of cases of cholelithiasis
the symptoms in the earlier stages are not ascribed
by the patient to the presence of gall-stones, but are
referred to "spasms,'* *' indigestion,'* or other equally
indefinite diseases.

The various diseases with which gall-stone disease
may be confounded are gastric ulcer, or, rarely, car-
cinoma; duodenal ulcer; appendicitis in its varied
forms; diseases of the right kidney, more especially
calculus, or that intermittent kinking of the ureter

Differential Diagnosis of Gall-stone Disease 139

or of the vessels of the kidney which causes Dittel's
crises ; lead colic ; affections of the right pleura or lung,
and the gastric crises of locomotor ataxia. Among rarer
conditions may be mentioned aneurysm of the hepatic
artery, which was first noted by Riedel, and has since
been observed by Kehr, and a diffuse syphilitic hepa-
titis, both of which have given rise to grave difficulties
in diagnosis.

CHAPTER V.

THE SPEQAL SYMPTOMS IN GALL-STONE DISEASE.

In discussing the symptoms of gall-stone disease
Nuunyn lias described two forms of cholelithiasis —
"rt^gular cholelithiasis*' and ** irregular cholelithiasis."
Of regular cholelithiasis he wTites: **This then is the
reguhir course of cholelithiasis that the concretions
traverse the bile-duct and enter the duodenum "v^Hthout
d«»ing any considerable amount of permanent damage."
Tlu^ use of the term *' regular/' therefore, is held as
applying to that form of the disease which manifests
itself in the classic gall-stone ** attacks." It is an im-
fnrtunate term if it suggests that such attacks are the
cnmnion or even a usual manifestation of the presence
nf gall-stones. It is certainly only in a small propor-
tinn of the cases that come to operation that regular
i'l»(»lelithiasis is seen. Gall-stones arouse symptoms that
n\v dealt with by operation in a ver\'' large number of
rust^s when nothing in the nature of a ** regular" chole-
litliiasis has been observed. Xaunyn*s work was, of
rnurso, based mainly upon clinical and postmortem
investigation, the ripe harvest of operative experience
was only then being sown.

In discussing the symptoms and in describing the

patholog)' of the various forms of gall-stone disease

it will, therefore. l>e desirable to consider, firstly, the

140

Special Symptoms in Gall-stone Disease 141

signs and symptoms which result in ** regular chole-
lithiasis,'* — that is, in those attacks in which a stone
leaves the gall-bladder, traverses the cystic and com-
mon ducts, and finally escapes into the duodenum, —
and, secondly, the signs and symptoms which are caused
by the arrest of the stone in any part of this course.

First. — The symptoms due to the passage of a stone
from the gall-bladder to the duodenum.

As a rule, the patient will have had previous warning
that there is something wrong in the abdomen, and
a diagnosis of gall-stones confined to the gall-bladder
mav have been made. In an ** attack" of the kind
now to be described the pain generally commences
with absolute suddenness. There are many conditions
which, by individual patients, are recognised as being
inciting factors, such, for example, as the onset of men-
struation, the ingestion of an unduly hearty or indi-
gestible meal, an attack of diarrhoea, due to irregular
feeding or perhaps to the taking of an aperient, and
so forth. In a certain, perhaps not inconsiderable,
number of patients a recent attack, one among a series,
of appendicitis may have been experienced. Some
patients are able to predict the onset of an attack by
the feeling of unusual heartiness and vigour which
they experience. In the days preceding an attack
there may be a better appetite and food may, there-
fore, be taken in larger quantity. This is probably
due to the fact, to which Ewald and others have drawn
attention, that hyperchlorhydria often precedes an
attack for two or three days. The pain usually comes
late in the day, in the afternoon or evening, or, espe-

142 ' Special Symptoms in Gall-stone Disease

cially in the first attack, as Naunyn has said, at mid-
night. It increases rapidly, becomes spasmodic in
character, and radiates to the shoulders, to the epigas-
trium, to the chest and neck. The pain, when attain-
ing its height, is generally said to cause the patient to
be ''doubled up,'* or to roll in agony upon the floor.
It induces collapse, a feeling of nausea, and vomiting.
The pain may last continually, without even the small-
est intermission, for hours, or it may be lulled for a
few moments, only to be renewed with equal severity.
When most intense, it seems to prevent the patient
from taking a deep breath, and the open hand is held
protectingly over the hepatic area, forming, as it were,
a splint. The vomiting, which soon follows, seems to
give some measure of relief; bile is often, indeed as a
rule, present in the vomit. There may be a feeling
of intense depression, and the patient may shiver with
the cold. The occurrence of a rigor with a tempera-
ture of 103° or 104° is rare, though not unknown.
Naunyn says ** very commonly severe rigors accompany,
the colic attacks," a statement which is not in accord-
ance with the observation of many authors. ** Severe*'
rigors are almost unknown in the classical '' gall-siofte
attack,'* though slight shivering followed by sweating
is commonly observed. In some instances tetany may
be seen. In one patient, a lady of twenty-seven, who
suffered for two years from gall-stones, the tetanic
seizures caused even greater stiff ering than the colic.
The pain may persist for hours or even days, and may
end gradually, or with as marked a suddenness as oc-
curred at the onset. A feeling of stiffness or soreness

Special Symptoms in Gall-stone Disease 143

is left for days, the patient often saying that the side
** feels bruised." During the pain or soon afterwards
jaundice is noticed, with the appearance of bile in the
urine and the absence of bile in the motions. Bile
is often noticed in the urine before a tinge of yellow-
ness is seen in the conjunctivae. The clay-coloured
appearance of the stools is not invariable; it may be
absent even when jaundice is present in the skin, and
the urine shews the colour of bile. There is not seldom
a troublesome itching of the skin, which appears before
the jaundice, and may remain when the jaundice has
quite cleared away, or more commonly may disappear
some days before the jaundice. During the attack
the pulse rate is said by Naunyn to be slow. This
is not in accordance with my own experience. I have
not found any reduction in the pulse rate in jaundice
unless a degree of chronic pancreatitis is present. Con-
stipation is present after and during the attack, appe-
tite is lost, and there is a feeling of general ill-health.
The tongue is foul and thirst is often unquenchable.
The liver and the spleen are generally enlarged, and
the former is very tender. The gall-stone, which is
the cause, in its transit through the duct, of all these
symptoms, is passed into the duodenum and may be
recovered in the motions. **In regular cholelithiasis,*'
Naunyn writes, **the stones are passed in the motions.
They are often sought for in vain, but such failures
are usually due to the examination of the stools being
not carried out continuously or over a long enough
period.*' The reasons for the want of discovery of
stones in the faeces are thus given by Naunyn :

144 Special Sympcoms in Gall-stone Disease

44

• •

1. Tbe sicoe, after having been driven into the
neck c*: the gall-bladder, may have fallen back
into the bladder. This can hardlv be a common
event.

2. The stone mav have remained fixed, whereas the
patency of the duct has been restored.

5. The concretion may have disintegrated in the
bowel."

It is not improbable that the condition first men-
tioned is, as a fact, distinctlv a common event, if not
the most common event, in patients who harbour stones
in the g;ill-bladder. An attack of this kind may be
the first and the only attack from which a patient suf-
fers. Such an event is, however, extremely rare. Other
attacks follow with greater or less frequency, and with
more or loss modification other complications may
develop, and "irregular** cholelithiasis in any of its
varied forms mav be seen.

The symptoms detailed above are those which are
ilue ti'i the passage oi a gall-stone from the gall-bladder
to the tlutnlenum. In the case of patients operated
n\xm for gall-stones by the surgeon a history which
sujj:j::ests that such a transit has occurred is decidedly
rare. In my own ex{K^rience it is present in less than
JO |HT ivnt. The great majority of the operations prac-
tisetl tn-dav are advised because recognition is made of
\\\v nature of the disease in an earlier stage than this.

The preseuiv of albumin in the urine during and
UiV some time after an atUick has been not seldom ob-
M'lvetl. ll is. however, by no means constant and
\mu iin dia^»nostie si^nuticance.

Stones in the Gall-bladder 145

Second. — Under this heading are to be described the
symptoms which are caused by the arrest, temporary
or permanent, of a stone, at any part of its course
from the gall-bladder to the duodenum, and, in brief,
the pathological changes which are thereby invoked.
It will be convenient to consider the subjects in the
following order:

(A) Stones in the gall-bladder.

(B) *' " cystic duct.

(C) " '' hepatic duct.

(D) '* " common duct, including the ampulla

of Vater.

(A) STONES IN THE GALL-BLADDER.
In all cases of choleHthiasis it is the inflammation
which the stones arouse, rather than the stones them-
selves, which is responsible for the production of the
chief symptoms. In a large number of cases gall-stones
are found at a postmortem examination when no evi-
dence of their existence has been observed during life.
Quincke, for example, writes: "In many, in fact in the
majority, of the cases of concretions within the gall-
bladder or the bile passages, all symptoms are absent
and the condition is only discovered at autopsy." This
statement and all the similar ones to be found in text-
books of medicine are probably exaggerated. They
do not take into account the facts, made clear bv the
experience of the surgeons, that what were formerly
considered the typical symptoms and signs of gall-stones
are present in very few cases of cholelithiasis. The
commonest symptom of gall-stones is not referred to

10

146 Special Symptoms in Gall-stone Disease

the biliary passages at all. It is ** indigestion*' in the
patient's vocabulary. Riedel, in a recent paper, states
that of 100 cases of epigastric colic (** stomach cramp*'),
97 are due to gall-stones. In a patient who has suffered
for years from ** gastric neuralgia'* the discovery of gall-
stones at the autopsy is not always held to explain the
symptoms.

It will, however, be allowed by all surgeons that the
presence of stones in the gall-bladder does not necessa-
rily cause symptoms, for gall-stones are occasionally
found during the performance of other abdominal
operations, when a close enquiry subsequently fails to
elicit any history of symptoms. Something more than
the mere presence of the stones is, therefore, necessary to
arouse the knowledge of their existence. This may be:

1. A sudden movement among the stones, a disturb-
ance or disarrangement of them, however excited.

2. The impaction of a stone or stones in the cystic
or common or hepatic ducts.

3. Infection of the gall-bladder or any part of the
bile-tract.

The bacillus coli is the organism most often found,
but in cases of suppuration the staphylococcus pyogenes
aureus or albus may also be present. Ehret and Stolz
(Berl. klin. Woch., 1902), in order to discover the cause
of the sudden onset of symptoms of an acute infective
character in cases of cholelithiasis, fed dogs, into whose
gall-bladders sterilised glass balls had lain for three
months without causing symptoms, upon decomposing
meats. An acute enteritis was set up and was followed

Stones in the Gall-bladder 147

by a purulent cholecystitis. The infection in these
cases was an ascending one from the duodenum. Any
irritating or decomposing food may not only introduce
fresh organisms into the intestine: it may also tend
to increase the activity of any that may be already
there. When stones are contained within the gall-
bladder, the symptoms which they cause are therefore,
due to one or other or all of the causes above men-
tioned. It is probable that disarrangement excites
infection, the mere moving of the calculi, apart from
some traumatism to the gall-bladder and subsequent
infection, being unlikely to excite any symptom. The
symptoms therefore of gall-stones in the gall-bladder
are those of cholecystitis, and they vary in severity
precisely in accordance with the intensity and virulence
of the infection.

In acute cholecystitis there are pain, nausea and
vomiting, collapse, great local tenderness, and perhaps
swelling and fever. The pain comes on suddenly and
is of great severity; it affects the whole of the right
hypochondrium, radiates to the back and over the
front of the abdomen and chest. It is of such intensity
in the more acute forms that the patient may roll in
agony on the floor. His face is then anxious and drawn
and ashen-coloured, he sweats profusely and is cold,
and his pulse may be extremely feeble. There are nausea
and repeated vomiting, and bile is not seldom present
in the vomit. The gall-bladder may be palpable, but
is more often protected by a rigid covering of muscle,
made tense by the irritation and inflammation beneath.
Jaundice is but rarely present, and is then due to an

148 Special Symptoms in Gall-stone Disease

extension of the inflammation dovm the cystic to the
common duct. It is probably not present in more
than one or two per cent, of cases of cholecystitis. The
symptom to which many patients refer is a stiffness
or soreness or sense of bruising in and about the right
hypochondrium for two or three days after an acute
attack of pain. This, which is similar to that felt before
a subacute perforation of an ulcer of the stomach, is
probably due to a localised but subdued form of peri-
tonitis. A patient suffering from this will hold the
hand firmly pressed to the side when walking up or
down stairs or in attempting to bend. In those cases
where a stone is temporarily impacted in the cystic duct,
the symptoms are always more severe. The tempera-
ture is higher, even to 104°, and there may be a rigor.
The temperature chart shews then the characteristic
"steeple" form— a sudden rise to a great height followed
by a fall to the normal. There is more serious depres-
sion and the vomiting is more exhausting. The patient's
condition is indeed serious. In some such instances
the infection may be so intense as to lead to ulceration
or gangrene of the gall-bladder or to empyema If the
stone drop back into the gall-bladder, the infection
generally subsides rapidly, and in a week, or rather
longer, the condition of things may return to the nor-
mal. After a respite all the symptoms may be repeated
in an attack of mild or great severity. After one or
more such attacks a condition of chronic cholecystitis
persists, and the gall-bladder may present a variety
of aberrations from the normal. It may be small,
shrunken, or shrivelled, with thin fibrous walls and a

Stones in the Gall-bladder 149

cavity that is barely to be recognised. In one such
example it was at first thought that the gall-bladder
was absent, and it was only after a tedious and pro-
longed postmortem dissection that an insignificant
remnant of it was laid bare. In other cases a thick gall-
bladder, intimately adherent to omentum, duodenum,
or colon, may be found, and in the cavity of this a small
quantity of thick viscid mucus. Or in still others the
gall-bladder may be a little thickened and adherent,
its walls are opaque, white and stiffened, but bile may
still enter the bladder, as a reservoir.

When chronic cholecystitis is present, there is almost
always a constant dull aching, sometimes hardly per-
ceptible, sometimes of severe degree, in the right hypo-
chondrium. The pain, during any exacerbation of the
inflammatory process, may be temporarily more acute.
It is in this form of disease that the differential diag-
nosis is most difficult. The symptoms are dull, diffuse
pain of the type mentioned; a feeling of fullness, flatu-
lence, or distension coming on during a meal, often after
the first few mouthfuls have been swallowed, occasional
backache, or aching in the shoulder and probably con-
stipation. In the symptoms there is, it will be seen,
nothing characteristic, nothing that by many surgeons
would be considered even suggestive of cholecystitis or of
any form of gall-stone disease. It is in this class of cases
that the pressure sign is of the greatest help. It is
the inability of the patient to take a full, deep inspira-
tion when the surgeon s fingers are hooked up deep
beneath the right costal arch, below the hepatic region.
If the tips of the fingers be *' worked in" gradually until

1 50 Special Symptoms in Gall-stone Disease

the muscles have relaxed and the liver edge can be felt,
then, as soon as the patient takes a deep breath, the
tender, chronically inflamed gall-bladder is forced down-
wards against the fingers and the inspiration suddenly
stops, ending in a deep sighing or brisk expiratory effort.
When an acute infection leading to suppuration occurs,
it is generally the result of a block in the cystic duct.
Gall-stones contained within the gall-bladder rarely
cause pressure symptoms.

The following case of death from pressure of gall-
stones contained in the gall-bladder on the vena porta is
recorded by A. S. Donkin (Med. Times, 1868, vol. 2, p. 396) :

The patient was a man aged fifty-six. On April 4,
1868, he had a hearty supper and went to bed in his
usual health. About midnight he awoke in great agony
with intense pain in the abdomen and vomiting of fluid
deeply tinged with bile. The pain and vomiting con-
tinued up to April 7th, when nine leeches were applied
to the epigastrium without giving relief. On April 8th
the pain had almost subsided, but there was great ten-
derness over the region of the stomach and the vomiting
was incessant. The patient gradually became worse
and died.

Postmortem. — The great omentum was deeply con-
gested and clots of dark blood were scattered between
its fold ; the lesser omentum was less highly congested.
The mesentery was congested, but to a much less degree
than the greater omentum. The ascending mesocolon
was extravasated between its folds. This congestion
extended to the transverse mesocolon, but to a much
less degree. The cajcum was highly congested, while
the ascending colon opposite the seat of haemorrhage
in the mesocolon was so intense that it presented through-

Stones in the Cystic Duct 151

out on its mucous surface a blackish colour from en-
gorgement of its minute vessels and ecchymosis. The
stomach contained a considerable quantity of fluid; the
rest of the intestines were quite empty. The mucosa
of the stomach everywhere showed venous congestion.
Several large blackish patches were observed on its
surface in the region of the greater and lesser curvatures.
The duodenum was highly congested, while the jejunum
and ileum were only slightly so. The liver was quite
healthy. The gall-bladder contained three large calculi
of about equal size. Together, in the gall-bladder,
they formed a hard solid tumour whose posterior ex-
tremity rested in the portal fissure over the portal vein
where it enters the liver, thus producing mechanical
compression of the portal vein to such a degree as to
give rise to all the phenomena of congestion of its tribu-
tary trunks and the resulting haemorrhages. The mus-
cular coat of the gall-bladder was atrophied, with thick-
ening of the external coat, which had assumed a whitish
colour.

(B) STONES IN THE CYSTIC DUCT.

The impaction of a stone in the cystic duct may cause
a great variety of results in the gall-bladder. These
may be enumerated as follows :

. X T^., . r , i, , i . . f simple hydrops,
(a) Dilatation of the gall-bladder .. i

^ ( empyema.

catarrhal,

suppurative,

(6) Acute cholecystitis

(c) Sclerosis of the gall-bladder.

(d) Calcification of the gall-bladder.

gangrenous, or
phlegmonous.

The frequency of this impaction has been very van-

152 Special Symptoms in Gall-stone Disease

ously estimated by different writers. Langenbuch found
stones in the cystic duct in one-third of the cases upon
which he operated, Riedel in two-thirds. Schlott, bas-
ing his figures upon a series of postmortem observ^ations
at Basle and at Erlangen, found stones in this duct in
only 5.5 per cent, of cases of cholelithiasis.

(a) Dilatation of the Gall-bladder. — When a stone
becomes impacted in the pelvis of the gall-bladder or
in the cystic duct, there is a rapid distension of the
gall-bladder behind the obstruction. At the first the
fluid therein contained consists of bile-stained mucus,
but as the obstruction becomes chronic the bile is ab-
sorbed and at last disappears entirely. The fluid then
consists only of mucus, which may be clear, turbid, or
opalescent; it is generally alkaline in reaction and con-
tains albumin. 1 have found it sterile in old-standing
cases. In recent cases the bacil us coli is generally
present. In both cr\''stals of cholesterin are seen. The
overfull gall-bladder, due to obstruction of the cystic
duct, never contains bile alone. When the gall-bladder
is tightly distended and contains bile, there is almost
alwavs an obstruction of the common duct, due to
other causes than gall-stones. The distended gall-blad-
der soon becomes palpable and projects from beneath
the edge of the liver. It may reach an enormous size,
and in a few examples, recorded by Lawson Tait and
others, the swelling has been mistaken for an ovarian
cyst. The wall of the gall-bladder is generally thin, in
proportion to the quantity of fluid, but in some instances
there may be an abundant deposit of fibrous tissue and
the cyst wall may be grossly thickened. The lining

Dilatation of the Gall-bladder

Fic. 40. — ^A dilated and thickened gail-bladder containing seven
large gall-stones, one of which, nearly one inch in diameter, is tightly
impacted in its cervix, and completely obstructs the passage into the
cystic duct. The patient, a gentleman sixty years old, died with a
strangulated hernia (Royal CoIWge iif Surgeons' Museum, No. 1815).

154 Special Symptoms in Gall-stone Disease

membrane of the gall-bladder loses its normal retictda-
tion and becomes rough, coarsely granular, and sodden
in appearance.

A condition of hydrops may result from any form
of obstruction to the cystic duct; as, for example,
stricture due to an old ulceration caused by gall-stones,
kink ng, enlargement of the lymphatic gland outside
the sigmoid curve, or growth in or around the duct.
In a few cases it is said that no obstruction of the duct
has been found. The probability is that in such in-
stances there has been a sharp kink in the duct, which,
on postmortem examination, has been undone by the
removal of the specimen. The cystic gall-bladder may
enlarge gradually during many years, or may remain
unaltered. A very remarkable specimen from a case
of Mr. Skey's, in the Museum of St. Bartholomew's
Hospital, shews an enormously distended gall-bladder,
a part of which was found as the content of the sac
of a femoral hernia.

The gall-bladder when enlarged forms a tumour which
is pendulous from the liver. It is club-shaped, the
narrowed end being the stalk of attachment to the
liver. A very wide range of movement is often pos-
sible, the tumour being readily made to present well
to the left of the umbilicus.

The symptoms caused by impaction of a stone in
the cystic duct are, as has been said, very acute at the
time of the occurrence, but if the obstruction becomes
chronic and a hydrops results, the symptoms may be
singularly few, or may be absent altogether. The pain
loses its colicky character very early, and there may

Dilatation of the Gall-bladder

Fig 41. — A gall-bladdor, measuring 5 J inches in length, due to the
impaction of a calculus in the cystic duct. In its cavity lay the other
four calculi shewn. From a. woman, aged twenty-eight, who had suf-
fered from pain in the right hypochondrium tor about two years,
but had never been jaundiced. She made a rapid recovery (Royal
College of Surgeons' Museum, No, 2830 S).

156 Special Symptoms in Gall-stone Disease

be merely a dull ache or a trivial sense of discomfort.
The tumour is not necessarily tender, though the free
handling of it often causes a feeling of nausea.

The tumour is to be recognised as being caused by
the gall-bladder ; by its attachment above to the liver,
the lower edge of the liver being traceable to its upper
end ; bv the fact that it does not fill the loin and cannot
be made to bulge by fonvard pressure in the flank; by
the fact that inflation of the cfjlon displaces it fonvards
or upwards, and not downwards Cexcept in those ex-
tremely rare cases in which the colon is adherent at
the upper part, and in front, of the gall-bladder), and
by the fact that inflation of the stomach causes a
displacement of the tumour slightly to the right. It
is thus recognised from kidney and gastric tumours.
The chief diflicultv, and at times an insurmountable
one, is to distinguish the lump from a tumour, hydatid
or malignant, of the liver near its free edge. The per-
fectly smooth contour and the absence of other irregular
nodules, and the free range of mobility will generally
permit an accurate discrimination to be made.

Hydrops of the gall-bladder results when infection is
absent or extremely attenuated. If the inflammation
aroused be acute and the infection at all virulent, empy-
ema will result. The clinical conditions associated with
the empyema var\' greatly in severity, and are in direct
proportion to the intensity of the infection. In the more
chronic forms the symptoms may be little more acute
than in hydrops; in the most acute they are so grave
that a fatal result mav occur within a few davs. In

Dilatation of the Gall-bladder 157

all cases the bacterium coli commune, with either the
staphylococcus pyogenes aureus or albus, is present.

In one case, illustrating the most chronic form of the
disease, the patient was a man, aged fifty-eight, who had
suffered for twenty years from "indigestion," and full-
ness and distension of the upper abdomen after meals.
Fifteen days before the operation a pain had suddenly
been felt in the gall-bladder region. This decreased day
by day for several days, and never at any time com-
pelled the patient to seek rest in bed. For the first two
days there was a temperature ranging as high as 100°.
After the first week a tumour was noticed and was recog-
nised by the medical men as a dilated gall-bladder. This
increased steadily in size, and at length was approxi-
mately equal to a cocoanut. It was slightly tender on
pressure, and after examination the side **felt stiff'* for
two or three hours. At the operation a large, densely
thickened gall-bladder was found full of stones and pus,
and a stone was impacted in the cystic duct. The gall-
bladder and cvstic duct were removed. A rather more
severe form is illustrated by the following record:

The patient, a lady of forty-one, had suffered for sev-
enteen years from gall-stone attacks, which were so
recognised by her husband, a medical man. Dieting and
medical treatment were carried out with alleviation to
symptoms, except on about six occasions during seventeen
years, when pain, and a rigor or tenderness in the region
of the gall-bladder, were noticed. There had never been
jaundice. Three weeks before I saw her the gall-bladder
had enlarged to the size of a lemon, but had subsequently
subsided until it was barely as large as a hen's egg. A

15S special Symptoms in Gall-stone Disease

rigor, p^in. prr:*fo-ini c-^IIap«se. lasting abcnit four hours.
had oocurrei at the onset of s>inptoms. On examina-
tion, the day before operatk^n. there was marked local
tenderness — the pressure sijpc being readily elicited — ^and
some enlargement of the gall-bladder was recognisable.
There was no temperature, no pain, when the patient was
resting, and food was taken with zest, though in small
quantities. At the operation an hour-glass gall-bladder,
distended with pus and stones, was found. The cystic
duct was blocked by a stone the size of a marble. The
gall-bladder and duct were removei and the patient made
a speedy recover\\

In the more severe forms the sisms of acute inflamma-
tion in the gall-bladder are more evident, and a local
peritonitis is clearly present. The gall-bladder is exquis-
itely tender, and its outline is dimcult to perceive, owing
to an intense muscular rigidity which protects the in-
flamed area. There is great pain in the whole hepatic
region, which is made worse by the taking of a deep
breath or by coughing or stooping. There is generally
a markeii rise of temperature, to 103° or 104°, and a
rigor is commonly observed. In cases of this type the
gall-bladder becomes ver\' intimately adherent to sur-
rounding structures, to the colon, the duodenum, or the
abdominal wall, and if ulceration be present a fistula
may form. In a certain, fortunately small, proportion
of cases, rupture of the gall-bladder may occur without
the formation of protective adhesions, and the perfora-
tion then occurs into the general peritoneal cavity. If
the ulceration extend deeply from the gall-bladder into
the liver, or into a mass of adhesions, a cavity may form
in the substance of the liver, or in the centre of a tough

Dilatation of the Gall-bladder 159

fibrous covering, and in this cavity, which is a sort of
diverticulum of the gall-bladder, the stones, bathed in
pus, may lie. These circumstances may all occur with
empyema or with acute cholecystitis, without blockage
of the cystic duct.

Jaundice is more likely to occur in the acutest forms of
empyema than in hydrops or in the less acute forms.
This is due either to an extension of inflammation along
the cystic duct to the common duct, an acute cholangitis
that is, or to a peritoneal inflammation which, by the de-
posit of lymph, compresses or kinks the common duct.

The following series of cases illustrate the various grades
in the intensity of an infection which depends upon the
blockage of the cystic duct by a stone :

Case I. — Miss G., aged fifty -one, seen with Dr. Johnson,
of Bawtry, July, 1899. The history was that forty -eight
hours before I saw her there was a sudden sharp attack of
abdominal pain and vomiting, which was attributed to a
dietary'' indiscretion. Pain had increased, vomiting had
been serious, and at the end of twenty-four hours a tense,
rounded swelling was felt in the abdomen.

On examining the patient I found a smooth, hard, ovoid
swelling at the ninth costal cartilage, which was clearly a
distended gall-bladder. It was tender on pressure, and
manipulation caused a sense of sickness. I opened the
abdomen, found the gall-bladder full of bile-stained fluid,
and a stone impacted in the cystic duct. The stone was
worked back into the gall-bladder and removed. No
other stones were found. The patient made a quick
recovery and has since remained perfectly well.

Case 2. — Mrs. S., aged thirty, seen July, 1900, with
Dr. Waugh, Skipton. There was impaction of stone in
the cystic duct, followed by hydrops of the gall-bladder.

i6o Special Symptoms in Gall-stone Disease

The patient has suffered from pain in the right hypo-
chondriac region for several years ; on a few occasions has
been jaundiced and the motions have been like *'drab
paint/' Four weeks ago a severe attack of pain, followed
by jaundice, which lasted seven days. Soon after the
attack subsided a lump was felt beneath the ribs on the
right side; the swelling has gradually increased in size,
has become exquisitely tender. On several occasions
has had severe attacks of vomiting.

The tumour was diagnosed as a distended gall-bladder.
On opening the abdomen a large, fully distended gall-
bladder, equal in size to a large lemon, was found. The
surface was injected, and there were many adhesions to
the omentum, stomach, liver, and abdominal wall. These
were separated and the larger ones ligatured. The gall-
bladder was aspirated, about eight ounces of thin clear
mucoid fluid removed, and the gall-bladder then incised.
A stone impacted in the cystic duct was gradually pushed
backwards into the gall-bladder and removed; it was
almost as large as a nutmeg and was solitary. The gall-
bladder was drained for eleven davs. Recoverv was
uninterrupted.

Case 3. — Mr. C. B., aged thirty-eight. Sent by Dr.
Booth, Grimsby. The i)atient's first attack of gall-stone
colic was five years ago; it was followed by jaundice,
which lasted only a few days. Two years ago there was
a similar attack, and since this the patient has had some
difficulty and pain after an ordinary meal. Three weeks
before I saw him a third attack of colic occurred, followed
by jaundice lasting one week. During this attack and
subsequently he noticed that the motions were pale and
the urine high coloured. A tumour formed beneath the
right rib margin, and assumed the size and shape of a
cocoanut. During the first week it steadily increased,
then remained stationary for a])out a week, and has since
very gradually diminished.

Acute Cholecystitis

i6i

I operated April, igoz, and found the gall-bladder
much enlarged, and the omentum and stomach a little
adherent; on aspiration about seven ounces of thick,
dirty-looking bile were removed. A stone equal to a
Barcelona nut was found in the cystic duct and si.\ other
stones in the gall-bladder. The hepatic and common
ducts were free. The stones w^ere removed and the gall-
bladder drained for eight days. The woimd then healed
and the patient has since been in excellent health.

Case 4.- — Mrs. T., aged forty-one. Seen March, 1901,
with Dr. Wiseman, Leeds. For the last three months has
suffered from pain and tenderness on the right side of
the abdomen. Sickness has been a troublesome symptom,
and wasting a marked feature. The attacks of pain are
referred to the right side of the abdomen at about the level
of the umbilicus. Four days ago an acute attack closely
simulating intestinal obstruction came on. There were
vomiting, hiccough, constipation, and marked prostration.
A tumour was then found on the right side of the abdo-
men, almost entirely below the umbilicus and vertical in its
longest diameter. The liver edge could be indistinctly
felt just above the swelling. The abdomen was opened
and the tumour found to be a largely distended gall-
bladder containing pus and forty -six stones. A single stone
was tightly wedged in the cystic duct. The gall-bladder
was deeply congested, and a few omental and colic adhe-
sions were found. The stones were removed and the
gall-bladder drained for eleven days. An uninterrupted
recovery followed,

(b) Acute Cholecystitis. — This in its various forms is
the most common variety of inflammation caused by
gall-stones. Indeed, many of the symptoms in the
slighter attacks of gall-stone disease are due to a mild
cholecystitis. When the gall-stone becomes blocked

1 62 special Symptoms in Gall-stone Disease

in tl\o ontraiire yf the cystic duct, an infection speedily
follows^ olTiiHion tfikes place into the gall-bladder, and
M>Tl\nun;»tinn of its walls speedily follows. Acute chole-
v'\s\Uis is ihvvcfore the precursor both of hydrops and
,M \Mnpvrinu of the gall-bladder. The inflammation
»\vu ulso start at the fundus of the gall-bladder or in-
xU-^mI i\\ Jiny part of the walls. The swelling rapidly
<|mvimIs ovrr the whole mucosa, and when it reaches
\\\v otilii r of tfie cystic duct, the swelling of the mucosa
^'lU-rlUfillv Mo<-ks the passage do\\Ti the duct. In acute
^hnliM v«5hli^ l)u' occlusion of the cystic duct may be
iMlmriiv. <;iti%iri^ the cholecystitis, or secondary, restilt-
\\\i\ (o'fM l\u' rhr,lc'cystitis. The block may be due to
(inpfH h'l '.Ufuc, to swelling of the mucosa, to kink of
lit!' 1 v^'tM 'lijct, or to swelling of the gland which is
hutmiilly pn-v-nt at the first bend of the duct.

I hi f.vrfipt/nns of an acute cholecystitis are identical
irilli llio^.<- cuusi'd in the early stage of a *' regular'* chole-
iHliliMJ!), ^i.'tvr for the fact that the gall-bladder is always
».nl»iiK''l. i*» pal|>al>le. and is tender on pressure. Jaun-
(|}M i>, n<*v<T |)resent unless the inflammation extends
flM'Arn In i\\t* cystic duct and affects the mucosa of the
niininnn duct. Such an extension is extremely rare.
I lir i\]\iiry,i'(\ ga!l-l)Ia(l(ler is sometimes the seat of acute
|(iiiii, which may radiate into the chest, back, or abdo-
MM II 1'h<* side is stiff and sore for several days. The .
w,iMrli«*s of acute inflammation described are catarrhal,
fiii|i|Mn";itivc, and gangrenous. The catarrhal form, and
iinli'i'l the other forms, may arise in the absence of
|/>ill hluncs, hut ill the great majority of instances it
\t^ \\n' i\n\)\iiyr (loiic by a calculus that opens the path

mI llllrclioll.

Acute Cholecystitis 163

In acute cholecystitis the symptoms are not seldom
those of an acute appendicitis; the signs also are sim-
ilar, though in the one the upper part, and in the
other the lower part, of the abdomen on the right side
is affected. Pain is the first symptom; it is sudden in
onset and increases rapidly; it is both paroxysmal
and continuous. It is felt . chiefly over the liver, es-
pecially along the liver border, but it may radiate
widely in several directions and may even mimic the
pain of appendicitis or of subacute perforation of the
stomach or duodenum. It is not long before other
symptoms of infection occur, nausea and perhaps vom-
iting, prostration, collapse, marked rigidity, and tender-
ness in the gall-bladder area. If there is a peritoneal
infection of wide extent, the symptoms are more severe
than those depicted. In some instances, indeed, they
may so closely resemble those of an acute intestinal
obstruction as to lead to an operation for that condi-
tion; and it is only during the manipulations that it
is recognised that the gall-bladder is the cause of the
symptoms. The temperature is generally raised to 100°
or even higher; the pulse too is rapid and weak. In
this, as in all other abdominal conditions, the' pulse is
the safe guide, and is more to be depended on than
the temperature.

The organism found is generally the bacillus coli,
but in the suppurative forms the streptococcus pyogenes
aureus and albus or staphylococci may be present.
The bacillus of Eberth and the pneumococcus are also
found.

So long as the inflammation is limited to the mucosa

164 special Symptoms in Gall-stone Disease

it does not give rise to acute symptoms, nor does it
endanger the life of the patient. Such a condition of
infection, however, is produced that subsequent troubles
from redisturbance of the stones or a fresh accession
of inflammation will almost without exception be
found to follow; that is to say, that gall-stones which
have once caused cholecystitis will rarely, if ever,
become quiescent.

In many cases the inflammation, even when apparently
slight in character, as estimated by the clinical disturb-
ance, has been of sufficient severity to penetrate to the
serous coat. A pericholecystitis is caused, a local peri-
tonitis involving the serous coat of the gall-bladder and
the immediately adjacent structures. The formation
of a plastic lymph, which in recent cases can be peeled
off in thin layers, is the result, and this at the last leads
to the firm adhesions which may be so troublesome a
feature in any operative procedure. Adhesions so
formed may in certain infrequent cases persist long
after the stone or stones which have caused them have
passed, and they may cause symptoms which are not
to be distinguished from those due to the irritation
of gall-stones.

When the acute inflammation has subsided, a thicken-
ing of the gall-bladder is left. There is never a resti-
tution to the normal; a chronic cholecystitis remains.
When a fresh infection occurs, the chronic choice vstitis
becomes acute, and this again subsides. There is an
alternation then between acute and chronic cholecystitis
to the serious and increasing impairment of the gall-
bladder.

Acute Cholecystitis 165

When the inflammation spreads to the serous coat,
a local peritonitis, easily recognisable on clinical ex-
amination, sf)ee(iily develops. The condition then is
only a degree less acute than that present in acute
phlegmonous cholecystitis, to be presently described.
The signs and the symptoms are those of an acute local-
ised peritoneal infection. As a rule, the rigidity, ten-
derness, and pain are limited to an area immediately
below the free edge of the liver. The condition is one
which demands early surgical treatment. Korte has
related 17 cases of acute cholecystitis upon which he
operated. Stones were present in 16 cases, absent in i,
but in this a stone had probably been present a little
earlier. Of these cases there were 7 in which the stones
had been absolutely latent, there were 5 in which symp-
toms were present but had led to an erroneous diag-
nosis of stomach or kidney disease; in the remaining 4
gall-stones had been diagnosed. In 6 cases cholecys-
totomy and drainage, in 5 cholecystectomy and tampon-
age, in 6 cholecystectomy and drainage of the common
duct were practised.

There is, however, a much more serious form of in-
flammation of the gall-bladder than these — phlegmonous
cholecystitis. This disease was first described by Cour-
voisier in his memorable paper in 1890. He collected
7 cases, and described them as ** acute progressive empy-
ema of the gall-bladder.'* The following cases which were
under my care illustrate the gravity of the condition :

Case I. — Phlegmonous Cholecystitis: Sloughing and
Perforation of Gall-bladder. — M. A., aged forty-six; male.

1 66 Special Symptoms io Gall-stone EKscase

Patient seen with Dr. Erskine Stuart, Batlev. Had
been jjcrfectly well up to December 31, 1900. On that
day he had a sharp attack of pain in the right hypo-
chondriac region about an hour after his evemng meaL
He felt sick and cold, vomited several times, and could
only obtain ease by doubling himself over the back of
a chair. He was given a large dose of opium and put
to bed. The next day he was slightly jatmdiced; the
day following more so. and the jaimdice has persisted.
Pain in the right h>"pochon<lrium has been constant — -
relief had only been obtained by opium administra-
tions.

On examination. Januar\' 11. 1901, the patient was
foimd moderately jaundiced and looking ill. The abdo-
men was full and prominent; the whole right hypo-
chondriac region was hard, strongly resisting, tender on
pressure. The muscular protection was so effective that
no deep examination was possible. A diagnosis of
cholangitis and cholecystitis, depending possibly upon
calculus, was made. The rigidity and tenderness were
supixvk\l to be due to a localised peritonitis, possibly
dependent upx^n distension of the gall-bladder as a restdt
of obstruction of the cystic duct.

The alnU^men was opened on January 12th by an
inoisiiMi thnnigh the right rectus muscle. On opening
the ivritoneum bile-stained liquid with flocculent masses
of Ivniph tliAVtHl fn^m the wound. At the least three
pints of tUiid were Removed. A collection was found
betwiHMi the liver anil the diaphragm, the fluid there
lH^in>; thick and semi-purulent. An examination of the
^all bladder iliselovseil the cause of the condition. The
l^all blavlder was thickly coated with lymph, was deep-
purple ni a>lour. and shewed a sloughing opening on
Us surfavv (\\m\ which bile-tinged fluid was oozing. The
open»uf: was about one and one-fourth inches in diameter;
lis viWys wciv ragged and a little thickened. In the

Acute Cholecystitis 167

gall-bladder seven stones were found; an eighth, the
largest, was discovered later in the upper part of the
renal pouch, partly buried in lymph. The cavity was
cleaned up as well as possible, the gall-bladder opening
trimmed, and a drainage-tube secured in it; the sub-
phrenic abscess was separately drained, and a tube was
also passed, in through a stab wound in the loin.

The patient, whose condition w^as bad before the of)era-
tion, died, gradually declining in forty-eight hours.

Case 2. ^-Gangrene mid Perforation of the Gall-bladder, —
W. D., male, aged fifty-two. Admitted Sept. 9, 1902,
with the following history :

The patient has suffered from indigestion, biliousness,
and discomfort after food for twenty-five years, when
he had typhoid fever; the vomiting, first observ^ed five
years later, was at first infrequent and copious. Eight
years ago his condition became worse. He had constant
severe pain after food, frequent vomiting, often twice
daily, and lost over a stone in weight in about three
months. He improved a little during the following year
but has since steadily lost health and strength. Six
months ago was seen by an eminent physician who
diagnosed "cancer of the stomach." His loss of flesh
has latterly been extreme, he is now very sallow, wasted,
and feeble. The stomach, reaches midway between um-
bilicus and pubes, can be seen contracting on distension.
Free HCl present in small quantity. At the operation,
the condition found was a dilated and somewhat hyper-
trophied stomach. A large thick mass in the duodenum,
involving the pancreas, was found, and was thought to
be malignant. The stomach was much dilated and its
coats were thickened. Posterior gastro-enterostomy was
performed and all went well for twenty-eight days. At

1 68 Special Symptoms in Gall-stone Disease

the on<l of that time the patient became suddenly verv
ill. ('()llai)S(? and the vomiting of bile were the chief
Irulurrs anrl jaundice quickly followed. The abdomen
WHM <lisUTnd(!d and exquisitely tender over the hepatic
i\\vi\. TIh! abdomen was re-opened and a gangrenous
111 id iH^rforatcd gall-bladder was found. Bile was seen
rnr/ipinj( from the openings in the gall-bladder. The
^[i\\\ hladdor and the peritoneum were drained, but the
putirnt died in a few hours. It was found that the
iiiiiliKnant growth had involved the pancreas along its
ilpprr anrl right margin, and the hepatic artery was
iinbrd/lirrl ifi the grr)Wth.

Thin ( as^t is instructiv^e as only three small gall-stones
wrnr f/;!ind (tither in the gall-bladder or the ducts, and
l\w paU'fU'y of the ducts during life was shewn by the
vnui'\l\uy, of bile. The interference with the blood sup-
ply wfi<* undoubtedly the cause of the gangrene.

The e/ifirlition is clearly analogous to the acute phleg-
Mionou*'. api»(!ndieitis which is occasionally seen; both are
r ofi/litioiis iti which the bacterial virulence is so exces-
tjive tliat a complete destruction of the apf)endix or
^^^\\ lil;idder is accomplished before the peritoneum
h/it) had tlie time to protect itself by the out-pouring
ni tjiTUin or lymph.

The Hyrn|)toms of phlegmonous cholecystitis are of
the gravest ty|H». There is a sudden onset of very acute
pnjti ill tlu! right hypochondrium. This may be so pro-
found /iH to cause collapse, faintness, and great prostra-
ll/Hi 1'lie pain comes generally on without obvious cause,
hul ui not a f(^w instances it has been attributed to the
fiikuii-' of an undulv heavv meal. The constitutional

Pressure Effects of Stone in Cystic Ducts 1^9

disturbance is alarming. The pulse is rapid, feeble,
almost running; the hands and, indeed, the body sur-
faces generally are cold, clammy, covered with sweat;
there is sometimes a rigor, but always an elevation
of temperature during the first few hours. The local
signs are seen early, and are those of a peritonitis,
limited at first to the gall-bladder region, but later be-
coming generalised.

(c mid d) Sclerosis and calcification of the gall-bladder
occur at a late stage of the disease and are the results
of a dense inflammatory deposit in the walls of the
viscus. The symptoms are those of chronic cholecystitis,
and have alreadv been detailed.

PRESSURE EFFECTS OF STONE IN THE CYSTIC DUCTS.

In addition to all these conditions a stone impacted
in the cystic duct may, by its pressure \rpon the common
duct, portal vein, or duodenum, give rise to symptoms
which tempt the surgeon to an erroneous diagnosis. The
pressure upon the common duct causes cholangitis, and
the symptoms of a stone in the duct are portrayed.
Pressure upon the portal vein causes thrombosis and
ascites. If both the common duct and the portal vein
are compressed, there will be jaundice and ascites, and
a diagnosis of malignant disease will be suggested.
Pressure upon the duodenum, as in two cases recorded
by Mikulicz, has caused the symptoms of gastric dila-
tation.

The following illustrative examples may be quoted.
In a discussion before the Chicago Surgical Society

T:e--::ax "** "ulccitis ji jsll-saxie E^^scasc

^nr _r J£cAri:ir gave

- ^ TZias. is i .^ssc resort,

izii who

^'.r». ^■. .^ •.:::5C5r-^rP "^i:^ r^sci: irsjr The

.-_- . *:cvii". "JI :x trj;rg:E: :c zbe liver.

:>;^ :x ^-.-."--J^''-xr J. 523il hiielnut-

■*.-5- •?'"*- X': '"^ iXirrriir?:r.. and

■— ^ -rrj.Iz^rriin: viisease

.. ,„ . . - x -i." •* o^ X runcn?Jis was

V-

Pressure Effects of Stone in Cystic Ducts 171

A similar case to this was under the care of Dr. Moore
of Minneapolis. Jaundice and ascites were present; a
stone was found impacted in the cystic duct, compress-
ing the common duct and the portal vein. It was re-
moved and the patient recovered.

For the notes of the following case I am indebted
to Dr. Barrs (the patient was under the care of Mr.
Littlewood, and subsequently of Dr. Barrs in the Leeds
Infirmary) :

Female, aged fifty-nine. November 18, 1903. Patient
was well up to six years ago, when present illness began ;
always temperate, no venereal disease, has had 14 children ;
well-built, fairly stout woman. Illness began quite sud-
denly with violent ** tearing ** pain in upper part of right
side of **body." She was doubled up, vomited and
sweated profusely. The attack lasted about twelve
hours, and she was yellow for three weeks after. Her
motions were white and her urine dark, and she was in
bed one week and attended by a doctor. Except for
slight pain in her right side, she got quite well.

Two years ago she had a severe attack of pain and again
one year ago, but was not jaundiced so far as she knows.

In September, 1903, she says she first noticed ** her body
was swollen" and that she w^as becoming ** yellow in the
eyes " ; then she noticed that her urine was dark coloured
(just as it had been in her severe jaundice attack six
years before) and **smelled badly"; she became consti-
pated and her stools were white. She went to a doctor to
have her urine examined and was given pills which re-
lieved her constipation. About the middle of September
she felt cold and chilly and went to bed, and for two or
three weeks vomited most of her food. Her appetite was
bad and she was very thirsty ; the distension of the ** body "

172 Special Symptoms in Gall-stone Disease

increased and the legs swelled a little. On October 20th,
the d(x:tor drew off from the peritoneal cavity 1 1 pints
of dark fluid. She rapidly filled again and was admitted
to I^eds General Infirmar\' on October 23d.

On examination, marked jaimdice; stools not clay-col-
oured; urine, sp. gr. 1012, bile present, no albumin, no
sugar, much ascites with usual signs, but the liver is pal-
pable through it. Liver reaches one to two inches below
costal margin, edge sharp, regular, not tender, moves freely
on respiration, absolute dulness reaches sixth rib in mid-
axillary line. Below margin of liver, opposite tenth right
costal cartilage, the hand **dips" through fluid on to a
mobile, rounded lump, probably gall-bladder.

Her general condition was fair ; no distended veins were
seen ; all other organs are normal.

November i6th: Abdomen tapped and 9 J pints of dark,
bilious, transparent fluid withdrawal.

November 17th: Xot quite so well, feels weaker, fluid
accumulating somewhat rapidly. Five p. m., much worse,
pain in abdcmien, more fluid in peritoneal cavity, pulse still
good. Hot fomentations applied tightly to abdomen,
and calcium chloride, gr. xx, given two hourly, because
haematcMnosis foaanl ; some vomiting, some dyspnoea.

Ten \\ M., still sinking rapidly, fluid now fills peritoneal
cavity, jnilse goo<l. anxious expression, probably bleeding
into iXTitoncal cavity.

NoviMiibcr 1 8th: 4.15 a.m.. death.

P. M. NoviMiibcr i8th: Body jaundiced, abdomen dis-
tended with fluid, iK^ritoneal cavity full of bloody fluid
and blood dots amounting to 6 pints; no place could be
found rxcrpt the recent wound through which tapping
had been d(»ne from which the hrematemesis had come, al-
th(»uKh the whole iH^ritoneal surface looked very vascular.
A dot was adherent to puncture wound on peritoneum.
Li\'er ^:«MU»rallv enlarged, bile-stained surface finely gran-
ular, siibstann* distinctly tough (early cirrhosis?). Gall-

Pressure Effects of Stone in Cystic Ducts 173

bladder sausage-shaped, 4J inches long, 2 inches broad,
containing multitude of minute stones in clear mucus.
Hepatic ducts markedly dilated. Half stone about size
of a medium-sized Barcelona nut. Common bile-duct is
dilated, contained a few minute stones and bile-stained
mucus. The stone in the cystic duct pressed against the
common duct, almost occluding it, the duct being dilated
above and natural below the point of pressure. The stone
in the cystic duct also exerted pressure upon the portal

2. ^Drawing made by Mr. L. R. Braithwaite, who performed the
postmortem examination.

vein, there being slight peritonitic adhesions between
them at this point, although the portal vein was readily
patent to a probe passed from below. A probe passed
easily from junction of cystic with common bile-duct along
into the duodenum.

Pancreas. — Markedly large. Substance unusually hard
and gritty. Head very hard and large. Substance on
section appears normal.

Microscopical Examination (Dr. Forsyth): "Pancreas
shows an early stage of chronic pancreatitis."

I "4 Special Symptoms in Gall-stone Disease

Coun'oisier records four cases in which the portal vein
contained a gall-stone which had ulcerated into it from
the gall-bladder or ducts.

(C) STONES IN THE HEPATIC DUCT-

Stones in the hepatic duct are less commonly seen than
stones .in any other part of the bile passages. As a rule,
when there are stones in the hepatic duct there are others
in the common duct or in the gall-bladder. This, how-
ex'cn is not universally the case.

In SQ cases collected by Courvoisier, in 56 stones were
present in cither parts of the bile passages. In 51, in
which distinct mention is made of the condition of the com-
mon duct, there were stones therein in 45. Small stones
i\>tniK)sed of bilirubin calcium are not infrequently found
in the hepatic duct when this is explored after the re-
moval (^f a stone from the common duct. Such small
calculi are black or dark brown in colour and are readily
i^>tnpresse(l to a fine powder by the pressure of the

lingers.

Miehaux (Bull. Soc. Chir.. 1894) comments upon the

extrtMne infrequency of stone in the hepatic duct. In
a search through the Bull, de la Soc. de Chir. since its
fiuindalion, in 1826, only eight cases of stone in this duct
xviMV U )und recorded. In almost all the cases a large calcu-
lus was also found in the common duct. Michaux ex-
pri*ssed the (^pinion that hepatic stone was always secon-
dary to stone in other parts of the biliary passages.

St(Mies may be formed, though this is probably ver>^
rare, in the hepatic duct, and there remain stationary.

Stones in the Hepatic Duct 175

gradually enlarging by added deposits from the bile stream,
or they may, and in the very great majority of cases they
doubtless do, pass down from the gall-bladder along the
cystic duct and turn upwards into the wider hepatic duct,
whether the common duct be blocked or free. A single
stone may be found ; more commonly there are many.
When solitary, the stone is generally of the size of a
nutmeg, or even larger.

The symptoms due to a stone or stones in the hepatic
duct are not separable from those due to blocking of the
common duct.

The following is the record of a case which was under
mv care:

Case 8. — Mrs. T. B., aged 39. Seen with Dr. SprouHe.
Mirfield. Three years ago she had an attack of epigastric
pain and vomiting, followed by slight jaundice — a typical
attack of biliary colic. Since then she has had nine simi-
lar but progressively more severe attacks. Nine weeks
ago an extremely severe attack. Pain has continued. all
the time, and jaundice, though varying slightly, has al-
ways been pronounced. The motions during this period
have been light coloured, the urine thick and scanty.
Pain is constant, but at times an acute paroxysm occurs.
Has lost flesh rapidly during the last two months, and has
been eating little, owing to pain and heaviness after even
light diet, and vomiting.

Operation, December 7. 1900. ^Eighty-seven gall-stones
were removed, mostly from the hepatic and common ducts.
A few lay in the gall-bladder, but both hepatic ducts and
the whole length of the common duct were filled with
tightly packed stones. These were removed through an
incision in the common duct, which was afterwards sewn
up. A stone was found tightly impacted in the ampulla

176 Special Symptoms in Gall-stone Disease

of Vater, and the duodenum had to be opened in order to
remove it.

The patient had severe haematemesis after the operation
and died on the third day.

Stones in the hepatic duct are liable to be overlooked.
I have on several occasions found well-formed stones
unexpectedly in the hepatic duct, or in one of the branches,
when engaged in removing stones from the common duct.
In all, the stones were easily milked downwards and re-
moved through the common duct incision. In some cases,
however, the separate opening and draining of the hepatic
may be needed.

When infective or suppurative cholangitis occurs,
the outlook is desperate indeed. Naunyn relates a case
from the practice of Kussmaul in which, after cholelithiasis
of many years' duration and three weeks of fever with
jaundice and rigors, the patient succumbed to marasmus.
At the autopsy the hepatic duct was blocked by a concre-
tion. Its branches and the intra-hepatic ducts were blocked
throughout. They formed a system of mutually commu-
nicating sinuous cavities, varying from the size of a millet
seed to that of a cherrv stone. Within the liver, near its
hilus, these cavities were so abundant that the liver ** resem-
bled a bath sponge with larger and smaller perforations."
These cavities were filled with bile-stained pus, and their
walls consisted of a distinct membrane with a ragged
surface ; the liver tissue was dry and jaundiced.

When suppuration behind a stone in the hepatic duct
has extended into the liver, the condition described bv
Leonard Rogers (Brit. Med. Joum., vol. 2, 1903, p. 706)
as ** biliary abscess" results. There is a universal suppu-

Fig. 43- — ^Dilated hepatic duct; ascending suppurative hepatitis.
The gall-bladder ia greatly contracted, and its cystic duct leads into
a cavity two inches across, produced by the dilatation ot the hepatic
duct, which contained bile and pus. with many small black calculi.
The common bile-duct, also communicating with this cavity, is some-
what dilated and contains a gall-stone the size of a cherry, impacted
half an inch from the papilla. Scattered through the liver and be-
neath the capsule are many small ragged abscess-cavities. From a
woman, aged thirty, admitted tor jaundice of fourteen days' duration.
Five months previously, after a severe attack of enteric fever, a
swelling was noticed in the region of the gall-bladder, but this gradu-
ally disappeared. On admission th« liver was uniformly enlarged;
pyrexia was present; she also suffered from rigors. After death, a
fortnight later, the liver was found to weigh ito ounces, and the
peritoneal cavity contained much bile-stained, purulent lymph {Guy's
Hospital Museum. No. 141S).

la 177

1 78 special Symptoms in Gall-stone Disease

rative cholangitis, the ducts \v4thin the liver being greatly
dilated and filled w-ith pus. There may be nothing which,
even on the closest scrutiny, suggests a diagnosis of gall-
stone trouble; there may never have been pain, vomiting,
colic, or jaundice. In other cases, however, a history
suggesting the impaction of a stone in the common duct
Vkill have been obtained. Leonard Rogers attaches great
significance to a group of symptoms which was present
in more than half the cases collected by him.

** It consists of a complete obstructive jaundice, which
is always present in the earlier stages of the disease,
followiHi by the reappearance of bile in the stools in
often small quantities and a decrease in the jaundice,
acaMUixmied by an aggravation of the general symptoms
with rigors and hectic condition, instead of the ameliora-
tion naturally ex| voted to ensue on the partial removal of
the oom]>lolo Dbstniction of the bile-ducts. This improve-
nuMtl in the jaundice and reappearance of bile in the intes-
tine, toj^vther with increasingly severe general symptoms,
is due ti» si^ftening and distension of the wall of the ducts
Iw suppuration occurring within them above the obstruc-
tiot\ leading to loosening of the impacted stone, which,
\\\ turn, allows of the escape of a little of the bile and pus
into the bowel past the stone.'*

lie iveonls the following case :

The patient was in the Forest Department (Calcutta),
and he i'an\e in on April 6. 1902, for the treatment of
enlmv.eil liver and a history of occasional attacks of ague
and n^peattnl attacks of jaundice, preceded by severe pain,
I he \au\ of whieh iKvurred thn?e weeks before admission.
Thi^ h\er dulness extended from the fifth rib to six inches

Stones in the Hepatic Duct 179

below the costal margin. Spleen not enlarged; heart
and lungs normal ; pulse 48 ; slight jaundice ; temperature
normal. From April i.^th to 17th he suffered from inter-
mittent fever and was treated with quinine. On the 22d
he had a rigor, the temperature rising to 104°, falling to
101° the next morning, when I examined the blood at the
request of the physician under whom the patient was at
that time, as liver abscess was suspected. 1 found no
leucocytosis, but, on the contrary, they were below the
normal, with a large proportion of large mononuclears, and
further search revealed malignant tertian parasites, and
quinine treatment was resumed; and with the exception
of a slight rise on the 27th and ague on May 4th and 7th
no more fever occurred; the jaundice improved and he
left the hospital on May i8th, the case at this period
having been one of biliary colic, accompanied by malarial
fever.

On December 18. 1902, he returned to the hospital and
came under my care. Ill since 7th in bed. Has passed
several gall-stones since the 15th, which he brought with
him, the largest being about J inch in diameter. The liver
dulness extended from the fourth space to three inches,
and much pain of a colicky nature, requiring morphine-
Temperature from iQo° to 102°, with profuse perspiration.
The fever continued, and on December 22d he coughed
up a quantity of viscid, frothy mucus. Temperature of a
hectic type, continued rising to 103° and 104° in the even-
ing. The vocal fremitus was slightly diminished, but
there was only partial loss of resonance at the right base.
I diagnosed suppuration in the bile-ducts in the liver,
and advised operation for the purpose of draining the
ducts and removing any gall-stones. After a consultation
this was agreed to. On the morning of the 2 sth he coughed
up a small quantity of pus, but in view of the case men-
tioned above, in which a fatal termination ensued in an
abscess of this kind, in spite of the opening through the

4

1 80 Special Symptoms in Gall-stone Disease

lung, and having certain knowledge of gall-stones having
been passed, it was decided to proceed xv-ith the operation
as pre\-ioiisly arranged. Captain H. Mackin, I. M. S.,
kindly helping me.

Operation. — ^An incision was made in the right linea
semilimaris. with its centre over the lower edge of the
liver. The gall-bladder was completely hidden beneath
the edge of the liver, but its fundus was reached and
opened, and a number of small gall-stones were ex-
tracted. On now passing the finger along the bile-ducts
beneath the Hver, a large mass of gall-stones were felt
deep under the liver, which could only just be reached.
The wound was now enlarged upwards and dowTiwards,
and a transverse incision made across to the middle
line, so as to enable the. lower edge of the greatly en-
larged liver to be turned up. The mass of stones in the
right hepatic duct could now be reached and opened, and
with ver\' considerable difficulty a mass of large gall-stones
some three inches in length and over an inch in diameter in
places, were removed, some of which were well within the
liver substance. As it was quite impossible at such a
depth to bring the opening in the duct to the surface,
and as the patient was in a low state, a glass drainage-tube
was inserted and gauze carefully packed around it, and
the wound united around the tube. The patient suffered
severelv from shock, rallied somewhat in the afternoon,
but was much troubled by coughing up mucus. At 10 in
the evening he was easier and coughing up mucus more
easilv. However, he never fully rallied from the shock of
the pn)longed oj^ration and died at 5.30 a. m.

Xtrropsw — The same morning the body was examined.
There woa^ already good adhesions around the gauze
packing and no trace of leakage of discharge into the peri-
toneal cavitv. The liver was removed with the stom-
ach aiul duodenum and right lung altogether. Only one
small gall-stiuio in the depth c^f the liver in the right hepatic

Stones in the Hepatic Duct i8i

duct was found, which was much smaller than some of
those removed at the operation, so would easily have
escaped through the opening made in the duct, and would
doubtless h:ive escaped through the wound, although too
deep in the liver to be removed at the operation. Behind
this stone the bile-ducts were much dilated and full of pus
in a limited portion of the upper posterior portion of the
right lobe of the liver. This tracking abscess had opened
posteriorly by the side of the inferior vena cava, and
travelled up through the diaphragm and the base of the
right lung into the inferior bronchi. The common bile-
duct was dilated and its opening into the duodenum was
large and free.

In rare instances the duct behind the stone may rup-
ture, as in the following case recorded, with comments, by
John Freeland, M.R.C.S. (Lancet. May 6. 1882):

Maria J., a black, aged sixty-five, who has been for
many years troubled with intermittent fever, followed by a
regular train of symptoms, commencing with vomiting,
colicky pains, and tenderness of the abdomen, and ending
with jaundice, more or less severe, applied to me during
one of these attacks, stating that, in addition to her gen-
erally distressing symptoms, she was now seized with
violent and excruciating pain in the stomach and chest,
and that she could retain nothing whatever^water, nour-
ishment, or medicines being immediately rejected with
greatly increased suffering.

On examination I found her skin hot and dry, pulse
hurried, abdomen fuller than natural, and in some parts
painful on pressure. She says she has been taking the
medicines I generally prescribed during these seizures,
but has not obtained the relief from them she usually
did on former occasions, and was quite sure, from the pain

1 82 Special Symptoms in Gall-stone Disease

and excessive prostration she now felt, that there was
some other complaint added to her old disease. I
immediately prescribed fifteen drops of tincture of opium,
with a little sulphuric ether, and applied a large warm
linseed poultice over the stomach and upper part of the
abdomen. This seemed to have a very good effect,
for the pain was completely subdued after a second dose,
and the tenderness of the abdomen, which was so evident
at the time of my first examination, was now almost
entirely gone; the warmth of skin, although somewhat
subdued, continued, however; and as there was now
a feeling of headache and nausea, which prevented my
patient from expressing herself as much relieved, as I
expected she would have been after having suffered so
intensely some hours before, I ordered a mixture of
carbonate of soda and nux vomica in small doses, and
desired her to report at once in case the pain should re-
turn. During the next night she was suddenly seized
again with acute pain, but was as readily and easily
relieved by the opiate, ether, and poultice, as in the pre-
vious instance. Her relief, however, was of short dura-
tion, for the pain soon returned with increased severity,
and was now accompanied with a somewhat tympanitic
and extremely tender abdomen. I at once ordered pills
of calomel and opium, to be administered every second
hour, and the poultice to be continued, with the addition
of spirits of turpentine freely sprinkled over it. On my
next visit, in about six hours afterwards, I found the
extremities cold, pulse 120 and small, and the body
generally covered with a clammy sweat; the pain in the
abdomen had ceased, but the vomiting returned at in-
tervals, with great depression, until she died in about
eight hours afterwards.

On examination of the bodv almost immediately after
death, the cavity of the abdomen was found literally filled
with blood and bile, the intestines gangrenous in spots,

Stones in the Hepatic Duct 183

and here and there highly inflamed and congested;
the peritoneum one mass of inflammatory deposit and
■adhesions, the liver and gall-bladder healthy; the latter
appeared, however, smaller than natural, and was
entirely empty, and the spleen, which was of a bright
orange tint, was so deeply stained with bile that even
when removed, washed, and broken up in pieces, the
bright colour remained and appeared to be so intimately
mixed up in its stricture that it was quite impossible
to lessen it. The hepatic duct was found lacerated, and
the opening in this through which the bile had escaped
appeared but recently formed, but the calibre of the
duct was much larger and its length greater than usual,
and in some places distended into pouches or bags which
contained gall-stones varying in size from a pea to a
strawberry. In one of these pouches or bags a most
remarkable appearance presented itself in the form
of a slit or opening, which was fully occupied and oc-
cluded by the point or apex of one of these stones. On
displacing and replacing the stone in its position fwhich
was most readily effected by the mere disturbance of the
parts), I discovered that the slit which it had occupied
was as completely and natural ly formed as if it had been
the normal state of the duct, the edges being firm, smooth,
an<3 slightly everted ; and altliough this stone must at
some time or another have caused ulceration by its
pressure and given rise to grave symptoms, there is no
doubt in my mind that it afterwards acted as a plug,
and so effectually sealed the aperture in the duct (so
long as it remained in situ) that no bile escaped into
the cavity of the abdomen except at times, and in such
minute quantities as only to give rise to those slight
attacks and symptoms which I already mentioned as
having been of frequent occurrence during the usual
intermittent fevers which my patient more or less an-
nually passed through.

184 Special Symptoms in Gall-stone Disease

Now it is evident, I think, that the second or recent
rupture in the duct, which was quite patulous and
surrounded with coagula, was the immediate cause of
death, and that the first or older opening existed for years
and had been nearly always occupied and closed by the
presence of the gall-stone which only occasionally al-
lowed the bile to escape when from some particular
exertion or vomiting it became temporarily displaced.

(D) STONE IN THE COMMON DUCT.

Obstruction of the common duct by a gall-stone or
several stones may be complete or incomplete. A single
stone may be so tightly wedged in the duct that no drop
of bile can pass by it, or, on the other hand, it may fit
so loosely that bile may, from time to time, flow past it
readily. Courvoisier, in 123 cases, found that the position
of the stone or stones blocking the common duct was as
follows :

In 17 cases at the commencement of the duct.

In 19 cases in the middle of the duct.

In 20 cases near the duodenum (retroduodenal portion).

In 41 cases at the ampulla.

In 26 cases the whole length of the duct was blocked.

In cases recorded by Cruveilhier and Frerichs, the whole
length of the bile passages, including all the intra-hepatic
ducts, was blocked by an infinite number of fine stones
and sand.

I. Complete occlusion of the duct is rare. It results
more often from growth or stricture in the duct or com-
pression of the duct from without than from stone.

Partial Occlusion of the Duct

185

A stone producing complete blockage of the duct may
lie wholly in the common duct or may be extruded into
the lumen from the cystic duct. In the latter condi-
tion there is always an immense thickening of the ducts,
the wall of the cystic duct in one specimen in my posses-
sion measuring nearly an inch in thickness. In all cases
where the block is complete the bile pent up behind
the stone becomes gradually absorbed and the hepatic
ducts become filled with clear, sticky mucus, and are
everywhere greatly dilated.

The chief, and often the sole, symptom of complete
occlusion of the common duct is deep and unvarying
jaundice. Pain may be present in the earliest stages,
but it is rarely or never severe and speedUy disappears.
There is no distension of the gall-bladder, and the signs
and symptoms of septic infection, which are such con-
stant features of partial occlusion of the common duct,
are entirely absent. It is often a matter of the greatest
difficulty to distinguish this form of disease clinically
from malignant disease of the ducts or of the head of
the pancreas. The early history of pain and colic and
the absence of enlargement of the gall-bladder are the
most helpful points.

2. Partial Occlusion of the Duct. — In the very great
majority of cases of obstruction of the common duct by
stone the block is only a partial and an intermittent one.
When the stone has become fixed, a dilatation of the duct
behind the obstruction always occurs. In this dilated
duct the stone is free to move. It then forms a ball-
valve, as was pointed out by Fenger, at times blocking
the duct absolutely, at other times allowing bile to pass

1 86 Special Symptoms in Gall-stone Disease

it unimpeded. A ball-valve stone may be found at any
part of the duct, but is more commonly found in the
ampulla of Vater. If one stone is fotmd to be blocking
the duct, other stones will often be discovered. In-
deed, obstruction of the common duct is far more often
due to many stones than to one. If a stone be fotmd in
the first portion of the duct, another may be felt in the
ampulla, or the whole length of the duct even may be
tightly packed with a multitude of large and small
calculi. In other cases stones may be found in the com-
mon duct and in the hepatic ducts. No operation can be
considered as complete which does not include a very
careful examination of other parts of the bile-duct than
that in which a large, apparently single stone is found.
If possible, an exploration of the duct should be effected
with the finger rather than with a spoon or probe. In
this way only can it be made certain that the ducts are
clear.

The statement that it is the rule to find multiple calculi
in the duct, rather than a single stone, is at variance with
the statistics of Courv^oisier, and almost all other authori-
ties. In the cases that come to the care of a surgeon
there can be no doubt whatever of its truth.

As a rule, the lower down in the duct a calculus is
found, the smaller is it. Those blocked in the ampulla
are approximately the size of a split pea. Those in the
upper part of the duct may be as large as a nutmeg.

The ducts behind a calculus are generally dilated to a
moderate degree: to a degree almost always that will
permit of the forefinger being passed along them. In
some cases the dilatation may be phenomenal, and in

Partial Occlusion of the Duct

187

Fig 45.— Biliary obstruction; cholecystenteroBtomy. The com-
mon bile-duct was occluded by a black calculus three-fourths ot an
inch in diameter, and reaching to within an inch of the papilla. The
stone shews a bifurcation corresponding to the junction ot the cystic
with the main hepatic duct, both of which are thus partially obstructed,
The gall-bladder and cystic duct are both dilated, as also the hepatic
ducts throughout the liver. Just beyond the line of suture in the
small intestine is seen a perforation {red rod). Froiii a man. aged
forty-one, who was admitted for enlargement of the liver and spleen,
with jaundice, from occasional attacks of which he had sutTercd for
fourteen years. On exploration it was found impossible to remove
gall-stones. An anastomosis was established between the fundus of
the gall-bladder and the jejunum. After death, general suppurative
peritonitis was found. The left pleural cavity contained some
sero-purulent fluid; the spleen weighed 53 ounces (Guy's Hospital
Museum, No. 14^')-

1 88 Special Symptoms in Gall-stone Disease

more than one recorded case the tumour formed has been
recognised on palpation of the abdomen and has been
mistaken for a dilated gall-bladder. In one case (Guy's
Hospital Museum, No. 141 9) the dilated common duct
had formed a thick-walled cyst six inches in diameter.
The obstruction was valvular. Terrier has recorded
three cases in which a dilated duct was mistaken for a
pancreatic cyst, a hydatid of the liver, and a distended
gall-bladder, respectively. In many cases the duct
beyond the impacted stone is dilated also, but it may be
found narrowed, or even, it is said, quite obliterated.
The wall of the dilated duct consists almost entirely of
fibrous tissue, the mucosa being thin and atrophied. The
fluid contained within the duct is always deeply tinged
with bile, and in fact consists of bile with an added
quantity of mucus. In accordance with Courvoisier's
observation, it is now generally recognised that in cal-
culus obstruction to the common duct there is rarely
any distension of the gall-bladder. On the contrary,
the gall-bladder is found shrivelled, thickened, and em-
bedded deeply in dense adhesions, in the great majority
of cases.

The symptoms of stone in the common duct are some-
times trivial and inconspicuous, and indeed are at times
entirely absent. I have twice found, during the per-
formance of cholecystotomy, that stones were present
in the common duct when symptoms were wholly lacking.
If the stone is small, or fits loosely in the duct, there may
be neither obstruction nor cholangitis, and the stone,
therefore, may never attract clinical recognition.

The symptoms are due, in part, to the mechanical

Partial Occlusion of the Duct 189

impediment in the duct; in part, to the cholangitis which
the stones excite.

Pain is present only at times. It comes, as a rule, in
attacks, which vary much in severity. The pain is dull
and aching, with, especially in the beginning of the
attack, spasmodic outbursts. As a rule, the pain is
accompanied by a rigor; the temperature runs rapidly
up to 102°, 103°, or 104°; there are shivering and collapse,
followed by sweating, and in the succeeding hours it is
noticed that the jaundice, which is persistent, has deep-
ened much in tinge. In the intervals between such
attacks as these the patient suffers little or not at all.
There is neither pain nor tenderness over the liver, and
the jaundice grows gradually paler. Jaundice, which
was described by Courvoisier as the *' cardinal symptom"
of common duct obstruction, never disappears, though
in very old-standing cases the patients may say that they
are free from jaundice, when there is still an obvious
tinge of yellow in the conjunctivae and in the skin. In
one patient, a lady, who had suffered from these ague-
like paroxysms for nine years, the skin was said to be
** sallow*' normally, and the suggestion that she was
jaundiced to a slight degree met with no confirmation.
It was only after the removal of one large and several
stones from the common duct that the 'patient became
convinced, as her skin gradually whitened, that the
sallowness was due to jaundice from which she had never
been free through all the nine years. Many patients
notice that the jaundice varies during the course of the
(lay, being lighter in the morning and becoming deeper
towards night.

igo Special Symptoms in Gali-stone Disease

I have, on two occasions, found stones in the common
duct when no symptoms were present. Kehr has said
that jaundice is absent in one-third of his cases of stone in
the hepatic and common ducts, an experience that is
almost certainly fallacious. In o\'er one hundred con-

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Fio. 46. — The "steeple" chart in a case o( stone in the

secutive operations for gall-stones I have never failed to
examine with scrupulous care the whole length of the
hepatic and common ducts, and the two instances
mentioned are the only ones I ha\'e met with.

The temperature angle in an attack is of the character-
istic "steeple" form — there is a rapid rise and a rapid

>

Partial Occlusion of the Duct 191

fall to the normal in each attack. Temperature elevation
is much more often present in common duct obstruction
when a stone is the obstructing agent than when growth
or any other form of blockage exists.

Courvoisier, in his analysis of recorded cases, found
fever in 25 per cent, of the cases of occlusion from stone,
and in only 10 per cent, of the cases of occlusion due to
other causes. The former estimate seems to me to be
considerably below the truth. If a case of common duct
obstruction be observed for a period of two or three weeks,
there will, with few exceptions, be found some abrupt
elevation of temperature coinciding with the pain, and
attacks of shivering and subsequent sweating, not of
sufficient gravity to be considered as rigors, will occur.

During an attack, and for some hours after, there may
be a slight enlargement of the liver, and the liver every-
where is tender to the touch.

In chronic obstruction of the common duct the liver
is always enlarged in the earlier stages; its increase in
size may indeed be considerable. The liver may reach
the umbilicus, or even descend beyond it. In each
attack, when a rigor and an elevation of temperature,
followed by a deepening of the jaundice, occur, an in-
crease in the size of the liver may be observed, and the
organ on handling is found to be tender. In the latter
stages the liver decreases slowly in size, and at the last
may be even smaller than the normal. According to
Mongourt, the shrinkage of the liver is the most impor-
tant sign of the degeneration of the hepatic cells.

The condition of the stools and of the urine varies from
time to time. As a rule, some bile passes always into the

192 Special Symptoms in Gall-stone Disease

intestine, so that the motions are a deep buff in colour.
After an attack there is obvious evidence, both in the
faeces and in the urine, that less bile is getting access
to the duodenum. The variations are, however, much
more readily recognised in the stools than in the urine.
The persistent presence of urobilin in the urine is held
by many observers to indicate the onset and the con-
tinuance of a process damaging to the hepatic cells. In
many cases an enlargement of the spleen is noticed, more
especially after an attack and for some days subse-
quently.

The gastric disturbances noticed in cases of gall-stone
impaction vary within very wide limits. There may be
nothing more than a sense of uneasiness in the epigastrium
and distension after food, for which there is often a dis-
taste, or, on the other hand, there may be severe vomiting
during and subsequent to the attack and a feeling of pro-
found nausea. Itching of the skin is almost constant,
as in all forms of jaundice, and symptoms of boils may
at times be noticed.

One of the most marked and characteristic symptoms
of obstruction of the common duct by stone is loss of
weight. A loss of two, three, or four stone is not infre-
quently recorded. The loss is both rapid and consid-
erable, and after a successful operation is very speedily
regained. This loss of weight was ascribed by Fenger
to ** intermittent, frequent, ptomaine intoxication, —
that is bile-absorption, — as well as to disturbed di-
gestion." It is most important that this symptom
should be recognised as a frequent and striking mani-
festation of stone in the common duct, for the haggard,

Partial Occlusion of the Duct 193

wasterl. often emaciated appearance of the patient may
strongly suggest a diagnosis of malignant disease. It

4;. — Impaction otalarj-f oval cakulus in the cxlreniity of the
n bik'Juct. a portion ol the stone projecting into the duode-
num. The patient was a very large woman, seventy years of age
For nearly six months before death she had been subject to spasmodic
pains at the stomach, which came cm with shivering, like an ague (it,
continued from half an hour to an hour, and were succeeded by
tmnatural heat- To these were added in the last month of life
frequent vomiting, great thirst, and a deep jaundice colour of the
skin. Throe days before death she was suddenly seized with un-
usually severe shivering and pain, which extended quite round the
abdomen, and continued without remission until her death. The
liver after death was found pale, soft, and fragile. The gall-bladder
contained nuTnerous small angular calculi: both it and all the bile-
ducts were distended, and all their coats were greatly thickened ; the
stomach appeared healthy (Royal College of Surgeons' Museum. No.

is more than likely that some measure of responsibility
for this symptom may rest with the pancreas, whose

194 Special Symptoms in Gall-stone Disease

secretion may be profoundly modified both in quality
and in quantity by an extension of the inflammation
from the common duct to the canal of Wirsung into the
substance of the pancreas. Chronic pancreatitis is by
no means an uncommon event in long-standing ob-
struction of the common duct, wherever the obstruction
mav be.

The characteristic signs and symptoms of stone in the
common duct, therefore, are: Persisting jaundice, which
alters considerably in depth of tinge, varying between
morning and nighty becoming markedly deeper after an
attack of pain and gradually lessening in the intervals.
The jaundice may be said to ebb and flow. Pain which
comes on in "attacks." The pain is diffused over the
whole hepatic area, is constant, and is liable to acute
exacerbations. During an exacerbation there is a rigor,
and a temperature of 103° or 104° is quickly reached, and
nausea and vomiting are present. During and after an
attack there are tenderness and enlargement of the liver,
and probably also of the spleen. Bile enters the in-
testine in small quantities, as a rule ; but after a paroxysm
the quantity, as shewn by alterations in the urine and the
faeces, is lessened. Itching of the skin is always present.
There is rarely any enlargement of the gall-bladder, and
ascites is absent, unless, as very rarely happens, there
is pressure upon the portal vein. The paroxysms are
ague-like in character and may occur with remarkable
regularity. Osier has attempted to associate a special
symptom group with ball-valve stone, which is most
commonly found in tlie ampulla of Vater.

Partial Occlusion of the Duct 195

''(a) Ague-like paroxysms, chills, fever, and sweating;
the hepatic intermittent fever of Charcot.

*' (fe) Jaundice of varying intensity which persists for
months or even years and deepens after each paroxysm.

** (c) At the time of the paroxysms, pains in the region
of the liver, with gastric disturbances.*'

The cause of the attacks is probably to be found in a
renewed attempt on the part of the duct to expel the
stone. From the dilated portion of the duct the stone
is made to enter the narrow portion, and a spasmodic
muscular contraction is set up. In this way a fresh
damage is done to the duct, tension is increased, infection
occurs, a cholangitis, or an increase of an inflammatory
condition already in existence, takes place, and the
mucosa throughout the ducts swells and narrows the
lumen. The obstruction, in fact, becomes for the time
mechanically complete, and partly for this reason,
partly because of the renewed attack of cholangitis,
the jaundice deepens. It is doubtful if an infective
process once s^t up in the common duct ever disappears
unless the obstructing agent is removed. There is al-
ways retention of bile behind the stone, and therefore
a ready opportunity for the constant proliferation of
organisms.

The existence of cholangitis is shewn by the presence
of jaundice and of fever. If a stone be lodged in the
common duct and neither of these be present, it may be
taken that cholangitis does not exist, and that the bile
is free from organisms.

In the most severe forms of infection suppuration may
arise in the duct. It is certain that infection is present

196 Special Symptoms in Gall-stone Disease

in all cases attended by the symptoms just enumerated ;
it is equally certain that the infection rarely gives rise to
suppuration. When a stone is removed from the conmion
duct, even when jaundice is marked and long-enduring,
it is, in my experience, very rare to find pus in the ducts,
however severe the clinical manifestations may have
been. Some authors, Kehr and others, talk of fetid pus
as being not uncommonly found behind a stone in the
common duct. In my experience it is almost unknown.

A suppurative cholangitis, therefore, is a rare com-
plication of impacted stone. It is also a most serious,
often indeed a lethal, one. The suppuration may ex-
tend not only along the whole length of the common duct,
but also may involve the cystic duct and the gall-bladder
(giving rise to empyema) and the hepatic ducts. In some
cases an abscess or abscesses may develop in the liver
by direct extension of the infection along the ducts. In
cases of multiple abscesses the symptoms are those
of profound septic poisoning. The temperature remains
high, losing its *' steeple" projections, rigors may occur
frequently, and the general health and strength of the
patient are rapidly enfeebled. There may be signs of
jH^ritonitis over and around the liver and fluid may be
found in the right pleura. There may be a subphrenic
abscess. The spleen becomes larger and very tender.

When the abscess is localised, a swelling on the surface
of the liver may be palpable. This is tender to the touch,
es|xvially, as Xaunyn and Osier p)oint out, during the
hours that succeed a rigor. The jaundice is not so deep,
nor are the variations so noticeable. The clinical present-
nuMit is, it will bo seen, one of a severe septicaemia, ac-

Partial Occlusion of the Duct 197

companied by signs of intense inflammation in the gall-
ducts.

A gall-stone may remain in the common duct for years.
In one of my patients the symptoms had been present
for nine years. One of the consequences of so long-
enduring an inflammation in the duct is that the head of
the pancreas may be involved by infection of Wirsimg's
duct, or, perhaps, by direct or by lymphatic infection-
Chronic pancreatitis, as was pointed out by Riedel, is a
not infrequent complication of gall-stones impacted in
the common duct. Opie has shewn that in all probabil-
ity many cases of acute pancreatitis are due to the im-
paction of a stone of small size in the ampulla of Vater.
In such a case the symptoms come on with marked sudden-
ness. They are epigastric pain and tenderness, followed*
by distension, vomiting, and collapse. The diagnosis
most often made is one of intestinal obstruction. In
acute pancreatitis, with fat necrosis, there is no in-
creased leucocy tosis ; in acute infective cholangitis there
is a marked leucocytosis.

The following are a few cases selected from a large
number upon which I have operated :

Stone in Common Duct: Duodeno-choledochotomy. — M.
A. R., female, aged forty-one, admitted March 23, 1901,
with jaundice. For eight or nine years has been sub-
ject to attacks of pain in the right hypochondriac
region, and pain after food in the epigastrium and ''right
round the body.'' Sixteen months ago for the first time
an attack was followed by jaundice. The pain came
suddenlv and overwhelmed her. She was in bed with
pain and soreness for three days. On the third day

198 Special Symptoms in Gall-stone Disease

jaundice was observed. Four months ago a similar
attack, and since then five attacks similar in character,
but varying in intensity. She was deeply jaundiced
four months ago and has been jaundiced since, though the
depth of colour has varied very much. When the last
attacks have commenced, she has felt cold and shivery,
and in a few minutes she has broken out into profuse
sweats. Nothing to be felt in the abdomen. On opening
the abdomen the gall-bladder was found shrunken and
thickened ; it was freed from adhesions, opened, and seven
sti>nos removed. A large stone was felt in the ampulla
of Vater; an attempt to push it back into the common
duct failing, the duodenum was opened and the ampulla
inciso(l and the stone removed. The duodenum was
oK>sim1 and the gall-bladder drained. The patient was
dischargtMl well on April 23, 1901.

Stottc in Common Duct: Choledochotomy. — M. A. C,
iVmale. aged thirty-three, admitted with deep jaundice
Jaiuiary 11, 1899. In May, 1899, she had an attack
wi pain in the region of the xiphistemum, passing round
tht* right side to the scapula. The pain was very severe,
PHmUicimI faintness and collapse, and was accompanied
(ind followed by vomiting. Jaundice followed two or
{\\w\} days later. Several similar though slighter at-
tacks since. For eight weeks has not been free from
jaundice, though there has been considerable variation
in its tinge. Each attack has caused profuse sweat-
ing-

( )n November 7th the abdomen was opened. The

pN'lorii' end of the stomach was found to be embedded in
iu 1 1 lesions with the under surface of the liver and gall-
Mat hler. After freeing the bladder and ducts two stones
Nvrrc felt in the common duct: one was crushed and
passed onwards into the abdomen, the other was fixed and
ua'> removed through an incision in the duct; it was of
I he si/e of a small Barcelona nut. The duct was stitched

Partial Occlusion of the Duct

and a Bantock's tube introduced. The patient was dis-
charged well on December 3d.

Stones in Common Dud: Chotedochotomy.—C \V., fe-
male, aged forty-two, admitted March 7, 1900. Patient
admitted with jaundice. For several years has had
occasional attacks of "spasms," followed by slight
jaundice. No attack has lasted more than a few hours,
and has never incapacitated her for more than a day,
or perhaps two, from her work until five months ago,
when she had a severe attack, followed by jaundice.
Pain and jaundice have been present ever since, varying
in intensity, but never very severe. During the last few
weeks has felt cold, and shivered when an attack was
impending; soon afterwards has sweated profusely.
The motions have been very pale for five months and the
urine high-coloured.

At the operation a small, thick, adherent gall-bladder
was opened and relieved of forty-six stones which lay
within it and the cystic duct. The common duct had
seven small stones in it; these were removed by a separate
incision, which was stitched up directly. The gall-
bladder was drained. The patient was discharged, quite
well, on March 31st.

Stone in Common Duct: Ckoledockoiomy. — MTS. G.,
aged fifty-eight, admitted June, igoi. The first attack
of biliary colic occurred at Christmas, i8Q6. This had
been followed by others at almost regular intervals
of three months until January, rgoi, when the severest
attack of all took place. She was confined to bed after
it for three months, and it was after this that she suffered
from continuing though varying jaundice. Shivering
was noticed on several occasions; on each the pain was
rather worse and the jaundice a little deeper.

Operation. June. 1 90 1 . — There were a host of ad-
hesions around the common duct, gall-bladder, and
duodenum. A stone was felt tightly fixed in the common

200 Special Symptoms in Gall-stone Disease

duct near the termination of the cystic duct. An in-
cision was made on to it and a stone equal in size to a
Barcelona nut evacuated. A couple of drachms of pus
followed the stone. The common and hepatic ducts
were thoroughly explored and found to be clear. A
large drainage-tube was fixed by one stitch into the com-
mon duct and the abdominal wound closed round the
tube.

After the operation there was retention of urine, and
cystitis followed upon catheterism. Healing of the
wound was delayed by cellulitis, due probably to infection
from the pus escaping from the common duct. Bile
was discharged freely from the wound for several weeks.
A year later the patient was quite well, and her doctor
informed me that **the relief from operation has been
complete."

Stone in the Common Duct: Choledochotomy, -^Miss B.,
aged fifty-five, May, 1902. Sent by Dr. Clarke, Don-
caster. Two and a-half years ago had the first attack
of jaundice, preceded by an extremely severe attack of
pain lasting two days. The jaundice passed away in
fourteen days, and afterwards she felt quite well. In
December, 1901, a similar attack of pain over liver,
passing through to the right scapula, was followed by
jaundice slight in character and lasting only five days.
After recovery from this attack she felt weak, easily
prostrated, and had a ''loathing for food." Flatulence
was distressing, and her weight gradually decreased.
Six weeks before admission a similar attack of pain,
followed by jaundice; since then jaundice has varied in
depth of tinge, but has never disappeared; pain has
varied, but a dull aching sense of oppression and weight
has always been present. She has had several shiver-
ing attacks during the last six weeks. She has lost
one and one-half stone in the last three months. The
jaundice is said by her friends to be less in the morn-

Stone in the Common Duct 201

ing, and to get gradually deeper in tinge during the day.
On examination there were tenderness and rigidity in
the gall-bladder area. Nothing definite felt.

Operation.^ A long incision was made. The gall-
bladder was found buried in adhesions thick and con-
tracted. There were many adhesions between the ab-
dominal wall, the liver, duodenum, transverse colon, and
bile-ducts — so firm and so widespread that rotation of the
liver was not possible. A stone was tightly wedged in
the common duct about one inch from its junction with
the cystic duct. As the common duct could not be
brought to the surface, it was necessary to cut down upon
the stone in the duct and to remove it with a scoop.
The stone was of the size of a nutmeg. The hepatic
and the rest of the common duct were explored, but no
other stone discovered. A large tube was fixed into the
opening made into the duct and the abdominal wound
closed ,

The tube came away on the eleventh day. The wound
rapidly healed, and the patient is now quite well and free
from pain, discomfort, and jaundice.

THE DIFFERENTIAL DIAGNOSIS OF STONE IN THE
COHHON DUCT.

In many cases, certainly in the majority, the diagnosis
of stone in the duct is correctly made with the most posi-
tive assurance ; in other cases the surgeon may waver in
his diagnosis, being uncertain as to whether a calculus
alone is present, or as to whether a stone is associated
with some other condition whose symptoms are similar,
or. finally, as to whether the symptoms suggestive of
stone are being caused by an entirely different condition.

In the characteristic case of common duct obstruction

20J Special Symptoms in Gall-stone Disease

l>y stone jaundice is always present and is remarkable
for the great variation it shews in depth of tinge. Jaun-
tliw. however, is not an invariable sign in cases where
stunw are found in the common duct during operation or
at an autopsy. Even when the blood is examined by
HHnicl's method, no yellow discolouration may be found.
In tlie absence of jaundice, however, it is almost im-
imssible to arrive at a correct diagnosis. Jaundice there-
fore is the cardinal symptom of common duct obstruction,
and is distinguished by a perfectly characteristic "ebb
ami flow" in those cases in which the stone forms a
"l>all valve," that is, in the ver\' great majority. The
"ebb and flow" is, however, in a certain number of cases
vcr>' slight, and may escape notice by the patient, or
those who are in immediate contact with the patient,
and only obtain recognition after the medical man has
given instructions for precise observations to be made.
Of all the conditions which simulate calculous ob-
struction of the common duct, probably none is so difficult
t(i differentiate as chronic pancreatitis. The frequency of
their association is now well recognised, but it is not so
generally understood that even after a stone has passed,
after long detention in the duct, the thickening of the
head of the pancreas which has been left behind may
cause a remarkable mimicrj' of the symptoms of stone.
The "pancreatic reaction" given by Cammidge's test
may. if experience prove it to be reliable, shew the ex-
istence of pancreatitis, but does not permit a <listinction
between the two diseases. It enforces, however, the
impcrati\'e need of operation, in order to prevent a
permanent and increasing damage to the pancreas.

Stone in the Common Duct 203

When the gall-bladder is distended, we know, by
** Courvoisier's law,'' that in all probability the jaundice is
caused not by stone, but by growth or inflammation press-
ing upon the duct. In chronic pancreatitis the gall-
bladder may be dilated, even when the pancreatic in-
flammation is primarily ' caused by the stone irritation.
In the first recorded cases of typhoid pancreatitis I had
diagnosed stone in the common duct from the symptoms,
yet found that the sole cause of the intermitting jaundice
was a condition of chronic inflammation of the pancreas ;
the gall-bladder was distended with bile containing an
abundance of the organisms of typhoid fever. Cour-
voisier's law, therefore, though of enormous value clini-
callv, is not invariablv true. But what law is?

CHAPTER VI.
REHOTE CONSEQUENCES OF GALLSTONE DISEASE.

The chief of these are biliary fistulae and their com-
plications, perforation of the gall-bladder into the peri-
toneum, and intestinal obstruction.

Biliary Fistulae. — Biliary fistulae may form between any
part of the bile -tract, on the one hand, and the surface of
the skin or of any of the hollow viscera, on the other.
They are conveniently classified as external and internal .
The following table, compiled by Naunyn, indicates the
frequency with which the various fistulae w^ere found in a
series of recorded cases:

Between the bile-ducts themselves 8

Retroperitoneal 4

Gastric — total 12

Gastro-hepatic 4

Between stomach and gall-bladder 8

Duodenal — total 108

Common duct and duodenum 15

Gall-bladder and duodenum 93

Between gall-bladder and jejunum i

Between gall-bladder and ileum i

Colic — total 50

Between gall-bladder and colon 49

Between common duct and colon i

Urinar\' passages 6

Thoracic viscera 10

Abdominal wall 184

This table is not supposed, even by its compiler, to

204

External Biliary Fistulae 205

represent with anything approaching accuracy the true
state of affairs. For, as Naunyn points out, fistulae of the
abdominal wall have always attracted, indeed, compelled,
observation, and other fistulae, those, for example, impli-
cating the urinary passages, are so remarkable and unex-
pected as to seem worthy of especial record. The intes-
tinal fistulae, on the other hand, produce no symptoms;
indeed, their formation always affords relief to symptoms
which may often have menaced the patient's life. They
are discovered, moreover, only after tedious dissection,
and are, therefore, on all grounds, liable to escape notice.

External biliary fistulae may be due to disease or may
follow operation. The fistula almost invariably im-
plicates the gall-bladder, and is the result of an empyema.
The suppurative cholecystitis may be due to the blockage
of a stone in the cystic duct, or be independent of calcu-
lous disease. As a result of the acute inflammation of the
gall-bladder, adhesions are formed to the abdominal wall,
the gall-bladder perforates, an abscess forms, and at
length the skin gives way. When the abscess discharges,
some or all of the gall-stones may escape from the fistula,
which may then close spontaneously. As a rule, a single
fistulous opening is present and is situated in the right
h\'pochondrium or near the umbilicus; but there may be
several fistulae, and these may open anywhere upon the
abdominal wall. A case of fistula discharging ''exactly
over the normal position of the appendix" is recorded
by Gibbon (Phil. Med. Joum., 1901). Porges (Wien.
klin. Woch., 1900, No. 26) has described a case in which
a fistula upon the thigh discharged gall-stones.

The inner end of the fistula mav communicate with

206 Remote Consequences of Gall-stone Disease

the cystic, or common, or hepatic ducts, or it may follow
the opening of a hydatid cyst or hepatic abscess, and will '
then be in relationship with the intra-hepatic ducts.
In addition to acute suppurative cholecystitis, injury
by stab or gunshot wound may be mentioned as causes.

Biliary fistulae after cholecystotomy were formerly
not infrequent. Now-a-days they are rarely seen. In
the earlier operations it was considered necessary to
stitch the gall-bladder to the skin, and a fistula was,
therefore, to be expected. Since the gall-bladder has
been fixed, as a rule, to the aponeurosis, a fistula has
become an extreme rarity.

The external opening in Courv'oisier's series of 169
cases was situated as follows:

In the right hypochondrium 49

At the right costal margin 36

On the right side of the epigastrium 17

In the right iliac region 10

In epigastrium 6

Near the umbilicus 22

At the umbilicus 12

Below the umbilicus 11

In the left groin ' i

Multiple openings i

Internal Biliary Fistulse. — These may connect any one
part of the bile-tract with any other part. Clinically, as
will be understood, they have little interest.

Fistulas between the gall-bladder and the duodenum
are common; those between the cystic duct and the
duodenum are rare ; those between the common duct and
the duodenum, far more frequent than is generally be-
lieved, owing to the fact that many cases, in reality
fistulous, have been regarded as examples of unduly large

Internal Biliary Fistiils

ampullary openings. The hepatic duct has not been
known to form a fistulous communication with any part
of the intestine.

The following is the record of a case of cysto-duodenal
fistula upon which I operated :

K. H., female, aged fifty-five, admitted February
y, igoi, complaining of pain in the right epigastric and
hypochondriac regions. The
pain is intermittent in char-
acter, comes on daily and un-
expectedly, lasts a few hours,
and then disappears. It is
three months since the first
attack ; since then the spasms
have increased in severity and
frequency. When an attack
comes on she feels cold and
faint and almost collapses.
She has never been jaundiced.
A fortnight ago a tumour ap-
peared on the right side of the
abdomen, described by the
doctor as "a hard, smooth,
globular tumour, larger than a
golf ball." No tumour can be
felt now.

Operation, on February ijth. The abdomen was
opened through the outer part of the right rectus muscle.
On exposing the gall-bladder and adjacent parts the
following condition was found. The gall-bladder was
distended with a grumous material; to its outer surface
the omentum and the duodenum were adherent; the
omental adhesions separated fairiy easily, the duodenal
with difficulty. On detaching the duodenum an opening

fierf oral ion of gall-bladder
into peritoneal cavity, prob-
ably due to calculi (Guy's
Hospital Museum. No. 1398).

±A

2o8 Remote Consequences of Gall-stone Disease

was found between it and the gall-bladder; there was,
in fact, a fistula equal in diameter to a lead pencil between
the two viscera. In the cystic duct a stone about the
size and shape of a nutmeg was found tightly impacted.
The gall-bladder, cystic duct, and stone were removed,
the cut end of the duct being ligatured close to the com-
mon bile-duct and the stump covered with peritoneum.
The opening in the duodenum was closed with sutures and
a split drainage-tube with gauze wick passed down to the
common duct. Recovery was uninterrupted and the
patient left the hospital on March 12th.

Mr. Cammidge examined the gall-bladder and re-
ported: ** Great increase of fibrous tissue and patches
of small-celled infiltration, and patches of calcified
material. No evidence of malignant disease in the ma-
terial examined."

An interesting case of cysto-duodenal fistula is recorded
by Pozzi, in which the stone was found to lie partly in the
gall-bladder and partly in the duodenum.

The gall-bladder may communicate with the stomach,
and its clinical recognition may readily be made by
observing the persistent vomiting of bile. According to
Naunyn, not more than a dozen cases are recorded.
The following is a good example:

Fistula between stomach and gall-bladder. ]Mrs. T.,
aged fifty. Seen with Dr. Galloway, Otley, April, 1902.
Xine years ago had an attack of typhoid fever. Five
years ago began to suffer from " spasms" at interv^als of a
week to a month. Jaundice followed on ever\" occasion.
Four months ago had a very severe attack which was
not followed by jaundice; the pain was acute and in-
tolerable in the right hypochondriac region and in the

Internal Biliary Fistiils 209

Fig. 49. — Shewing a large fistula leading from the fundus of the
gall-bladder into the duodenum, through which a large calculus
had passed. Other calculi are still contained in the gall-bladder.
During the passage of the gall-stones, along the intestine the adhesions
between duodenum and gall-bladder weru ruptured during the vio-
lent vomiting ot the patifnl. Extravasation into the peritoneal cav-
ity occurred. From a woman, aged twenty-seven. She suffered from
symptoms of acute peritonitis, and died in seven days. At the in-
spection the peritoneal cavity was found to contain bloody serum.
The small intestines were extensively distended from the stomach
to within a few inches of the termination of the ileum, while the
cfEcum and colon were contracted and empty. At the spot where
the distension ceased a large biliary calculus was found which entirely
filled the canal {vide Trans. Path. Soc.. vol. 1. p. jjs). (Royal College
of Surgeons' Museum No. iSiS.)

2IO Remote Consequences of Gall-stone Disease

epigastrium; vomiting was severe; after two days bile
was noticed in the vomit. From that date she has
vomited almost every day, and on all occasions bile has
been present in the vomit. For the last month she has
vomited daily between ten and thirty ounces of bile,
little, if at all, altered. She has steadily lost flesh; in
all about three stone in weight have been lost in four
and one-half months. The vomiting is not attended by
pain, but comes on suddenly, and about 'ten ounces
are ejected at one effort. The right hypochondriac
region and the epigastrium were tender. No blood was
seen in the vomit and the stomach was not dilated. The
diagnosis rested between fistula communicating with the
gall-bladder, on the one hand, and the stomach on the
other, and infra-ampullary growth in the duodenum.
The history pointed strongly to the former, and it was
that which 1 accepted.

As I was at the time suffering from a poisoned wound
of the hand I was unable to operate myself. My col-
league, Mr. W. II. Brown, in whose beds she was, kindly
undertook the operation for me. He found a fistula
betw^een the fundus of the ^all-bladder and the anterior
wall of the stomach near the pylorus. The gall-bladder
and stomach were detached, the opening in the stomach
closed, and the gall-bladder drained. The stitches used
to close the stomach opening were applied with difficulty,
as they cut through the friable stomach wall very readily.

The patient died forty-eight hours after operation,
and it was found that two of the stomacli sutures had
given way.

In some instances gall-stones have been vomited, as is
recorded by Oppolzer, Miles, Frerichs, Muri)hy, myself,
and others. Hayem has recorded a case where gall-
stones were evacuated througli a stomach-tube. Van der

Internal Biliary Flstul^e 211

Byl has related the history of a case in which gall-stones
were vomited; at the postmortem a cysto-duodenal

Fig 50. — Gall-stones biliary obstruction; choice ysto-coHc fistula.
The gall-bladder is adherent to the liver, thiclcened and contracted,
and contains a. gall-stone. The colon is adherent to the fundus, com-
municating with it by several ulcerated openings. The common
bile-duct admits the middle finger, a calculus being lodged at its
end. One and a half inches above the papilla is seen an open-
ing in the wall of the duodenum leading into the dilated duct above
the stone. From a man, aged sixty, who was admitted for slight
jaundice of sixteen months' duration and enlargement of the liver.
Death took place sixteen weeks later ; the body was deeply jaun-
diced. There was tuberculous disease of the meninges, lungs, pericar-
dium, peritoneum, and spleen (Guy's Hospital Museum, No, 14*3).

fistula was found. The duodenum is more commonly
involved than either the colon or the stomach, as might

i2i2 Remote Consequences of Gall-stone Disease

be anticipated from the anatomical relations of the parts.
The jejunum and ileum are rarely affected.

The preparatory stages in the formation of fisttdae
connecting the gall-bladder with the stomach, duodenum,
or colon can not seldom be seen during the performance
of operations. The gall-bladder may be fotmd intensely
adherent, and, in separating it, its walls may be torn or the
intestine or stomach may be opened. Or, on completely
effecting the separation, it can be seen that the walls
on one or other side are thinned and that the peritoneal
coat is wholly lost. In such conditions a fistula would
soon have developed. A further step is seen in those
cases in which the gall-stone has ulcerated completely
through the walls of the gall-bladder, but has not reached
the general peritoneal cavity, owing to the protective
barriers formed by the copious outpouring of lymph.
Such cases are recorded by Sharman (Med. Times and
Gazette, 1859), and Mr. Simon (Trans. Path. Soc, vol. 5,
p. 156) quoted two cases from St. Thomas's Hospital,
where a process of discharge of stones from the gall-
bladder had appeared to be in progress at the time of
death. In one (whereof the specimen is preserved in the
museum) there was found l^eyond the fundus of the
gall-bladder a cyst, constructed of dense cellular tissue,
communicating with the gall-l^laddcr by a small ulcerated
opening and completely filled in its interior by a con-
cretion of cholesterin. In another of such transitional
cases (Postmortem Book, October 19, 1850) the fundus of
the gall-bladder was found communicating by an ulcer-
ated opening a quarter of an inch in diameter, with a
cyst about as large as a pigeon's egg, formed of dense,

Internal Biliary Flstulae

cellular tissue, coherent with the abdominal wall an-
teriorly and filled with irregular masses of concrete
biliary matter and small calculi.

Fig. si. — Gall-stone removed from the ileum by operation. The
stone is two inches long, more than one inch in diameter, weighs
»38 grains, and is moulded to the shape of the gall-bladder. The
gall-bladder is thickened and contracted, and there is a fistulous
communication between it and the bowel, the parts being united
by firm adhesions. The anterior edge of the liver is thin and bent
back upon the upper surface of the organ. From a woman, aged
fifty, who was admitted with symptoms of acute intestinal obstruc-
tion of three days' duration, never having previously suffered from
any illness except occasional dyspepsia. At the laparotomy the
peritoneum was found to be acutely inflamed. After death which
took place seventy hours later, the incision in the piece of gut
separately shewn was found to be 13 inches above the ciEcum (Guy's
Hospital Museum, No. MSS)-

In cases where gall-stones of large size are found in the
fasces, or when intestinal obstruction results from the
plugging of the lumen of the gut. it is certain that in
almost every instance the stone has passed, not through the

314 Remote Consequences of Gall-stone Disease

common duct, but through a fistula. The largest stones
that have been known to pass are referred to subse-
quently. After the stone or stones have escaped from

Fig. 5 j.—Cholecysto- duodenal fistula; gall-stone impacted in the
ileum. The gall-bladder is thickened and contracted and firmly
adherent to the duodenum. The fistula easily admits the middle
finger. The opening into the intestine is situated about one inch
from the pyloric ring. The stone measures one and one- half by one inch .
From a woman of fifty-nine, who was admitted for intestinal obstruc-
tion. For six days she had suffered from constipation, vomiting,
and abdominal pain. Two days later an artificial anus was estab-
lished in the small intestine. Death ensued in sLi hours. The
stuie was impacted jj inches above the ileo-c^ca] valve (Guy's Hos-
pital Museum, No, 1399I.

the bile passages into the intestine, the fistulous track
may close. Roth observed one such instance. Fistulse
from the gall-bladder generally open pear the fundus,

Internal Biliary Fistulae 215

but any part down to and including the cystic duct may
be involved.

The occurrence of choledocho-duodenal fistulae is prob-
ably far more common than is generally recognised.
When the first or second portions of the duct are impli-
cated, a recognition of the fistula is easy; but when the
transduodenal portion is involved, the appearances
presented are most deceptive. If a stone be blocked in the
ampulla, it may break loose by causing ulceration of the
papilla, or of the lower part of the duct, as it lies within
the duodenal wall. The lower end of the duct then ap-
pears to open by a long slit in the duodenum rather than
by a minute orifice on a pout of mucous membrane.
Many records speak of a ** wide-mouthed termination/*
or "an abnormally large opening'* of the common duct.
In reality a choledocho-duodenal fistula is present.

There are no symptoms which are especially due to
any of these varieties of fistula. In many cases their
formation might be expected to afford relief to long-
troublesome symptoms, but their discovery, in most
cases, is a matter of chance. If, for example, an im-
permeable block were present in the common duct, the
formation of a cysto-duodenal fistula, or of a choledocho-
duodenal fistula, the former, imitated by the surgeon in
the operation of cholecystenterostomy, would give relief
to all the symptoms.

The following are the notes of a case in which a fistula
was diagnosed, with every probability of accuracy:

Dr. M. S., aged fifty-eight, had suffered for several
years from ** indigestion,** epigastric colic, and occasional

2f6 Remote Consequences of Gall-stone EKsease

%'^/miting. Seven months before I saw him he became
jaundice^l for the first time, after an attack in which the
foreg^^ng symptoms were unusually severe. The jaun-
dia- persisted, but shewe^l the ebb and flow characteristic
of ball-valve stone in the common duct. There were the
asual symptr^ms of Vjall-valve stone, rigors, sweating,
pains in and around the hepatic area, slight, transient
enlargement and tenrlemess of the liver, during the whole
of the seven months. I advised operation, in order that
the sU^ne in the common duct should be removed. \\Tiile
debating the matter an attack of colic of the usual type
Vxjgan. Three days later a stone, as large as a nutmeg,
was passerl; the jaundice, after deepening, gradually
cleared away, and for the last four and one-half years
there have been no symptoms of any kind. After the
discovery of the large stone no further search was made,
and it is, therefr>re, impossible to say whether others were

When intestinal obstruction follows speedily upon an
atUick of pain, swelling, and tenderness in the hepatic
r(»gion, and a gall-stone is recognised as being the cause
of the block, it will be clear that, in all probability, a
fistula has formed. Such cases are not unusual. Fistulae
between the gall-bladder and the colon are not infre-
quent. They may be diagnosed when a large stone is
passed i)er anum without any biliary or intestinal dis-
comfort having been observed. As a rule, the beginning
of the transverse colon is joined to the gall-bladder. As
Courvoisier was the first to point out, a cysto-colic
fistula is not seldom associated with other fistulae, cysto-
duodenal, choledocho-duodenal, and so forth. One
oxam])le of fistula between the common duct and the

Internal Biliary Fistulas 217

colon is recorded, Riedel relates a case of cysto-colic
fistula in which death occurred four hours after the per-
foration of the gall-bladder near its point of junction
with the colon. Faeces and gall-stones were found free
in the peritoneal cavity.

Among the surgical curiosities are fistulse which have
formed between the bile passages and the uriitary tract. I
have once seen a gall-stone, which had escaped from the
gall-bladder into a renal pelvis, dilated behind an im-
pacted ureteral calculus. A stone so placed may escape
into the bladder. Guterbock has performed lithotrity
and Bier lithotomy for what were found to be gall-stones.
Murchison records a case where 200 gall-stones were
passed from the bladder. In such rare cases the tract
between the gall-bladder and the urinary passages may
be very long and tortuous.

It has, indeed, been shewn that a path may be created
along the round ligament of the liver to the umbilicus,
and thence along a patent urachus to the bladder,

Pelletan records a case of gall-stone impacted in the
urethra which was pushed onwards by the pressure of a
finger in the vagina. This stone was the last of 200 little
stones that were passed within a period of eight days.

Faber records the case of a man who suffered for four
years from gall-stone disease ; calculi passed by the bowel,
and nine small and four large stones were voided with the
urine. One of these became impacted in the urethra
and the patient himself extracted it. A second stone
became impacted, and this could only be removed after
the performance of external urethrotomy. The stones
were passed between the years 1834 and 1838. The

2i8 Remote Consequences of Gall-stone Disease

patient died in 1863, ^^^ a postmortem examination
shewed the existence of a connecting strand between the
gall-bladder and the urinary bladder. The upper half
of this strand consisted of the gall-bladder, the lower
half of a patent urachus.

Abt records the case of a woman thirty years of age
who suffered for eleven months from gall-stone attacks.
Eleven calculi were passed in the urine and recovery
speedily followed.

J. Israel communicated a case to Langenbuch, which
the latter records, in which a gall-stone was found in the
urinary bladder.

Cases are recorded in which operative treatment has
been adopted by Kocher, von Bergmann, and Kronlein.
In Kronlein's case a communication existed between the
gall-bladder and the urinary bladder through a patent
urachus. The gall-bladder was removed and the urachus
closed. The patient, a woman aged fifty-six, died three
days later as a result of the giving way of the ligature
upon the cystic duct.

Von Bergmann's patient was a woman sixty-three years
of age who had suffered for eighteen years from pain and
inflammatory swelling in the right hypochondrium.
A tumour the size of a fist formed in the neighbourhood
of the umbilicus. This was opened and gall-stones were
removed from what was recognised as being a dilated
urachus. The patient recovered.

Fistulas Between the Bile Passages and the Female
Genital Organs. — In one very remarkable example re-
lated by J. P. Frank, in 1790, a gall-stone is supposed
**to have passed along a fistula between the gall-bladder

Fistula Between Bile Passages and Genitals 219

and the uterus, and to have escaped from the vagina
during labour." The case, however, is open to question.
The patient, at the age of twenty-two, had suffered, when
pregnant, from severe pain to the right of the uterus.
After confinement there was profuse hasmorrhage. Three
months later a hard, round lump was felt to the right of
the uterus. It remained stationary in size, but was very
painful during menstruation. Pregnancy occurred after
eight years, and at once the swelling increased in size and
became continuously painful. After a few weeks pus
escaped from the vagina. An incision was made into the
swelling and pus was evacuated. From this opening
pus continued to escape and the discharge from the
vagina gradually lessened. After some weeks a sudden
pain was experienced, followed by shivering, jaundice, and
convulsions. Bile was discharged from the fistula and from
the intestine. A gall-stone escaped into the vagina, and
later twenty-five were passed in the fteces. Delivery was
induced at the seventh month. The closure of tlie fistula
speedily followed. There is here no mention of the
escape of the stone during labour. The case is one either
of .vaginal or uterine fistula. More than that cannot be
said.

Two cases are recorded by Osier and Kummell in which
a stone-containing gall-bladder became adherent to the
broad ligament and the ovary. A case of biliary fistula
between the gall-bladder and the pregnant uterus is
mentioned by Faber. R. H. Lucy (Lancet, April 21,
1900, p. 1132} records a case of ovarian cyst communicat-
ing with a thickened gall-bladder containing a solitary
calculus. The contents of the ovarian cyst were bile-
stained.

220 Remote Consequences of Gall-stone Disease

Fistulse may connect the bile passages artd the thoracic
organs, A subphrenic abscess, or an intense inflammatory
deposit, may form as the result of an empyema of the
gall-bladder or an abscess of the liver. The pleura may
become adherent on the upper surface of the diaphragm,
and when the wall of the gall-bladder or of the abscess
gives way, the gall-stones may escape into the lung, and
there cause an abscess to form. Gall-stones, bile, and pus
may be coughed up, and the taste of bile may be recog-
nised by the patient. Cayley has recorded a case where
gall-stones entered the left pleura from the left lobe of
the liver ; Simons one where the mediastinum was opened ;
and Wickham Legg one in which the pericardium was
involved. Vissering and Colv6e have recorded cases in
which gall-stones were expectorated. Harley found stones
in a pleural effusion. So far, almost all such cases have
proved fatal.

Courvoisier, in his work, collected twenty-four cases of
fistulae between the bile passages and the pleura of the
lungs. Graham (Brit. Med. Journ., vol. i, 1897, p. 1397)
published ten additional cases, including two observed by
himself. In Courvoisier's series of cases a necropsy was
performed in eighteen cases ; in ten of these the fistula was
found to be secondary to gall-stones. The usual sequence
of events in these cases is (i) occlusion of the common bile-
duct; (2) suppurative cholangitis, extending upwards to
the liver and causing biliary abscess; (3) adhesions of the
liver to the under surface of the diaphragm ; (4) adhesions
of the lung to the upper surface of the diaphragm; (5)
perforation of the liver, diaphragm; and lung and escape
of bile into the bronchi.

Fistulse Between Bile Passages and Genitals 221

In a. very few cases surgical treatment has been at-
tempted. The following case is recorded by Mr. Rigby
(Brit. Med, Joum., vol. 2, 1903, p. 313):

History. — ^A female patient, aged fifty, was admitted
into the Poplar Hospital on December 14, 1902, with the
following history :

She had been an in-patient in the Radcliife Infirmary,
Oxford, eighteen months ago, owing to a severe illness
which lasted for six weeks. The symptoms, which were
acute for the first week after admission, were those
of cholangitis, due probably to gall-stones, jaundice,
pyrexia, and pain in the right hypochondriac region be-
ing present. The acute symptoms gradually subsided
and no operative treatment was carried out.

About ten days before admission she had a severe fit
of coughing, which resulted in the expectoration of some
green fluid with a very bitter taste ; since that time she
had been troubled with a persistently distressing cough
and expectoration of similar fluid. She had kept in bed
and lived on milk diet for the last ten days. She thought
she had wasted a good deal.

Condition on Admission.^-A fairly well-nourished wo-
man, looking somewhat prematurely aged. The colour of
the face appears normal, but the conjunctivEe are a little
yellow. The tongue is red and clean. She is not in pain,
but complains greatly of cough, which is frequent and
distressing. After each fit of coughing she brings up with
but little effort a drachm or two of dark-green frothy
fluid expectoration, which she says has a bitter, unpleasant
taste. She cannot lie down at all, owing to this per-
sistent desire to cough. There is no pyrexia.

The lungs on examination show well-marked signs of
emphysema, as evidenced by hyper-resonance, with pro-
longed expiration; rhonchi and rSles are audible on both

222 Remote Consequences of GaH-scooe Disease

SKies: irjt rjtSkiz sc/^i^-^s art c^ear. ^nc tre apex beat is
heard in the aorrr^ rositfon-

The alyiotren is faccid, but exarr-inari-z-r: in the re-
cumbent p^iySTiire is 'ii^ctilt, cwin? to the incessant
desire to cough. The liver can zk felt »low the costal
margin for about two fengert'reaiths. ani on percussion
dulness corresponds with this. There is no increase of
liver dulness in an upward direction. S3me tenderness is
e^'inced on palpation over its anterior margin and in
the gall-bladder region, but this is slight, and nothing
resembling an enlarged ga!!-b!a ider can be felt. Xo rub
can be felt over the liver regi-jn. The rest of the abdomen,
both to percussion and palpation, appears normal.

The spnitimi was carefully examine*! and gave the
characteristic reactions for bile, which appeared to be
j>resent in considerable quantities.

Operation. — On Februar\- 17th the patient was an-
aesthetised with A. C. E. mixture, and the following
operation performed by Mr. Hugh Rigby. A sandbag
was first placed transversely beneath the lower dorsal
region. An incision was then made in the upper part
of the right linea semilunaris, three and one-half inches
in length. The liver came into view on opening the
peritoneum. It was enlarged downwards, its edge ex-
tended one and one-half inches below the costal margin,
it appeared congested, and its anterior border was
rounded.

The fundus of the gall-bladder was seen, but the body
of this viscus was concealed from view by the hepatic
flexure of the colon, which was adherent to it and to the
inferior surface of the liver. The adhesions were care-
fully separated ; the colon was found to be firmly fixed at
r)ne point to the liver, to the right of the gall-bladder. In
separating this the wall of the gut was slightly torn ; the
r>pening was immediately closed by two Lembert sutures
of silk. The gall-bladder, cystic and common bile-ducts

Perforation into Portal Vein 223

were then exposed. The gall-bladder was found to be
empty, contracted, and its walls thickened and fibrous.
The cystic duct was slightly dilated. The common duct
was distended to about the size of one's forefinger.
Some calculi were felt low down in the common duct
behind the head of the pancreas.

An incision one inch in length was made in the common
bile-duct, above the first part of the duodenum. A good
deal of dark bile escaped, which was quickly sponged
away. By means of a finger and thumb the calculi were
squeezed up from behind the pancreas and first part of
the duodenum, and made to present in the wound in the
duct, and were then extracted without difficulty. There
were two calculi present. After their extraction a probe
could be easily passed down into the duodenum. The
opening in the common bile-duct was then closed by two
rows of sutures, one for cut edges of the wound and
another for serous covering by Czemy-Lembert method.
The gall-bladder was next sutured by silk to the peri-
toneum of the wound in the belly wall at its upper part,
and the rest of the wound closed by silkworm-gut
sutures.

The fundus of the gall-bladder was incised and a small
drainage-tube inserted, but no bile escaped at all from
the gall-bladder. A gauze drain was passed down to
the opening in the common duct through the lower part
of the abdominal wound. The calculi were facetted,
dark green in colour, and evidently composed of bile
pigment and cholesterin. The larger was the size of a
marble, the smaller, that of a hazelnut. The patient
made a good recovery.

Perforation of a stone from the common bile-duct into
the portal vein has been observed on four occasions; in
one, a stone lay partly in the pelvis of the gall-bladder

224 Remote Consequences of Gall-stone Disease

and partly in the vein; in one, a stone half an inch in
length had ulcerated into the vein adherent to the head
of a malignant pancreas; in one, there was a subhepatic
abscess; in one, a stone 2 cm. in length, composed of
cholesterin, lay in the portal vein, and other smaller
stones were foiind in the branches. Thrombosis of the
portal vein due to compression by a stone in the hepatic
or common ducts is also recorded. Ascites may be
caused by thrombosis, and also by direct pressure upon
the portal vein by the stone. In several instances stones
have been found to have ulcerated out of the bile passages
and to lie in cavities of the liver substance, or to be
confined within an abscess cavity hemmed in by peri-
toneal adhesions. I have met with several examples
of the former and with one of the latter condition, in
operations for gall-stones.

In rare instances multiple internal fistulae may be
present. Ignatius Loyola is said, upon the authority of
Realdo Colombo, to have suffered from gall-stone dis-
ease, and gall-stones were found in the liver, portal vein,
kidneys, and lungs. Morgagni remarks that the intra-
hepatic ducts were probably mistaken for the portal vein.

Internal and external fistulae may both be present,
as in the following very remarkable example recorded by
Leonard Rogers (Brit. Med. Joum., vol. 2, 1903, p. 706) :

The patient, a man, was first admitted to St. Mary's
Hospital for empyema of the gall-bladder, which was
successfiilly drained, the pus being bile-stained. The
wound healed and the patient left the hospital only to
return shortly after, coughing up bile-stained pus. This
continued in varying degree for upwards of a year, the

Fistulae into Duodenum 225

case being considered to be one of suppurating hydatid
cyst of the liver opening through the lung. Lastly, a
perinephric abscess formed and was opened, the pus being
again bile-stained, and the patient died exhausted a
few weeks later. Postmortem, the liver was found
riddled by suppuration. The bile-ducts were found very
greatly dilated above some gall-stones and full of pus.
On tracing up the dilated ducts a long probe could be
passed from the common hepatic duct through the liver
and diaphragm into an abscess in the base of the right
lung and into the right bronchus. A direct communica-
tion could also be traced between the dilated hepatic
duct and the perirenal abscess, while the scar of the
empyema wound also led through the diaphragm down
to another dilated pus-containing hepatic duct.

A case in which fistulae from the gall-bladder led into
the duodenum, the stomach, and the colon is recorded by
Naunyn (p. 152).

There is a specimen in the Museum at Saint Barthol-
omew's Hospital which shews two fistute leading from
the gall-bladder, one into the ileum the other into the
colon.

Fistulae between one part of the bile passages and
another have been observ-ed in eight cases. They are
found between the gall-bladder and the hepatic duct
(Ottiker and Fauconneau-Dufresne) or between the gall-
bladder and the common duct (Schloth). Only a path-
ological interest attaches to these conditions.

15

CHAPTER VII.
PERFORATION OF THE GALL-BLADDER.

Gall-stones, in working their way through the walls
of the gall-bladder, may give rise to various conditions.
They may ulcerate through that wall of the gall-bladder
that lies in contact with the liver and so come at last
to lie in cavities in the liver substance entirely outside
the gall-bladder, but communicating with it by the open-
ing through which the stones have escaped. This is
by no means an infrequent occurrence — one which may
pass unnoticed when cholecystotomy is performed. If,
however, cholecystectomy be attempted, it will then
be found that what seemed on first examination to be
nothing more than a greatly thickened gall-bladder is
in reality a mass of inflammatory thickening around a
fistulous track leading into the liver, in which one or
many gall-stones may be found. In my first 20 cases of
cholecystectomy I found no fewer than four in which
stones had found their way through the gall-bladder
wall into the substance of the liver.

Stones ulcerating through the surface of the gall-
bladder clad with peritoneum may have their passage
barred at the first by a mass of protective adhesions,
which have been thrown out around the gall-bladder.
In such circumstances a stone may have escaped entirely

from the gall-bladder and be found in the centre of a

226

Perforation of the Gall-bladder 227

mass of organised lymph or of omental adhesions. If
there should be an infection of this cavity, a localised
abscess will form, but suppuration does not necessarily
follow upon the perforation of the gall-bladder, for stones
which lie in adherent masses of omentum may have
caused therein no obvious signs of inflammation. In

FlO. 53. — Gall-bladder shewing stones in process of ulceration
through the gall-biaddcr; one stone is seen to be almost through
(from a successful case of cholecystotomy).

many recorded cases a "secondary gall-bladder" has
been formed around gall-stones which have ulcerated
through the walls of the gall-bladder into a mass of
adhesions. Within this space stones may lie at rest
for several years. Acute symptoms are, however,
aroused either by the onset of a virulent infection or
by the rupture of the secondary gall-bladder, or by the

i

228 Perforation of the Gall-bladder

detachment of any omental adhesion which has formed
a part of its walls. The following case is recorded by
Morton (Lancet, 1893, vol. i, p. 586):

The patient was a female, aged sixty, who gave the
following history: Two years before death the patient
suffered from slight jaundice of about nine days* duration,
without any colic. During the last year she had several
attacks of severe abdominal pain, chiefly on the right
side, with vomiting. She had never been jaundiced
during the last two years. Neither had there been any
ague-like paroxysms.

Postmortem. — The abdomen was distended, and on
opening it much orange-coloured fluid escaped and
general recent adhesive peritonitis was discovered. Just
below the liver was a cavity the size of an orange, bounded
above by the under surface of the liver and in front by
the thin margin of the liver and the omentum which
had been adherent to it. Below, it was separated from
the colon by much thickened tissue. On its inner side
lay the omentum, and on its outer side, covered by ad-
hesions between the liver and adjacent parts, lay the
gall-bladder, which opened into the cavity by an aper-
ture which would admit one or two fingers. The wall
of the gall-bladder was much thickened, and several
stones half an inch in diameter were found lying in it.
Where the omentum had before been adherent to the
anterior edge of the liver, forming the anterior wall
of the cav4ty, it had become detached, and thus the bile
had escaped into the peritoneum and set up fatal peri-
tonitis.

In the common duct, just where the cystic and hepatic
ducts join, was another gall-stone, square or nearly so,
and half an inch across in all directions. The wall of
the duct around it was much thickened, but it did not

Fic 54. — Gangrene of the gall-bladder with pcrfitration. Two
apertures are seen, through which stnnes cscapedi at the lower left-
hand comer a stone is seen presenting.

Perforation of the Gall-bladder 229

completely obstruct it, though there was very little
space indeed for bile to flow by its side. The hepatic
duct was much dilated; not so the cystic duct, which
was much reduced in length and looked more like a
foramen than a duct. There was no trace of jaundice
postmortem.

Simon (Trans. Path. Soc, vol. 5, p. 156) quotes
two cases from St. Thomas's Hospital where a process
of discharge of stones from the gall-bladder had appeared
to be in progress at the time of death. In one (where-
of the specimen is preserved in the Museum) there was
found, beyond the fundus of the gall-bladder, a cyst,
constructed of dense cellular tissue, communicating with
the gall-bladder by a small ulcerated opening and com-
pletely filled in its interior by a concretion of choles-
terin. In another of such transitional cases (Postmortem*
Book, 19 Oct., 1850) the fundus of the gall-bladder
was found communicating, by an ulcerated opening a
quarter of an inch in diameter, with a cyst, about as
large as a pigeon's egg, formed of dense cellular tissue,
coherent with the abdominal wall anteriorly and filled
with irregular masses of concrete biliary matter and small
calculi.

If a localised abscess should form, it may burrow
extensively, and open, at its further end, on to the skin
or into a hollow viscus. Stones ulcerating through the
neck of the gall-bladder or the cystic duct may cause
subphrenic or retro-peritoneal abscess, and the discharge
of bile or of stones may then make clear the origin of
the disease.

The gall-bladder when ulcerating may become ad-

230 Perforation of the Gall-bladder

herent to the stomach, duodenum, or colon, and the stone
escapes into them through an internal biliary fistula.

Stones may ulcerate into the portal vein from the
gall-bladder or any of the ducts. Four at least of such
cases are recorded.

These, however, are all chronic manifestations of the
perforation of the gall-bladder. In rarer cases the
perforation may be acute, and the gall-bladder ruptures
directly into the general peritoneal cavity. Of this
acute perforation two forms may be met with; in the
one the whole peritoneal cavity is at once invaded and
a general peritonitis is caused; in the other, more com-
mon in traumatic than in calculous cases, the peritonitis,
though almost equally severe, seems to be limited by
the mesocolon and adherent omentum to the right
hypochondrium ; the bacilli in such cases have, no doubt,
a slighter virulence. The symptoms of an acute per-
foration of the gall-bladder are those of peritonitis of
a severe and rapid form, recognised in some as beginning
in the right hypochondrium, but in many being so intense
and widespread as to leave the point of its origin a
matter of speculation.

The gall-bladder when examined is seen to present
patches of ulceration upon its inner surface. There
may be one large ulcer, similar, as Budd pointed out, in
many of its attributes to the perforating ulcer of the
stomach, or there may be several ulcers, one or more of
them being almost gangrenous in appearance, and ap-
parently ready at any moment to give way. The relief
of tension in the gall-bladder as a result of the perfora-
tion has probably saved these from rupture. The outer

Diagnosis 231

surface of the gall-bladder is maroon coloured or bright
green, and shews a rent or a circular opening or, rarely,
two or more openings. The peritoneal surface is covered
more or less imperfectly with layers of ochre-coloured
fibrin, which may be thick and tough, and almost of the
appearance of wash-leather. The peritoneum around
the gall-bladder is intensely inflamed, and upon all the
coils of intestine in the neighbourhood layers of pale
yellow fibrin are adherent. Bile is present, as a rule,
in the peritoneal cavity, being absent only in those
cases in which a stone occludes the cystic duct. Gall-
stones may be found in the peritoneal cavity or in the
gall-bladder or in both ; there may be few or there may
be hundreds. In five cases treated by operation a
stone was found in a rent in the gall-bladder.

The rent or perforation, as a rule, is at the fundus
of the gall-bladder, but any part of the wall may suffer.
The edges are thin and ragged and torn.

Diagnosis. — A correct diagnosis has been made in
certain cases by the observation of preceding phenom-
ena of gall-stone disease. Incases recorded by Naunyn,
Kuster, and others, gall-stone colic had occurred. In
one patient attacks of abdominal cramp had occurred
and had been attributed to lead poisoning. In all cases
the symptoms were ushered in by pain. The pain
resembles, very nearly, that caused by the perforation of
a gastric ulcer; indeed, in more cases than one such a
perforation has been diagnosed. The pain is sudden
in origin and is intense. It cannot often be localised,
but is said to spread over the whole abdomen. Prostra-
tion, collapse, and vomiting speedily follow, and the

232 Perforation of the Gall-bladder

abdomen, at first rigid and tense, becomes distended,
flatus ceases to pass, and the pulse becomes rapid, fre-
quent, and perhaps irregular. After a few hours the
patient may rally, having the ** interval of repose *' seen
in all forms of perforation within the abdomen. Jaun-
dice may appear, but is never deep in tinge. The ab-
dominal distension increases progressively, and free
fluid is discernible in the peritoneal cavity. In a case
related by Schabad (Petersb. med. Woch., 1896) the
patient lived twenty-five days after the time of the
perforation of the gall-bladder. In traumatic rupture,
where presumably the bile, in the absence of gall-stones,
is sterile, the duration of life may be even greater than
this. In St. Bartholomew's Hospital Museum there is
a specimen (2268) of a gall-bladder ruptured by the
impact of the abdomen against a piece of timber; the
patient lived five weeks, dying from peritonitis. Mr.
Arbuthnot Lane records a case (Lancet, March, 1894)
in which operation five weeks after the rupture of the
gall-bladder and the free escape of bile into the peri-
toneum was successfully performed.

Treatment. — Apart from operative treatment, the issue
is always fatal. The earlier the operation, the greater
will be the chances of success, though cases are related
when life has been saved when the operation has been
performed two and even three days after the catastrophe
had occurred. Much will depend, of course, upon the
virulence of the infection. The only bacteriological
examination made up to the present is that recorded by
Neck, the bacillus coli being the solitary organism found.

Mistaken diagnoses of perforated gastric ulcer, vol-

Treatment 233

vulus, acute intestinal obstruction due to a band, and
strangulated umbilical hernia have been made. One
remarkable case is recorded by Kiimmell in which a
tumour supposed to be ovarian became acutely inflamed,
peritonitis followed, and death in two days. The tumour
was found to be a distended gall-bladder.

When the abdomen has been opened and the con-
dition realised, the case must be treated on the ordinary
surgical principles. All stones must be removed and
the peritoneum cleansed. It may be necessary in certain
cases to remove the gall-bladder ; in other cases drainage
alone will be indicated. Experience is too slender to
permit of any definite rules being given.

It is clear that as soon as a perforation of the gall-
bladder is diagnosed, operation should be undertaken,
for the risks of septic infection increase with the lapse
of time.

In the earlier stages bile itself has little infectivity,
but with stagnation of the inflammatory exudation into
the peritoneum, and increasing interference with the
absorption of fluids, the culture medium becomes con-
stantly improved and the bacteria acquire an increasing
virulence. In all probability cholecystectomy followed
by free drainage will prove to be the safest method of
treatment.

Surgical treatment has been adopted in fifteen cases,
including two of my own cases. The subject is so im-
portant and so little understood that a brief epitome
of the recorded cases is given.

Case I, operated on in 1881 by Schonbom, reported
by Naunyn (Naunyn, Klinik der Cholelithiasis, p. 83) as
follows :

234 Perforation of the Gall-bladder

F., fifty years, had stiff ered some months from severe
gall-stone colic with icterus; stones not found. In one
attack sudden abatement of the colicky pain, with severe
collapse ; some hours later most violent but now diffuse
abdominal pain, severe vomiting, abdominal distension,
rapidly increasing free peritoneal exudation. On the
third day following Prof. Schonbom performed laparot-
omy at my request. An incision was made about lo
cm. long in the median line, between the umbilicus and
the symphysis, and through this was evacuated a large
quantity of slightly bile-stained serous pus. Drainage
of abdominal cavitv. After-course favourable, uninter-
rupted by any relapse. Patient lived eight years longer
in good health, without any further symptoms of chole-
lithiasis.

Case 2. — (Kiister, 1884, Congress der deutsch. Ge-
sellschaft f. Chir., 1887.) F., aged fifty-seven. Patient
had had several attacks of gall-stone colic, without dis-
charge of stones being obser\'ed. On Nov. 26th (even-
ing) violent diarrhoea with pain in neighbourhood of
gall-bladder, increasing in severity. Small, rapid pulse ;
cold sweat on face and body; gall-bladder neighbour-
hood painful and tender on pressure. There was severe
vomiting; morphia injections gave ease to the pain but
did not produce sleep. Next midday pain became most
violent, and distension and sensitiveness of abdomen were
observ^ed. In the afternoon of the next day the vomit
was coloured brown, the pulse was weaker, there was
slight icterus, and bile-pigment was seen in the urine.
In the evening an enema was given without result; the
vomiting continued and became faeculent.

The abdominal distension continued and increased.
Lavage of stomach, which yielded evil-smelling brown
fluid, gave some relief. Next day the condition was
much the same, the pulse, which had been weak, increas-
ing in tension. A second washing out of the stomach took

Treatment 235

place and operation was then decided on. The diagnosis
was not absolutely certain, though gall-bladder disease
could hardly be doubted.

Operation: Nov. 29th. Abdomen opened in the middle
line from ensiform process to umbilicus. Free bile was
seen between reddened and distended coils of intestine,
pointing to origin of the disease. By means of a trans-
verse incision across the first incision the neighbour-
hood of liver was exposed, and the gall-bladder was found
to be rather small ; bile flowed away from the fundus.
The opening was small and partly obstructed by a stone,
which was plainly the cause of ulceration and rupture.
The opening was widened, the stone removed, and the
ulcerated wall cut away on every side into sound tissue.
The gall-bladder remnant was then closed after careful
cleansing with a double row of sutures of fine catgut.
The abdominal cavity was most thoroughly cleansed,
and the abdominal wound was closed with several rows
of sutures. The effect of operation was but temporary,
symptoms of peritonitis soon returning in their former
severity. Death twenty-four hours after operation. No
postmortem allowed.

Case 3. — (Jenner-Verrall, Brit. Med. Journal, 1897, ii,
341). The patient (P., forty-four) had frequently suf-
fered from gall-stone colic with jaundice. For four days
previously there had been frequent vomiting and pain
in upper abdomen. Purgatives gave some relief, but
the abdominal distension continued. " Facies perito-
nealis" present. There was a resistant area in neighbour-
hood of gall-bladder. An incision was made in the mid-
dle line of abdomen. Coils of intestine presented, covered
with bile-stained fluid and fibrin. A perforation, about
\ cm. in diameter, was found on the under surface of the
gall-bladder. Gall-stones were found in bladder, and a
large number removed. The cystic duct appeared free.
No gall-stones were found in abdominal cavity. On

i

236 Perforation of the Gall-bladder

account of its friability, the gall-bladder was closed with
great care by sutures which passed through all layers
of wall. A second row of (Lembert's) sutures was passed
over the first. All careful precautions as to drainage
and plugging with gauze were taken. First stool passed
thirty-six hours after operation. Gradual subsidence
of abdominal distension and remission of fever. Patient
discharged cured after forty-four days.

Case 4. — Allmann, 1897 (Allmann, Ueber Perforation
der Gallenblase in die Bauchhohle, Wiener med. Wochen.,
Nos. 25, 26, 1899). Patient, M., aged forty-two. There
had been previous frequent attacks of colic which had
been mistaken for lead colic. Another violent attack was
experienced six days before the patient came into hos-
pital. The abdomen was sensitive to pressure in neigh-
bourhood of gall-bladder. An injection of morphia gave
temporary relief. Next morning there were violent
pain and slight collapse. Abdominal distension and con-
stipation were present. Abdominal section was carried
out forty-eight hoiirs from beginning of illness. An
incision was made parallel with the right costal arch,
one fingersbreadth below it. The presenting intestines
were distended and covered with somewhat viscid J3uid
and here and there with small clots. The gall-bladder
was small and very shrivelled; on its anterior surface
there was a perforation, the opening being about the
size of a cherry kernel; in it the stone was fixed. No
stones were found in the abdominal cavity. Chole-
cystectomy was performed. The cystic duct was liga-
tured and the peritoneum sutured over the stump.
Abdominal cavity drained with strips of iodoform gauze,
and the wound, except at the point where the iodoform
gauze was projected, was sutured with three rows of
stitches. In the evening patient's condition was fair;
he vomited once in the evening and twice in night;
hiccough was present the following morning. Abdomen

Treatment 237

was much distended and most sensitive to pressure.
The abdominal cavity was again opened, as it was clear
that septic peritonitis was present, and some fluid which
had collected in Douglas' pouch was mopped out. The
patient died next morning. The gall-bladder was re-
moved and found to be packed with stones, and a larger
stone was found impacted in the cystic duct.

Case 5. — (Allmann, loc. ctt., 1897.) F., fifty- three.
Suddenly attacked with violent pain in neighbourhood
of liver, and repeated vomiting of yellowish material;
jaundice not present. There had been two similar
attacks previously. When the patient came into hos-
pital she was suffering from dyspnoea and was without
fever; the pulse was small and frequent; the abdomen
was distended, on left especially. Palpation showed
greater resistance in right hypochondrium, commencing
within right mammary line, and especially under costal
arch, with great sensitiveness to pressure. Percussion
revealed duiness corresponding to area of resistance. A
diagnosis of perforation of gall-bladder being made,
laparotomy was performed. An incision was made from
the ensiform cartilage parallel to the right costal margin.
The peritoneum appeared everywhere inflamed, reddened,
and covered with bile-stained, viscid fluid. The gall-
bladder, nowhere adherent, was small and perforated.
Nine gall-stones were found between coils of intestines.
The abdominal cavity was cleansed with tampons, and
the gall-bladder was sutured. The abdominal cavity
was plugged with iodoform gauze in direction of gall-
bladder, and drained with iodoform gauze in different
directions. The abdomen was sutured up to the point
from which the gauze projected. Next day the patient
was better, but hiccough and abdominal distension per-
sisted ; on the day following the vomiting and hiccough
ceased and the pulse was less rapid. On third day dis-

238 Perforation of the Gall-bladder

charge of flatus. All drainage ceased by seventeenth
day; on twenty-fifth the patient discharged cured.

Case 6. — (Hochenegg, Ein Fall von Perforation der
Gallenblase gegen die freie Bauchhohle, geheilt durch
Operation, Wiener klin. Wochen., No. 21, 1899.) F.,
forty-five. Patient admitted Jan. 26, 1899. Two days
previously the patient had vomited after a heavy meal.
The vomiting was violent, and the ejecta consisted of
food and later of bile. Symptoms of illness not ascribed
to presence of gall-stones. On Jan. 26th, after an ener-
getic forward movement, there came on suddenly violent
abdominal pain, collapse, and constantly increasing symp-
toms of peritonitis. These were followed by abdominal
distension. Intestinal obstruction due to volvulus of
sigmoid flexure was suspected. After some hours a
tense swelling appeared, giving tympanitic percussion
sound, and was regarded as a twisted coil of intestine.
Temperature normal; pulse 96; diaphragm stationary;
respiration frequent. There was an umbilical hernia
which was for the most part reducible. Much sensitive-
ness in region of upper abdomen. The abdomen was
opened in middle line; the transverse colon was seen
to be enormously distended. In the attempt to free
the omentum from it two litres of yellowish, viscid,
bile-stained fluid escaped from the upper part of the
abdomen. In the gall-bladder, at about the middle, was
found a rent about i cm. long by + cm. wide, partly
blocked by a stone which was blackish brown in colour.
From the perforation bile was slowly trickling ; the gall-
bladder was of normal size though the wall was thick-
ened; it was not infiltrated with bile nor inflamed. The
rent was sutured and a fresh opening made at the fundus.
From here seven stones about size of hazelnut were
removed. The abdominal cavity was cleansed and the
fundus of the gall-bladder traced to the abdominal wall;
a drainage-tube was inserted in the gall-bladder. Two

Treatment 239

strips of iodoform gauze were introduced into abdominal
cavity, and rest of laparotomy wound closed. After
eight days the tampon was removed from abdominal
cavity; after fourteen days, the drainage-tube. In
another six days the gall-bladder fistula was closed.
On thirty-second day patient discharged cured.

Case 7. — fKonig. Deut. med. Woch,, 1902, No. 7.)
A woman, until then healthy, was taken ill late one
evening with internal pain and vomiting, etc. The
stomach was found to be distended, sensitive to pressure,
with painful swelling, the size of a hand, to right of um-
bilicus. Volvulus was suspected. On reception into
hospital there were noted a rather wasted appearance,
a foul tongue, and occasional sickness. Later, no sick-
ness, but hiccough. Xo spontaneous passage of faeces ;
abdomen unevenly swollen, mostly on the right and some-
what beneath the umbilicus; here there was slight
resistance. There was e^'erywhere sensitiveness to pres-
sure, and the peristaltic movement of intestines was
neither visible nor audible. When the abdomen was
opened in the middle line, an omental cord which pro-
ceeded from region of umbilicus to inner right inguinal
ring was seen and was ligatured off. The fluid in ab-
domen was distinctly bile stained, and on extension of
incision upwards over umbilicus blood coagula were
visible on reddened intestinal loops, and in several places
large dark gall-stones. The ascending colon was fixed
by numerous old adhesions. The gall-bladder was found
to be unusually large, lengthened, and thickened on its
inner side; about two fingersbreadths from the fundus
a rent was visible, surrounded by blood coagula; the
opening was about the size of the tip of the finger, and
was closed by a round brown gall-stone. A transverse
incision was now made in the right rectus muscle. The
gall-bladder contained several stones; the ducts were
free from them. The general abdominal cavity was en-

240 Perforation of the Gall-bladder

tirely free of pus. The gall-bladder was separated from
liver and removed with several stones. The abdominal
cavity was cleared of gall-stones which lay near the rent,
and the abdominal wound was closed without either
drainage or tamponading. On second day after opera-
tion there was slight but distinct icterus. During the
first two days the pulse (128) and the temperature (on
one day up to 38° C.) were raised. Then both declined.
Flatus passed on the day after operation. The wound
healed without reaction so that patient got up at end
of three weeks and could go home.

Case 8. — (Von Arx, Ueber Gallenblasenruptur in die
freie Bauchhohle, Correspondenzblatt f. Schweizer
Aerzte, Nos. 19 and 20.) F., forty-eight. Patient had
had some pain for eight months; there was a violent
attack on March 23,' 1902, and again another attack two
months later; in both, cramp and vomiting; and in the
last, constipation after severe diarrhoea. On May 14th
the gall-bladder was palpable to below the umbilicus.
Morphia and opium gave relief for one day. On May
15th, after a vain attempt at defaecation, the patient
became aware of something suddenly giving way. There
were alarming pain, meteorism, and vomiting. An in-
jection of morphia was given. The tumour was no
longer palpable. There was no jaundice. About twenty
hours after the onset of perforation a median incision
was made. There was a copious outflow of mucous
bile with shreds of fibrin from abdominal cavity, and bile
was seen between the coils of intestines which were in-
jected, distended, and adherent. The gall-bladder was
wholly collapsed, non-adherent, and its wall was thick-
ened. Below, at the neck of bladder, was a perforation
2 cm. in length with necrotic edges; just behind it was
found a stone the size of a nutmeg. The fundus was
opened; the stone extractetl. Freshening of superficial
openings and suture of same. Abdominal cavity cleansed

Treatment 241

with hot, sterile saHne solution. Drain with tampon
inserted in gall-bladder, which was sutured to the parietal
peritoneum; an iodoform gauze drain was placed below
the bladder. The patient recovered, and at the time
of publication of this case the biliary fistula was com-
pletely closed.

The following case is recorded by Mr. G. P. Newbolt
(Lancet, May 31, 1902, p. 1534):

Case 9. — A married woman, aged forty-eight, was

seen on March isth. She was very ill, and evidently
had some grave abdominal lesion. She had suffered
for some years fri>m attacks of dyspepsia but had never
had hrematemesis or jaundice. For about a week before
she had dyspepsia and for two nights had not slept on
account of the pain referred to the umhilicus. During
this time she had only taken a little liquid food. At
10 A. M. on March 15th she was seized with agonising pain
at the umbilicus which caused her to double up and
collapse. Three hours later the pulse was no, feeble
and compressible; the abdomen was not distended, but
was hard like a board and tender all over, and her tem-
perature was 103°. The liver dulness was present.
The abdomen was opened in the middle line above the
umbilicus. Yellow, turbid, serous fluid was seen amongst
the coils of small intestine. Thorough examination of
the stomach, back and front, revealed no perforation,
and so it was distended with a pint of water passed
by means of an cesophageal tube. The fluid did not
escape. The incision was therefore enlarged down below
the umbilicus. On introducing the hand into the right
flank, a large gall-stone was felt in the cystic duct, and
a much distended gall-bladder, adherent to the liver,
which was enlarged. There was a minute hole in the
gall-bladder from which thin, puriform fluid was escap-

242 Perforation of the Gall-bladder

ing, A transverse incision was made into the rig^t loin;
the gall'bla/lder was exposed and opened freely and six
large st//nes were removed, one being impacted in the
cystic duct. It was necessary to cut away the sloughing
part of the gall-bladder, which was behind and to the
inner side of the fundus; the edges were then inverted
and sewn ovc*r, completely closing the cavity. Ha\Tng
th^/r^/ughly cleansed the abdominal cavity, a gatize pack
was left in leading down to the gall-bladder, and the
right flank was drained by placing a tube below the
kidney. The patient stood the operation well and pro-
mised at first U) make a good recovery; she sank, how-
ever, five days after the operation, apparently from ex-
haustion. There were troublesome vomiting and slight
distension unrelieved by salines or enemata.

The following case is recorded by Lediard (Lancet,
July 4, 1903, p. 21):

Case 10. — The patient was a female, aged forty-seven,
who sufTered from jaundice, fever, and tenderness in the
region of the gall-bladder. Attacks of biliary colic had
lasted on and of! for three years, but generally yielded
to hot ai)plications and opium, and were not followed
by jaundice, bile-stained urine, or chalky stools. When
I first saw her, on March 26th, the abdomen was fiat, but
when 1 went to operate upon her gall-bladder a week
later, the abdomen was swollen and a tumour of the
size of an adult head existed in the middle line of the
abdomen, the highest point of distension being rather
below the umbilicus. It was clear that something had
alliMvd the ai^ix\iranoe, and in consequence the incision
l>latmod was changed to a cut in the middle line over the
swelling. On reaching the jx^ritoneum, matted omentum
and recent jvritonitis were met with, and on passing
the linger mnvards towards the liver, a gush of thick

Treatment 243

yellow bile escaped over the wound to the amount of
some half a dozen ounces, On swabbing the discharge
the upper surface of the liver was seen lying outside
the gall-bladder. After the bile had been removed with
swabs I enlarged the perforation with scissors and re-
moved thirteen small gall-sti:)nes, packed the gall-bladder
with gauze, and cleaned the abdomen. The perforation
was invaginated and stitched with Lerabert's sutures,
one suture passing through the edge of the liver, owing
to rottenness of the gall-bladder wall. The entire ab-
domen was now flushed out with salt solution, and the
wound was then closed absolutely. The patient suffered
from shock and had a subnormal temperature for a few
days and was fed rectally for some five days, but made
a good recovery.

The three following cases are recorded by Neck ; the
notes of the last two having been sent to him by Wiegel
of Nuremberg:

Case II. — F., forty-two. Patient admitted on August
a8, 1902. The illness had begun with gastric catarrh,
vomiting, and finally severe and general abdominal pain.
Umbilicus distended and very painful. Peritonitis was
present. The diagnosis lay between strangulated um-
bilical hernia and disease of- gall-bladder. The patient
had suffered from general malaise and vomiting for three
days, and also from pain below the right costal arch
and about the umbilicus. On the morning before her
admission her pain became suddenly worse; it extended
all over the abdomen, which was much distended. Res-
piration became rapid, and there were all the signs of a
sudden peritonitis. It was probable that there was some
affection of the gall-bladder, but an absolutely certain
diagnosis was not possible, owing to the presence of a

244 Perforation of the Gall-bladder

small umbilical hernia which might prove to be strangu-
lated. These were the circumstances that led to the
abdomen being opened in the middle line. As nothing
was found in the hernial sac, the gall-bladder was ex-
amined, and disease of the gall-bladder was indicated
by the presence of the peculiar mucous (though not bile-
pigmented) pus, coming from the right side of the ab-
domen.

Operation: The abdomen was opened in middle line
by an incision commencing at ensiform process and
terminating 5 cm. below umbilicus. An umbilical hernia
about size of plum was opened. Neither intestine nor
omentum was found in the hernia sac, but muco-puru-
lent fluid in large quantity was evacuated from right
side of abdomen. The presenting coils of intestine
were all reddened and markedly distended; on some
coils to the right were seen fibrinous layers in patches.
By means of an oblique incision above the umbilicus
taking a course parallel to tlie right costal arch, the re-
gion of the gall-bladder was laid open. It w^as here
specially, between the intestinal coils of the right side
of the abdomen, that the mucous pus was present. The
gall-bladder was not increased in size; at the fundus
there was a perforation of the diameter of a pea; its
edges were thin and irregular. The lower surface of
liver as well as part of stomach was covered with fibrin.
From the orifice of the gall-bladder only a little pus was
evacuated.

The abdominal cavity was cleared of the muco-puru-
lent contents as far as ix)ssihle by sponging; no gall-
stones were found in it. The gall-bladder was isolated
by gauze compresses, and the opening already present
in it was slightly enlarged after it had been found, by
sounding, that there were gall-stones present in the
bladder. Xo stone was seen in the perforation opening.
Twelve facetted gall-stones, size of hazelnut, were

Treatment 345

extracted. No flow of bile. Mucous membrane much
swollen, coloured dark-red, showing ulcers at se\'eral
points. An attempt was made to stitch the gall-bladder
to the abdominal wall, but owing to the friability of the
walls the stitches cut through. A tube was introduced
into the gall-bladder and the wound was left unsutured.
The patient slowly recovered, bile ceasing to flow from
the wound at the end of the fifth week.

Case 12. — M,, forty-five years old, who had had for
years numerous attacks of gall-stone colic, and on this
account was treated medically in different ways. Patient
had also visited Carlsbad. On August 2 ad he had severe
tearing pain in right side of abdomen. After this, severe
pain over the whole abdomen set in. The pulse was
very small and rapid. Perforation of gall-bladder was
suspected. Dr. Wiegel was called in to operate. The
pulse was rapid and small. The abdomen was as hard
as a hoard and very sensitive to touch.

In the abdominal cavity was a quantity of blood,
partly coagulated, partly fresh. Between the intestinal
loops were numerous gali-stones. The gall-bladder was
enormously enlarged — to about the size of a goose's egg.
On the side of it, adjoining the under surface of the
liver, was a rent about 6 cm. long which had passed
through the whole wall of the gall-bladder. The tear
was bleeding severely. Haemorrhage was stayed by-
pressure. Afterwards the gall-bladder was opened in
the fundus. After opening it was found to be filled with
coagulated blood. All the stones and blood clots were
evacuated from the abdominal cavity, and gall-stones
were removed from the gall-bladder and cystic duct.
Afterwards the gall-bladder was packed with gauze, and
the fundus of the gall-bladder was sewn to the abdominal
wound. A drainage-tube was inserted and the abdominal
wound was partially closed by suture. Saline infusion.
After the operation the pulse rose a little. On the next

246 Perforation of the Gall-bladder

day general condition was bad; towards evening signs
of peritoneal irritation set in. Death followed on August
25th, with symptoms of peritonitis.

Case 13. — F., aged forty-two. Patient stated she had
suffered from ** catarrh of stomach" three years pre-
viously. For some years past had had pain nightly
in right side of abdomen. Present illness (1903) com-
menced with severe rigor at midday, lasting two hours.
Towards evening violent pain set in on right side of
abdomen. Some jaundice supervened, varying in
amount. Stools regular. On September 5 th, sudden
accession of pain in great severity. Jaundice increased
and pain became general over abdomen during next
five days, up to reception of patient into hospital. Stools
ceased two days before admission. Flatus was not
passed, and vomiting, which became faecal in odour, set
in.

The usual signs of peritonitis were predominant, the
abdomen becoming tense, distended, and sensitive to
touch, especially so beneath right costal arch. Abdom-
inal dulness from free effusion. No tumour palpated.
Respiration hurried. Pulse 126 per minute and small.
Temperature 38^.

Three hours after admission, abdominal section, under
chloroform, incision being made from umbilicus to sym-
physis pubis. Bile-stained fluid evacuated. Incision
therefore i)rolonged u]^wards o\er umbilicus. Above
umbilicus transverse incision to right made. Large
quantity of bile-stained fluid welled up everywhere
between coils of intestine. Gall-bladder could not be
located. In ductus choledochus was felt round hard
body about size of cherry (gall-stone).

On account of patient's bad condition radical opera-
tion not undertaken, iodoform gauze strips being in-
serted in abdominal cavity. Abdominal wound closed
by suture in middle line. Opening made for drainage

Treatment

in right lumbar region. Saline infusion injected
camphor administered subcutaneously every two hours.
Next day pulse stronger, but more frequent (
Vomiting ceased, but distension still persisted.

Change of bandage on September 13, as bandages
soaked with bile. Abdomen still distended and
siti\'e to touch. One attack of vomiting, and for first
time, still of liquid consistency and whitish-grey colour.

Plugging changed September i6th. General improve-
ment in condition from this date up to October 8th, when
general symptoms of gall-stone colic (violent pain, rigor,
vomiting, etc.) returned with accession of icterus. At-
tacks continued to October 13th.

Operation undertaken under chloroform for attempt
to remove stone impacted in ductus choledochus. Granu-
lations of wounds pared off. Wounds wiped with iodo-
form tincture. Rectangular incision made, one side of
which reached from middle line above umbilicus to
the right as far as prolongation of anterior axillary- line ;
the other took a course downwards to the centre of
abdomen. Triangular flap thus formed folded back,
and adhesions between parietal peritoneum, omentum,
colon, liver, and stomach detached. Between stomach
and liver was found layer of tissue about i mm. in thick-
ness, which might have been either organised pseudo-
membrane or remnant of degenerated gall-bladder.
On pressure with blunt instrument inwards, clear bile
fluid was evacuated from this region. Layer of tissue
above mentioned was remo\'ed. At lower surface of
liver, portion of tissue of similar appearance remained
behind. Gall-bladder could not be located with cer-
tainty. After stomach had been detached from liver
it was possible partially to unfold Hgamentum gastro-
hepaticum (lesser omentum), and by separating the
adhesions behind it to introduce finger-tip into bursa
omentalis. Round hard stone, size of cherry, in chole-

247 ^^1

ours. ^^H

were ^^H

sen- ^^H

J

248 Perforation of the Gall-bladder

dochus was now felt ; it was easily movable, now slipping
behind duodenum, now upwards to ductus hepaticus.
It was finally fixed and cut do^\Ti upon. Incision of
about 3 cm. had to be made. After removal of stone
abundant flow of bile. India-rubber tube introduced into
hepatic duct, over which the choledochus wound was
closed, up to point of exit of tube, by means of thread
and catgut suture. Plugging with iodoform gauze around
drainage-tube.

Towards evening there was secretion of bile in larger
quantity through drainage-tube. Patient vomited but
once after operation, and then no more. Secretion of
bile through drainage-tube gradually diminished and
then ceased. Patient left hospital with abdominal
bandage and free from discomfort on November 26th.

Case 14. — The following case was recorded by me in
the British Medical Journal, November 8, 1902:

Phlegmonous Cholecy stilts: Perforation of Gall-blad-
der. — M. A., aged forty-six; male. Patient seen with
Dr. Erskine Stuart, Batley. Had been perfectly well
up to December 31, 1900. On that day he had a sharp
attack of pain in the right hypochondriac region about
an hour after his evening meal. He felt sick and cold,
vomited several times, and could only obtain ease by
doubling himself over the back of a chair. He was
given a large dose of opium and put to bed. The next
day he was slightly jaundiced ; the day following more
so, and the jaundice has persisted. Pain in the right
hypochondrium has been constant — relief had only been
obtained by opium administrations.

On examination, January 11, 1901, the patient was
found moderately jaundiced and looking ill. The ab-
domen was full and prominent; the whole right hy-
pochondriac region was hard, strongly resisting, tender

Chronic Perforation of the Gall-bladder 249

on pressure. The muscular protection was so effective
that no deep examination was possible. A diagnosis
of cholangitis and cholecystitis, depending possibly upon
calcujus, was made. The rigidity and tenderness were
supposed to be due to a localised peritonitis, possibly
dependent upon distension of the gall-bladder as a result
of obstruction of the cystic duct.

The abdomen was opened on January 12th by an
incision through the right rectus muscle. On opening
the peritoneum bile-stained liquid with flocculent masses
of lymph flowed from the wound. At the least three
pints of fluid were removed. A collection was found
between the liver and the diaphragm, the fluid there
being thick and semi- purulent. An examination of the
gall-bladder disclosed the cause of the condition. The
gall-bladder was thickly coated with lymph, was deep
purple in colour, and showed a sloughing opening on
its surface from which bile-tinged fluid was oozing. The
opening was about one and a quarter inches in diameter;
its edges were ragged and a little thickened. In the
gall-bladder seven stones were found; an eighth, the
largest, was discovered later in the upper part of the
renal pouch, partly buried in lymph. The cavity was
cleaned up as well as possible, the gall-bladder opening
trimmed, and a drainage-tube secured in it; the sub-
phrenic abscess was separately drained and a tube was
alsi> passed in through a stab wound in the loin.

The patient, whose condition was bad before the
operation, died, gradually declining in forty -eight
hours.

Many cases of chronic perforation of the gall-bladder,
with abscess, have been recorded. As a rule, the abscess
cavity lies between the gall-bladder and the abdominal
wall, and it is only after the evacuation of the pus that

250 Perforarion of the Gall-bladder

gall-stones are found and a rent in the gall-bladder dis-
covered.

The following interesting case is recorded by Wendel
^Annals of Surgery, vol. 27. p. 199):

The r>atient, a woman, twenty-three years of age, had
an extremely movable ovoid tumour in the upper part
of the mesogastric and left lumbar regions; the lump
was five inches in length and three inches in breadth;
it was clearly cystic. The patient was seen on several
occasions, and on each the tumour was found in a differ-
ent fKjsition in the abdomen. After nine months a
tcnrlcr swelling was found in the right hypochondrium.
There had been a sudden seizure of severe pain in the
rij^ht iliac rej:^ion, faintness, vomiting, high fever, and
abdominal rlistonsion. Operation was declined, and the
patient gradually recovered from her serious condition,
btjt six months L'lter she consented to operation on
accotint r)f i,h(; distress caused by the lump in her side.
All ificii.ioii was made in the right semilunar line, over
the mni.t, pn;ijiin(!nt ])art of the swelling. As the knife
\H']u-U'iiU'(\ the. thickened ])eritoneum, pus welled up
Irrely, the opening' was enlarged, and several ounces of
stiiikin^^ piij; and stivcral gall-stones were evacuated.
The hn^^rr drilncd .-ni al )scess-cavity communicating with
the ^'.;dl hliiddcr, which luid a perforation about one
inch in Imj'th ;ind one lialf inch in breadth on the pos-
trin exti'inal ;is|)ccl of its body. The viscus was filled
willi y.i\\\ f.lnni's. 'I'hc ^all-bladder was loosened from
ihr adhesion'., a portion of the adherent omentum tied
(ill and lenioNi-d. 'IMie cystic duct was found to be
ii\H' et^dilh inch in diameter, throe and a quarter inches
ni h'nf;tli loHn ihe anttM'ior border of the liver to the
ni'ik. .n\d \e!V nnich twisted. The peritoneal invest-
nu*nt ol tlu- duel pri'SiMUcil a niesonieric development

Chronic Perforation of the Gall-bladder

about two inches in length, which was attached to the
inferior surface of the liver. The neck of the gall-
bladder was obstructed by the largest of the concretions.
The duct was divided at the anterior border of the
liver, inverted, closed with a fine catgut suture; the
peritoneum was finally closed over the stump. The sac
contained 213 gall-stones.

I have operated upon the following case:

The patient was a female, aged thirty-nine, who was
admitted to the Infirmary under my care. She had
suffered for years from attacks of pain accompanied by
vomiting and soreness of the body. There had never
been jaundice nor any symptoms which were attributed
to gall-stones. Hsematemesis was said to have been
observed on two occasions. While in the Infirmary
she was seized with an acute attack of pain with rigor,
a temperature of 104°, coIUipse. and vomiting. The
abdomen was a little distended and there were exquisite
tenderness and rigidity over the gall-bladder area. Her
condition improved rapidly, but a stiffness of the ab-
domen remained. The upper part of the right rectus
was rigid for the four days which intervened between
this attack and the operation. I opened the abdomen
through the right rectus and found the gall-bladder
inflamed and adherent. On separating the omentum
from its inner side an abscess cavity about the size of
a hen's egg was disclosed, and in this five small gall-
stones were lying. The opening into the gall-bladder
would admit a lead pencil. It was near the fundus. I
enlarged the opening and trimmed its edges. Over sixty
stones were removed from tlic gall-bladder. A drainage-
tube was introduced into the gall-bladder and a separate
gauze-drain was placed in the abscess cavity. The pa-
tient made a speedy recovery.

CHAPTER VIII.
INTESTINAL OBSTRUCTION DUE TO GALL-STONES-

The obstruction of the intestine by a gall-stone is
an infrequent occurrence. At the Leeds General In-
firmar\-. where probably more cases of gall-stones are
operated upon than in any other British h<:>spital. we
have had only one case during the last ten years.

Barnard Annals of Surger\'. August, 1902"^ found that
during eight consecutive years 360 cases of intestinal
obstruction were operated upon at the London Hospital ;
among these were eight examples of gall-stone ileus.
The proportion of cases of obstruction due to gall-stones
to other forms is said by Fitz to be i to 13. by Leichten-
stem, I to 2S. The average age of patients is from fift>'-
five to sixty years, and women are artected five times
more frequently than men. the youngest being twenty-
seven Path. Soc. Trans., vol. i. p. 2^^'. In 120 cases
obser-.e*! by Xaunyn, five patients were imder thirty',
seven between thirty and forty, and ninety-six between
fort>'-one and sixty. The gall-stone which causes the
obstruction may ulcerate through the gall-bladder into
the stomach. ver\* rarely ^Jeafterson. British Medical
Journal. May 30. iS68». the duodenum: most commonly,
the jejunum or the colon. Cysto-duodenal fistulae are
more frequent than all other forms of gall-bladder fis-
tula-. Xaimyn. in 30 fatal cases, found a duodenal per-

2^2

Intestinal Obstruction Due to Gall-stones 253

foration in a8, and a perforation into the colon in the
remaining two. The passage of a
stone from the gall-bladder into
the duodenum is obviously more
likely to cause ohstniction than
the passage into the colon. In
rare cases the gall-stone may have
passed down the common duct,
which is then considerably dilated.
Such a case is recorded by Aber-
crombie, who says; "The com-
mon duct was enlarged so as easily
to admit a finger." (Diseases of
the Stomach, etc., p. 134.) The
following brief notice is recorded
by Lynn Thomas:

"A gall-stone passed through
the common bile-duct without giv-
ing rise to obstruction, and got
impacted in the ileum about one
yard from the ileo-cscal valve,
and caused death from obstruc-
tion within three days. I got it
through an insurance company
questioning the cause of death of
a man who was struck on his right
side whilst getting into a dogcart
through his horse running away:
slight umbilical pain came on at
once, and passed off for a short

time, to recur and develop within twenty-four hours into
a case of acute intestinal obstruction. I made the ne-

FiG, 56,— Th-(. Inrge
and articulated calculi
which were passed nat-
urally. The larger meas-
ured one and a half
inches in extreme diame-
ter, and weighed 2 50
grains; it has a second
facet, indicating the
presence of a third cal
cuius From a lady,
aged forty, who
cred after
days' symptoms of
testinal obstruction.

She lived fourteen years
attenvards (Royal Col-
lege of Surgeons'

254 Intestinal Obstruction Due to Gall-stones

cropsy nine years ago ; no operation had been performed.
The stone is remarkable as being conico-cylindrical in
shape, like a pom-pom shell; it is one and five-eighths
inches in diameter and its point had travelled in front.
There were no adhesions around the gall-bladder and bile-
duct/'

Leichtenstem and other writers have recorded cases
of blockage of the bowel by concretions which consisted
of a gall-stone nucleus and a laminar deposit of salts.
The very great majority of gall-stones which cause
obstruction have passed through a fistulous communica-
tion between the gall-bladder and the duodenum. The
stone may obstruct the duodenum, the jejunum, the
ileum, the sigmoid flexure, rarely the colon. The small
intestine from the duodeno-jejunal angle to the ileo-
caecal valve gradually narrows in calibre. A stone
therefore which causes obstruction high up in the je-
junum will be, as a rule, larger than a stone which blocks
the ileum near its termination.

If a stone, therefore, escapes from the duodenum, it
will most probably be arrested near the ileo-caecal valve.
In 32 cases quoted by Leichtenstem the stone was found
in the duodenum or jejunum in 10 cases, in the middle
ileum in 5 cases, in the lower part of the ileum in 17
cases.

Courvoisier found the obstruction in the duodenum
and jejunum in 21.4 per cent, of cases; in the ileum in
65.4 per cent. ; at the ileo-caecal valve in 10 per cent. ; and
in the sigmoid flexure in 2.4 per cent. In rare instances
the stone may cause symptoms of obstruction by becom-
ing impacted in the colon (Korte, Berl. klin. Woch.,
1893, p. 690) or in the sigmoid flexure.

Intestinal Obstruction Due to Gall-stones 255

The obstruction in the majority of instances is due
to the actual plugging of the bowel by the calculus.
When the gut is opened, the stone seems to lie upon a
sort of diaphragm which is caused by the sudden nar-
rowing of the gut at the lower margin of the stone, for
the bowel below the obstruction is generally quite flaccid,
thin, and empty. It would seem that in exceptional
instances a volvulus may be due directly or indirectly
to the blocking of the intestine by a gall-stone. The
following instances are recorded by Mayo Robson (Trans.
Royal Med.-Chir. Soc, 1895, p. 117):

Case i.^" Acute intestinal obstruction in a woman
of sixty-eight; operated on November 12, 1890, by
laparotomy. On the eighth day of the obstruction a
volvulus of the small intestine was discovered and un-
twisted. Bowels moved by enema on the sixteenth day
after onset of obstruction atid eighth day after opera-
tion, and a large gall-stone, three inches in circumference
and one and three-eighth inches long, was passed, this
being manifestly the cause of the obstruction and second-
arily of the volvulus. The patient returned home on
the twenty-sixth day and remained quite well when
heard of a year subsequently."

Case 2. — "On March 13, 1894, I received a telegram
asking me to go prepared to operate on a case of acute
intestinal obstruction. I found a Mrs. 0., aged sbcty-
two, suftering from acute obstruction of six and fsecal
vomiting of two days' duration, the onset having started
like a gall-stone attack, with pain over the gall-bladder,
and later in the umbilical region. She gave a history
of having suffered from attacks of gall-stones for several
years, some of which had been followed by jaundice;
and from the mode of onset of the present seizure, and

256 Intestinal Obstruction Due to Gall-stones

the slight jaundice following it, she was qtiite sure the
attack had been one of her old. seizures at the commence-
ment. From the persistence of the faecal vomiting, the
presence of visible intestinal peristalsis, and the pinched
and anxious countenance, with the absence of relief by
ordinary medical means, operation was decided upon.
Laparotomy was performed, and volvulus of the small
intestine being found, the loop of gut, which was much
congested, was untwisted and the abdomen closed.
Flatus passed the same day and the bowels were opened
the next. The wound healed by first intention and re-
covery was uninterrupted.*'

The following remarkable example of impaction of a
stone in the duodenum is recorded by Meisel (Munch,
med. Woch., 1900, No. 7). A woman, forty-three years
of age, had suflfered for three months with signs of dila-
tation of the stomach and pyloric stenosis. When the
stomach was washed out, remnants of food taken eight
days before were found. Wasting, acute pain, more
especially after food, and vomiting were the chief symp-
toms, and a large movable tumour was felt by the patient
herself through her lax abdominal wall. The abdomen
was opened under the expectation of finding a carcino-
matous growth at the pylorus. The tumour was found
to be due to a large gall-stone impacted in the beginning
of the duodenum. Mikulicz (Archiv f. klin. Chir., Bd. 51)
found that duodenal obstruction in one case was due
to the pressure of gall-stones lying in a diverticulum
from the cystic duct. Several stones were superim-
posed and their pressure had greatly narrowed the lumen
of the duodenum.

Symptoms 257

The narrowest part of the bowel from the pylorus to
the anus is at the ileo-caecal valve. The valve may
cause the arrest of a stone, or may be ruptured or damaged
by its passage. Thus Maclagan (Trans. Clin. Soc, vol.
21, p. 87) records a case in which a woman, after four
attacks of intestinal obstruction, passed spontaneously
four large gall-stones, each one inch in diameter, and at
the postmortem only the fringes of the ileo-caecal valve
remained. It would appear that the gall-stone may, by
the irritation of its rough surface, induce a spasm of
the bowel, and thus cause intestinal blocking, for Duplay
and Reclus state that on postmortem examination the
stone has often been found lying quite loose in the flaccid
intestine. Israel has recorded a case of obturation due
to a gall-stone whose largest diameter was barely three-
quarters of an inch; muscular spasm was considered a
potent factor causing the obstruction. The conditions
present in a case of gall-stone ileus differ from those
present in most cases of intestinal obstruction. There
is a block in the lumen of the bowel, but there is no
interference with the circulation. The experiments of
Kader have shewn clearly that the intensity and severity
of the symptoms of strangulation are in no small measure
due to the interference with the vascular supply of the
involved loop. In gall-stone ileus we have to reckon
only with a plugging of the lumen.

SYMPTOMS.

The symptoms of intestinal obstruction due to gall-
stones vary within the widest possible limits. They are
17

258 Intestinal Obstruction Due to Gall-stones

most intense and of greatest urgency in those cases in
which the duodenum is blocked or the upper part of the
jejunum; they are subdued and of the type present in
chronic intestinal obstruction when the sigmoid flexure
is affected, or when, as in one case related by Ord, the
stone is caught in the rectum just above the internal
sphincter. In the majority of cases the stone is impacted
in the ileum and a definite clinical picture can, therefore,
be drawTi to illustrate the average case.

A histor}' of previous attacks of gall-stone colic may
be obtained, but generally there is no mention made of
jaundice as one of the symptoms. The stone, as we have
seen, generally makes its way through the wall of the
gall-bladder directly into the duodenum; there is no
interference with the free passage of bile, and. as a rule,
there is no cholangitis. In only about one-fifth of the
recorded cases, so far as my reading goes, was an un-
doubted history of regular cholelithiasis obtained before
or after the o}x?ration.

The onset of symptoms is usually abrupt. There is
a sudden seizure of acute alxiominal pain, attended either
by faintness or nausea. \'omiting occurs soon, increases
quickly, K^th in quantity and frequency, and is, in all
cases, the most conspicuous and the most distressing
symptom. The character of the ejected fluids alters
in apix\iranco every few hours. At first the vomit is
green, deeply bile stained, and contains a little mucus.
Soon it Ixvonies turbi*.!, ^iark-yellow or b^o^^Tlish in
colour, and i-as a raiur. sioklv sitie'I. \Vit;:in twentv-
four hours r::ere is v-r. u:::r.:sMk.iMe sour, oriensive,
almost favulen: ».\lour. a^vi siiortiv afterwards the vomit

Symptoms 259

is recognised as consisting of the contents of the small
intestine, and is usually described as being stercoraceous.
SchuUer found that ** faecal vomiting'' was present in
77 out of 120 cases. The vomiting is decidedly more

•

severe when the obstruction is high in the jejunum, and
is then unremitting and exhausting. When the block
is lower, there are less distress and less urgency. The
quantity of fluid that may be ejected is astonishingly
large. Dr. Pye Smith has related a case in which, when
the upper jejunum was blocked, ten pints were vomited
within forty-eight hours.

After the initial shock has passed off, the symptoms,
apart from the vomiting, are by no means so intense as in
other forms of small intestine obstruction. The pain is
generally slight and continuous, but there are often in-
tense, though transient, exacerbations. During these
attacks of colic there may be faintness and collapse.
In most cases the obstruction is not at once complete.
Flatus is passed once or twice and the bowels may act.
Naunyn emphasises the fact that flatus may be passed
even at the time that the vomiting is stercoraceous.
Rarely a loose motion may be discharged, or there may
be a brisk attack of diarrhoea. Obstruction, with the
passage of flatus in small quantity, once or twice, is the
rule. Abdominal distension is rarely present. The
greater number of the patients are women over fifty
years of age, in whom the abdomen is fat, flabby, and
pendulous. Palpation reveals a soft, unresisting ab-
domen. Intestinal coils are seen only in the chronic
cases. A very good example of this is recorded by Eisner
(Med. Xews, February, 1898, p. 167). There is little

26o Intestinal Obstruction Due to Gall-stones

or no tenderness on examination. In rare instances the
stone has been felt through the abdominal wall or
on rectal examination. (Eve, Brit. Med. Joum., 1895,
vol. I.)

In a typical case of gall-stone ileus, in which the
stone is impacted in the ileum, the following will be the
characteristic signs and symptoms : The patient is gener-
ally a woman, over fifty years of age, and of full habit
of body; the onset of symptoms is sudden; pain and
slight collapse are first observ-ed, and ver\' speedily,
vomiting; vomiting is incessant, copious, and exhausting;
it is the most striking feature of the case: the ejected
fluids become stercoraceous in about twentv-four to
thirty-six hours; obstruction is often incomplete, flatus
or even faeces being occasionally passed; rarely, there
is diarrhoea. The abdomen remains, as a rule, soft and
flaccid.

Though this is the type, the variations from it are
not seldom encountered. The following illustrative cases
may be quoted:

Eisner (Med. News, 1898, p. 164) records the case of
a woman, fifty-seven years of age, who consulted him
in March, 1895, on account of repeated acute pains in
the upper part of the abdomen. There was a history
of gall-stone colic with jaundice. From March until
July progressive emaciation and anorexia were observed ;
there were repeated attacks of pain, but no calculi
were observed in the stools. On July 5th a hard swell-
ing ** about the size of a hazelnut was palpable near the
border of the epigastric and right hypochondriac regions."
A diagnosis of pyloric carcinoma was made. There

Symptoms 261

was constant indigestion and the stomach was very
dilated. Free HCl was absent on all occasions. This
condition persisted until October, 1896, a period of
fifteen months from the discovery of the tumour,
which was always palpable. In this month symptoms
of partial intestinal obstruction were manifested and the
tumour had disappeared. On October 8th there was
observed a "characteristic coiling of a portion of the
intestine into a sausage-shaped mass in the upper part
of the abdomen." There was vomiting of a dirty green,
at times brown coloured, sour-smeliing fluid. A few
days later a tumour was found in front of the tense
intestine, and was equal in size to the tumour formerly
palpable in the epigastric region. A diagnosis of gall-
stone obstruction was then made. On October 14th the
coiling seemed to involve the whole length of the small
intestine. The increase in coiling seemed to justify a
delay in instituting surgical interference. I concluded
that obstruction was not complete, and that the obstruct-
ing mass was movable, as shewn by the increased length
of the intestine involved from day to day. On October
i6th a gall-stone was passed; it measured five and a
half inches in circumference, three inches in length, and
its weight was 368 grains. Eleven months later, after
an attack of "acute indigestion." a second gall-stone was
passed, weighing 240 grains and measuring three inches
in circumference. Since the passage of the second
gall-stone the patient had remained quite well.

This case illustrates several interesting points: The
error in the diagnosis of the tumour felt in the position
of the pylorus; the discovery that the "tumour" was
wandering; the intestinal distension which was recog-
nised as increasing day by day, and finally the safe
passage of so large a stone. Somewhat similar instances

262 Intestinal Obstruction Due to Gall-stones

are related by Miles (Lancet, 1861), Hale White (Brit.
Med. Joum., vol. 2, p. 903, 1886), and other writers.

In other recorded cases the symptoms of obstruction
have recurred, owing to the blockage of the gut by other
stones. Such an instance is recorded by Maclagan (Clin.
Soc. Trans., vol. 21, p. 87):

The patient, a lady of spare habit, sixty-three years of
age, was seized on February 14th with a severe attack
of pain in the abdomen, accompanied by much sickness
and nausea. The vomiting was peculiar, the ejected
matter exceeding in quantity anything that could have
been lodging in the stomach; it came up without any
effort in large quantities and evidently consisted of the
contents of the small intestine. The acute symptoms
lasted five days and then passed off. On March 4th
a similar attack occurred. There was intense griping
pain in the abdomen; intense nausea and occasional
vomiting were present. This attack passed away, and
on March 21st another attack began, characterised by
the same symptoms — vomiting, constipation, and acute
pain. On April ist there was a fourth attack; on April
1 8th she passed a large gall-stone, nearly an inch in
diameter; on the following morning a second, a little
over an inch in diameter; the next day she passed a
third, and two days after, a fourth. The patient grad-
ually became weaker and died. At the postmortem a
free communication was found between the gall-bladder
and the duodenum. The cystic duct was obliterated.
Dr. Maclagan sums up as follows: **It will be observed
that the illness which this patient had consisted of four
distinct attacks, characterised by acute pain in the
abdomen, sickness, nausea, and the occasional ejection
bv the mouth of the contents of the small intestine.
During each attack the bowels ceased to act. There

Symptoms 263

can be little doubt that these four attacks correspond
to, and were symptomatic of, the passage down the
small intestine of the four gall-stones which she. subse-
quently voided/*

The symptoms in some few recorded examples have
approached in indolence and quietude those due to
chronic intestinal obstruction. The following case is
recorded by Everley Taylor (Lancet, 1895, vol. i, p.
867):

The patient, a woman fifty-six years of age, had been
suffering from continuous vomiting for thirty-six hours
when first seen. On examination, a rounded swelling,
slightly movable and dull on percussion, was noticed.
For the first two days after treatment, morphine, diet-
ing, etc., was begun; the vomiting continued incessantly.
For the next five days all food was stopped. During
this time there was no retching or nausea, and flatus was
passed. On the twenty-sixth day the abdomen became
distended, no flatus passed, and the vomiting for the
first time became stercoraceous. Operation was decided
upon; the abdomen was opened and a gall-stone found
in the small intestine and removed.

Dr. Wilkinson gives brief notes of a case under his
own care (Mayo Robson: ** Diseases of the Gall-blad-
der,'' etc., 2d ed., p. loi):

" My patient is a lady of sixty-three, and the facts are
briefly: An attack of acute intestinal obstruction,
stercoraceous vomiting, etc. Obstruction lasted three
weeks, giving way finally under rest, opium, and copious
enemata; and three weeks later a gall-stone was passed.

I Ofastmctioa Due to Gali-stoaes

aboat the size of a pigeon's ^g, and
faar and a half grains."

PROGNOSIS.
■K b certain that a spontaneous recoven' may be
.MHJKi^Ued far more frequently in cases of gall-stone
dns Am in any other form of acute intestinal obstruc-
ts*. Etcq vben the patient has been ill for dajrs and
«, %ao«^t periknisly near to death, recovery- may ensue
«)mi the stone is passed. Hutchinson (Archives of
-s^MgiBr>'. 1892. P- 9) gives notes of a case in which the
;^«^!toms were of such severity that on the sixth day
aK |h9|» of recovery was abandoned, and it was expected]
t ^ patient would die in the night. The following^
:, however, improvement set in. a gall-stone was
x^whct, and complete reco\-er>' followed. Other similar
JOTtlfT^ have been related. At times the s^inptoms
HMiy be acute, the pain and incessant vomiting most
tj^ltnssing till a moment when, quite suddenly, ease is
^jierienccd and recovery is assured. It is not difficult
|o bolie\'e that at such a time the stone escapes through
Ihe ileo-ciecal valve into the more capacious large in-
Mtttinc. presently to be passed by the rectum.

The frequency with which an attack of acute obstruc-
lion. due to gall-stones, passes off with complete recovery
tins been variously estimated. Xaun>-n considers that
over 5° P^'" cent, of patients recover under the expectant
Ijwtmcnt— morphine, enemata, etc. He mentions that
jB a series of thirteen operations only one terminated
^HKjcessftilly, He further points out that frequently the

Prognosis 265

obstruction yields after seven or nine days, and con-
cludes that operation is not to be recommended. Langen-
buch remarks that ** Gall-stone obstruction is a surgical
disease, the treatment of which is to be entrusted to the
physician only during a very short period/'

The various museums contain very large stones which
have been safely passed, and side by side with these may
sometimes be seen smaller stones which have caused fatal
obstruction. Fitz (quoted by Hemmeter: ** Diseases of
the Intestines,*' vol. 2, p. 236) collected notes of 23 cases
of gall-stone obstruction. Twelve were treated medically,
of whom eight recovered, and eleven surgically, of whom
two recovered. The passage of the gall-stone in those
cases which recovered occurred on the fourth, fifth,
sixth, tenth, fourteenth, fifteenth, seventeenth, and
twentieth days. Since all the cases operated upon after
the seventh day terminated fatally, and as five cases
under medical treatment after this date recovered, Fitz
is of the opinion that the condition of the patient must
chiefly determine the treatment to be followed. There
can be no doubt, however, that in many patients, as is
abundantly confirmed by the reading of recorded cases,
operation is only advised when prolonged medical treat-
ment has proved unavailing. Under such conditions
it is not surprising to find that the bowel has been found
gangrenous at the point of blockage or above it, and the
general intestinal congestion and distension above the
stone of the most marked degree. The operation is
then only a last resort in a case in which death was
certain and imminent.

If a sure diagnosis of gall-stone obstruction could be

265 Intestinal Obstruction Oue to Gall-stones

made, a delay of two or three days, during which medical
treatment was being tried, would, in some cases, permit
of the passage of the stone. There are. however, very
few cases recorded in which the stone was passed before
the fourth dav. It is certain that the best results would
be obtained if a series of cases could be treated upon the
ordinar\' principles now governing the treatment of all
forms of acute intestinal obstruction — operation at the
earliest possible moment after the diagnosis of acute
obstruction has been definitely made. If the abdomen
is opened in a case of gall-stone ileus, the operation is
frequently of extreme simplicity, and is rapidly per-
formed. The gall-stone is easily found, removed by a
simple incision, and the resulting wound, barely more
than an inch in length, can be securely stitched up in
less than five minutes. The whole operation need not
occupy more than twenty to thirty minutes. The shock
is therefore slight, the peritoneal handling tri\'ial, and
the exposure of the intestines of the briefest.

Operations performed during the first three daj's
would probably have a mortality little, if at all. in ex-
cess of lo per cent.

TREATHENT.

If medical treatment be advised, it will consist chiefly
in withholding food by the mouth, in the administra-
tion of nutrient enemata hourly, and aperient enemata
once daily, and in the injection of small doses of mor-
phine and atropine subcutaneously. The constant vomit-
ing may be relieved by occasional lavage of the stomach.

Treatment 267

If operation be advised, it will be carried out with
the precautions and preparations necessary in all ab-
dominal operations. An incision just large enough to
admit the hand is made between the umbilicus and
pubes. When the peritoneum is opened, the caecum is
sought and the terminal portion of the ileum. This
will probably be found collapsed. The empty gut is
rapidly passed through the finger till the stone is met.
The loop containing the stone is then withdrawn
from the abdomen, clamped above and below, or nipped
by an assistant's fingers. The stone is then removed
by an incision down on to it through the intestinal
wall, the cut being of such length as the size of the stone
demands. If the bowel below the stone be very empty
and narrow, the stone may be displaced upwards two
or three inches, into a distended portion of the gut, to
make the subsequent suture of the bowel easier. The
stone being extracted, the incision is stitched by two
layers of continuous sutures, the bowel cleansed and
replaced, and the operation completed in the usual
manner.

The gall-stone may be pushed onwards into the large
intestine in certain cases, as in the following, recorded by
Glutton :

A woman, aged seventy-six, passed a large gall-stone
per anum with symptoms of cholelithiasis, including
jaundice. After these symptoms had subsided a tumour
could be felt in the position of the gall-bladder, but
the patient remained well for fifteen months, when she
was suddenly seized with severe abdominal pain, vomit-
ing, and other symptoms of acute intestinal obstruc-

268 Intestinal Obstruction Due to Gall-stones

tion. The tumour in the region of the gall-bladder was
found on examination to have vanished, and the true
cause of the obstruction was suspected. Laparotomy
was performed and a conical concretion was found about
eight inches from the lower end of the ileum, which
was pushed on through the ileo-caecal valve without
much difficulty. Five days later it was passed per
anum, after some trouble with the rectum, and was
foimd to consist of a gall-stone one and a quarter inches
(3.1 cm.) long by one inch (2.5 cm.) broad, and three
and three-tenth inches (8.25 cm.) in circumference. It
had one large facet which fitted to that on the calculus
passed fifteen months previously.

The successful result in this case was due mostly
to the fact that the operation was undertaken only
twenty-four hours after the onset of the acute symptoms,
by which time the gut aroimd the stone had hardly
had time to become much injured. The manipulation
of the stone was also rendered more easy by its narrower
end lying nearer the valve than the broad end.

C. L. Gibson, in a study of 646 cases of intestinal ob-
struction recorded between 1888 and 1898, foimd that
40 were due to gall-stones (Annals of Surgery, October,
1900, p. 506); of the 40 cases, 21 died. There were 9
males and 27 females; in the remainder the sex is not
mentioned. The youngest patient was thirty-five years
of age; only seven patients were under fifty, and eight
were seventy years or over.

The obstruction was onlv once found below the ileo-
caecal valve; once the stone was impacted in the valve.
In 21 cases the history distinctly states the site of its

Treatment 269

arrest as the ileum ; in two, as the jejunum, and in one
at the junction of jejimum and ileum.

There was a clear history of gall-stones in 18 cases;
in five cases it is distinctly stated that there had never
been any suspicion of cholelithiasis.

The largest stone weighed three and a half ounces.

CHAPTER IX.

DETAILS OF PREPARATION FOR OPERATIONS UPON
PATIENTS SUFFERING FROH GALL-STONES.

Success in abdominal surgery, as in all the affairs
of life, depends very largely upon the observance of
details. In the careful examination of the patient,
\\4th reference both to the local and to the general con-
ditions; in the strict preparation for a few days before
the operation, whenever possible; in neatness, rapidity,
and thoughtful planning of the operation — in all these
there lie the means and the secret of success. With
few exceptions, the same technique is desirable in all
operations. I proj^ose to describe the details which
are carried out in my own operations, first, with refer-
ence to the surgeon, assistants, nurses, instruments, and
dressings, and, sccofuily, with reference to the patient.

PREPARATIONS ADOPTED BY THE SURGEONS AND

ASSISTANTS.

It is most (lesira])lo, it is even more, it is absolutely
necessary, tliat for tlie proper ol)sorvance of cleanliness
(lurin<^ ojKTations the surgeon should be properly clad.
The [i^arments wliich are suita])le for daily wear are
surijfieally unc^lean and should be changed by all those

whr) are in immediate ])roximity to the area of opera-

270

Preparation for Operations 271

tion. In former days the surgeon felt that he was ade-
quately prepared for an operation when he had per-
functorily turned back the cuff of his coat, and in the

illustrations of all the older works on surgery (borrowed
and reproduced, it is sad to say. even up to the present)
the surgeon's oiffs and links are neatly depicted. The

272 Preparation for Operations

removal of the coat and the wearing of a special coat —
generally an old-fashioned and almost worn-out over-
coat — were considered a striking improvement. Such a
garment was worn from day to day, and becoming more
and more stiffened by freshly added splashes of blood,
was as disreputable and as greatly prized as the dilapi-
dated gown of an undergraduate. I can still recall the
thrill of excitement and the murmur of amusement
that greeted the appearance of the first white operation
coat in my own hospital. To-day, however, the surgeon
should be clad from head to foot in spotless sterilised
garments. A sterilised cap is worn so that the heads
of the surgeon and his assistant when they meet in sharp
contact over the abdominal wound shall not scatter hair
and dirt broadcast. A sterile coat is worn, sterile sleeves,
and boiled rubber gloves. Sterilised, or, at least, newly
washed white trousers and clean shoes, preferably with
rubber soles, are worn. Prepared in this way the sur-
geon is safe not to inflict a chance infection in any wound.
All parts likely to be near tlie wound or to touch it
are absolutely clean.

It is not enough, though one can see the practice
every day, to wasli the hands and i)erhaps the forearms
and to be content with this. When instruments are
lying on a towel during the performance of an opera-
tion, the surgeon may, in some manipulation, allow an
unclean elbow or arm to rest for a few moments upon an
instrument, and ].)resently employ tliat instrument again.
The operator should be so prepared that all his acces-
sible surfaces are clothed with sterile garments. Exactly
the same rules apply to tlie assistants and the nurses.

Hands 273

There should be no uncovered surfaces, which, by con-
tact, are likely to cause infection.

Hands. — The preparation of the hands shovdd be
the same whether gloves are worn or not. It is almost
impossible to over-emphasise the importance of thorough
cleansing of the hands and nails. The literature of this
one subject alone would require almost a life-time for
the reading, but the conclusions of all investigators are
unanimous in stating that an assured and absolute
sterilisation of the hands is impossible to obtain. But
there can be no question that a sufficiently near approach
to perfection can be attained by the exercise of the
greatest care. Professor Kocher, for example, whose
results are at the least the equal of any, operates with
bare hands. But of the care taken by him to ensure
cleanliness, all those who have seen him work or who
have read his book will realise. It could, I think, be
successfully argued that of all the details in the prepara-
tion for an operation none equals that of the cleansing
of the surgeon's hand.

The preparation begins with a thorough washing in

soap and hot water. When the hands and arms are

socially clean, a nail-brush may be taken and a thorough

scrubbing of the hands, fingers, and nails especially,

is begun. Each finger and each nail separately scrubbed

and frequent rinsing in water as hot as can be borne is

necessary. If possible, running water should be used,

but failing that, a series of basins will do equally well.

After prolonged washing in one basin, a second is used,

and a third, and finally a fourth. Each basin and the

water which it contains should be sterilised. It is of
18

274 Preparation for Operations

no advantage to have sterile running water if the basin
into which it runs is a fixed basin, which cannot be ren-
dered sterile; nor is it possible to have water remain
sterile if the basin in which it fills is fixed as in the or-
dinary lavatory. Either the water must be running
continuously and allowed to flow over and away from
the hands and arms, or the basin and its contained
water must each be easily sterilisable. The washing
must be carried out regardless of time. After at least
fifteen minutes of soap and water the hands and nails
may be scrubbed with sterile gauze, which is worked
into all the crevices and cracks which exist on every
hand and finger. After this some antiseptic application
is necessary. The best is alcohol in some form or another.
Eighty per cent, of alcohol to the extent of two or four
ounces may be poured over the hands, rubbed well
over, and wiped off with a sterile towel, or the hands
may be soaked for a few minutes in a solution of spirit
and biniodide of mercury. Instead of alcohol a watery
solution of biniodide of mercury i : 2000 may be used,
and the hands, forearms, and elbows allowed to soak
therein for at least five minutes by the clock. The great
disadvantage of all antiseptic preparations for the hands
is the imdoubted tendency that they have to cause
roughness. This rough and coarse condition of the skin
makes any cleansing very much more tedious and any
reasonable sterilisation very diffictilt of attainment.
In these matters the personal idiosyncrasy of the surgeon
goes for much. Some operators can bear mercury com-
pounds, others are immune to the irritation of carbolic,
but all, so far as I can judge, can bear to use alcohol

Gloves 275

preparations better than any other antiseptic agent.
My own practice is to wash thoroughly in the way I
have described, with soap and hot water, to use gauze
friction, to steep for a few minutes in i : 2000 biniodide,
then to have a wash over with alcohol, and finally to
rinse well in sterile salt solution.

Gloves. — It is now my invariable practice to use
rubber gloves during operations. At the first I found
some difficulty in working in them, and I felt clumsy
and inapt. That was the favdt of the gloves, and of my
want of knowledge of the proper method of putting them
on.

I now use yi light rubber gloves. They are a size
smaller than my ordinary glove, and therefore fit fairly
tight. After being boiled for twenty minutes they are
put on in the following way : The opening in the glove
is held stretched wide by two fingers and the glove is
filled, by a movement of "scooping," with sterile salt
solution which fills the basin in which the gloves lie.
When the glove is nearly filled with water it is held
in one hand while the other hand gently wriggles into
it. As the hand enters, water escapes until the fingers
have reached to within about an inch of the tip. Then
the other glove is filled and put on in exactly the same
way. The further pulling on of the gloves is impossible,
but they may be made to go on by rapidly stroking the
glove from the fingers to the wrist with dry sterile gauze.
The glove when fully on should fit quite tight, but shotdd
not be so tight as to hamper the movements of the
hand. The outside of the glove should never be touched
with the opposite hand, which, though scrupulously

276 Preparation for Operations

prepared, should be considered, as it doubtless is, ca-
pable of infecting the glove if friction be used. (See
Kocher*s Operative Surger\% second English edition.)

During an operation the glove-covered hand is rinsed
in sterile salt solution as soon as soiled. As a rule, it
is easier to work with a glove which is wet than with
one which is dry, for when dry, the gloves are apt to
stick to instruments, ligatures, and swabs. A frequent
rinsing in a sterilised solution is therefore necessary.
No antiseptic solution is ever used, and none is permitted
to touch the peritoneum. There is abundant experi-
mental evidence to shew that the delicate peritonetmi
is seriously damaged by contact with antiseptic solutions,
and that its power of absorption is decidedly lessened.

During an operation a glove may be pricked or torn
by a needle or other sharp instrument. This is more
likely to happen when the operator is unused to gloves;
as he becomes more accustomed to them and has cul-
tivated a slightly altered tactile sense, he will find that
an injur\^ to a glove is rarely caused. If the prick be
on a finger, a finger stall or a finger cut from another
glove which has been partially spoilt must be used to
cover the damage. This should be done at once, for
if the glove has been worn even for a few minutes, the
hand will be septic. The sweat glands and the deeper
portions of the skin will have emptied their organisms
on to the surface of the hand. If a rent be made in the
hand of the glove, a fresh glove must be put on at once.
It is, therefore, always necessary to have a reserve pair
of gloves, for the surgeon and for his assistant, and several
glove fingers.

Assistants 277

At the first using of the gloves the operator will
doubtless feel that his fingers are clumsy, and that it is
difficult to get a proper grip of any structure. A little
practice, however, will soon overcome all these initial
difficulties. If a flat gauze swab be used on the gloved
hand, it will be found that a better hold is thereby ob-
tained than is possible with the bare hand. A pattern
of glove has recently been sold in which the surface of
the rubber is roughened by the impress of innumerable
fine pits. In use, however, I have not found any ad-
vantage from this.

Assistants. — The remarks made as to the preparation
of the surgeon apply also to his assistant. As a rule,
only one assistant is necessary or desirable. Indeed,
many operations, such, for example, as gastro-enteros-
tomy, can be done without any assistance. A good,
well-trained assistant is, however, a great help. More
assistants than one are rarely, if ever, necessary, and each
one is an additional potential source of infection. The
fewer persons engaged in an operation the fewer are
the chances of infection. The nurse or nurses im-
mediately engaged in the operation are instructed to
prepare in the same manner as the surgeon. A white
sterilised dress or overall is worn, the hair is covered
with a sterile cap, and clean white rubber shoes are
worn. If a nurse helps in the operation by handing
swabs or sponges, or by cutting ligatures, threading
needles, or the like, she should prepare her hands as
does the surgeon and should wear rubber gloves. In
these circumstances she becomes an additional assistant,
and if the same nurse be employed over a series of months

278 Preparation for Operations

or years, she will soon become expert in her work, and
scrupulous in the preparation for it.

Swabs. — Swabs are employed for all operations. I
have ceased to use marine sponges for several years;
they are more diffictilt and more tedious to prepare,
and are not so trustworthy. The large flat sponge
certainly answered its purpose, the protection and cover-
ing of the viscera, rather better than any flat swab I
have used, but the difference is only slight and is more
than compensated, in my opinion, by the greater sense
of security that one has in regard to the sterility of a
gauze swab.

Swabs are made entirely of gauze or butter muslin.
I prefer the latter. The swabs are of various sizes from
three inches square to six inches square, and are made
by folding over two or three times a large square of
gauze. The frayed ends of the gauze are tucked in,
so that no loose filaments are left on the woimd when
the swab is used.

The large flat swabs are made of several layers of
muslin, and are quilted at the edge in order to prevent
fraying. At the comer of each a piece of tape eighteen
inches in length is stitched. This ensures that no swab
is left in the abdomen. The whole of the gauze square
can be introduced and the tape left hanging from the
wound, a clip being fastened on the end. This method
is the most satisfactory of all, for if no tape be affixed,
the sponge or swab must be kept in sight, or a portion
of it must project from the wound, and the space in
which the surgeon has to work is thereby greatly nar-
rowed.

Swabs 279

The small swabs are put up, for sterilising purposes,
in packages of two dozen, the large ones in packages of
half a dozen. The number of each size used is counted
at the completion of the operation so as to make certain
that none has been left in the abdomen. My own rule
is never under any circumstances or in any operation
to allow a small swab to be left even for a moment in
the cavity — a small swab is not allowed to leave the
hand of the surgeon or his assistant; the large swabs
are introduced in any number, but a clip is at once ap-
plied to each tape, or to a group of two, three, or more
tapes. The counting of the swabs imder these conditions
is not necessary, but it is as well to observ^e the ceremony,
as it impresses upon all concerned the importance of
being exact in such matters.

The swabs, after being made in the manner described,
are packed in a hold-all made of gamgee tissue, protected
on the outer side by brown hoUand. The number in
each package is always the same — two dozen of the
smaller sizes, half a dozen of the larger size. In these
packages the swabs are sterilised, three or four of the
hold-alls being wrapped together in a strong large towel.
The sterilisation is effected in a pressure steriliser, a
temperature of 250° C. being maintained for forty to
sixty minutes.

It is important that as short an interval as possible
should elapse between the sterilisation and the usage
of the swabs. The most desirable, though not always
the most convenient, arrangement is for the process
of sterilisation to conclude within an hour of the opera-
tion, and for the packages to be taken from the steriliser

z>: Preparation ibr Operatioos

f .TirrwT^ lo ibe operarioa rrocn. Bat if this cannot be
5:xjs, h is rn»Tsi iesrrable that the interval should not
re r!:!»?re than c-nje '^r. at the nsost. two »iav5- After a
I»:c§^r peraxi than this it cs tiesirable to repeat the
sterilisation. The same rales and prnceitne apply to
the towels used dor'Lng the opetation. There should
be an abundance of these, itsed to o^^'er in the patient
vX>rapletely. These sb.xild be sterile, and their sterilisa-
tkm should have been recently completed.

Instminents and Lagmtiire& — Everything used by the
surgev^i or by the nurses engaged in the operation should
be sterilisevi. Powls. ligamre. and instrument dishes,
jug^ tor sciline solution, and similar articles should all
Ix" K^ilevi. These are often large and even cumbersome
in sire and their sterilisation by boiling is not easily
otYtx^ttnl. I have a large copper \-at. measiiring two feet
bv twi^ t\vt bv two feet, into which all bowls necessary
tor any o{x:*ration are placevl and therein boiled for
thirty to forty minutes. If the operation should prove
t\> bo a septic one. as in appvndix or tubal or gall-
bhuUler opn^rations. esjvcial care is subsequently taken
that all Ix^wls, etc.. are subjectevi to prolonged boiling.
The \vasl\ing mit of such Ixisins with strong antiseptic so-
huions may be sixnhing to the cv^nscience of the surgeon
or of tlie nurse, but it probably di^^es not much affect the
|H»\ver of jmx^reation of a pyogenic organism. Prolonged
boilii\g is iKvessiiry,

( \itiiut, Vov some years now I have used catgut pre-
pared by a nunlHHl 1 ilescrilxHl in the Lancet (vol. 2, 1902,
p I |So). 1 have fouuil the methvxl most satisfactory, and

Instruments and Lig^atures 281

&'

I have long ceased to have any anxiety whatever about
the sterility of the catgut in any operation.
The following is the process:

For the boiling, an enamelled pan is used. In this
about one and a half pints of water are boiled. While
the water boils ammonium sulphate is gradually throT/vn
into the water. To obtain a concentrated solution about
a pound of ammonium sulphate is used. When this
concentrated solution boils, the catgut is introduced and
allowed to remain for fifteen minutes. With sterile
forceps the reels are then lifted out, washed thoroughly
in boiled or boiling water, and placed in the following
solution: iodoform, one part; ether, six parts, and ab-
solute alcohol, fourteen parts. The catgut improves
with keeping up to about six or eight weeks. The
solution of ammonium sulphate boils at 128° C. The
catgut may be kept in it for an hour without being
softened, but fifteen or twenty minutes at a temperature
of 128° C. are sufficient to insure sterility. The rinsing
of the catgut in boiled water is necessary to remove the
excess of salt, which otherwise crystallises on the catgut
and on the glass. The solution splashes a little while
boiling. If the xylol process of preparing catgut is
used, the metal receiver may be boiled in this solution
instead of in water, and the temperattire of the xylol
thus raised well above 100° C.

Recently I have used catgut prepared by the method
of Claudius. The preparation is simple, the catgut is
easy to handle, and its sterility is absolute.

Catgut is used for almost all ligatures. If anything
stronger is needed, then Pagenstecher's celluloid thread is
used. This is made in several sizes, but the thin and a

282 Preparation for Operations

medium size are all that are necessary. I use this
material for all sutures that are required to be long-
enduring, and for all sutures that require to be retained
in place for more than a few days. The use of silk has
been entirely abandoned by me for some years, as I find
that the celluloid thread is more easily sterilised, that it
presents a smoother surface, and that it is far stronger
than an equal size of silk. The breaking of a Pagen-
stecher thread ligature or suture is an extremely rare
occurrence ; when it happens, it is almost certainly due
to the fact that the thread has been boiled too often.
The thread when wound on glass reels can be boiled
for four or five operations, but after this it begins to fray
and is then liable to break. It is, moreover, then most im-
suitable for sutures, for the rough surface tears the peri-
toneum as it is being pulled through. This is the only
fault that the thread has, and as the thread is very cheap,
it is better to throw it away after being boiled three or
four times than to run any risk of its breaking.

Drainage Material. — During recent years a marked
change has come over surgical opinion with regard to the
question of drainage after abdominal section. At one
time it was considered that drainage was the safeguard
after all operations ; that the provision for the free escape
of inflammatory products made up for any slight fatdt
in the operative technique. Now, thanks largely to the
work of Clark and others who have studied the question
with great care, we know that when employed as a routine
measure drainage is rather a means of sepsis than a meas-
ure of escape from its effects. Drainage of the peritoneal
cavity is ver>' rarely necessary. The point will be dealt

Instruments and Ligatures 283

with again when we come to speak of the various opera-
tions ; but, speaking generally, one may say that it is only
for septic conditions that drainage is ever needed.

The best drain in the majority of cases is gauze. It
absorbs well and conducts fluids away better than any
other material. Its only disadvantages are that after
remaining in the abdomen for a few days it is prone to
become offensive, and its removal is difficult. In order
to overcome the latter difficulty the gauze may be sur-
rounded by a rubber tube or by dental rubber. The two
forms of drain which prove most satisfactory in general
use are (i) the split rubber tube with gauze wick, and (2)
the so-called "cigarette drain.'*

The split rubber tube may be of any size; as a rule, the
larger the tube, up to a diameter of seven-eighths of an
inch, the better. The tube is cut of adequate length, and
a slit is made along it with scissors ; in it a wick of gauze is
then laid, to fit loosely in the lumen of the tube and to pro-
ject for a couple of inches from each end. The gauze wick
at one end of the tube is then carefully laid in position
within the abdomen, and if necessary either the gauze or
the end of the tube may be fixed in position by a single
catgut suture. This is especially necessary when the
drain is needed at the upper part of the abdomen, as,
for example, after cholecystectomy. The movements of
the diaphragm, and the consequent up-and-down move-
ments of the liver, are apt to displace the gauze or to roll
it up into a ball which blocks the end of the tube. If
fixed with a stitch, this will not occur ; the stitch being of
catgut, softens within five to eight days and the tube can
then be removed. The cigarette drain is made in the

284 Preparation for Operations

following manner: A piece of dental rubber, well boiled,
is cut, about ten inches square. Over this a four-fold
layer of gauze of the same size is placed. The edge of the
two squares is then turned over about one-fourth of an
inch, and again over, and then rolled onwards tintil a
cylinder of gauze and rubber is formed. A section of this
cylinder shews a series of layers, alternately gauze and
rubber, lying one within another. It is as though there
were a series of rubber tubes, of gradually lessening size,
each with its own wick of gauze, one within another. The
terminal edge of the roll may be fixed with a stitch or with
chloroform, a little gauze being turned in so that the edge
of the outer rubber can be opposed to the underlying
rubber and there fastened. This drain may also con-
veniently be fixed in any desired position with a suttire
of catgut. In cases of subphrenic abscess or of localised
perforation of the gall-bladder where the cavity to be
drained is often extremely foul, the cigarette drain may be
made slightly antiseptic by dusting a thick layer of
powdered boracic acid, with or without a little iodoform,
over the gauze before the rolling-up is begun. Such a
drain is best made at the moment it is needed. The
ordinary form can be made some time before the opera-
tion, and sterilised just before usage. As a rule, however,
I make the drain wlien I find that I want it, the materials
for it being always ready to hand.

PREPARATION OF THE PATIENT.

In all cases an adequate i)reparation of the patient is
most necessary. There are certain surgical emergencies,

Preparation of the Patient 285

catastrophes like the perforation of a gastric or a duodenal
ulcer or the rupture of a tubal gestation, in which the
urgency of affairs does not permit any elaborate detail
to be observed. But whenever time and circumstance
and opportunity render it possible, the preparation of the
patient, both locally and generally, should be most scrupu-
lously observed. It is said by some surgeons that strict
preparations are absurd, but there can be no question
that they repay one in better results. The patient should
be kept in bed for the whole of the day preceding
operation, and for the afternoon and evening of the
day before that. If the operation is to be done on
say Wednesday morning, the patient goes to bed on
Monday afternoon. He is at once given five grains of
calomel, which is followed early on the Tuesday morning
by a full dose of saline aperient. Later in the morning,
if these have not acted, an enema of soap and water is
given, and if the bowels are at all loaded or the patient
has previously suffered from constipation, the enema is
repeated late at night. The condition of the mouth
receives close attention. Every patient is given a new
tooth-brush and a bottle of antiseptic mouth- wash on
arrival in the nursing home or hospital, and the nurse is
instructed to see that a thorough cleansing of the mouth
is observed every hour or two during the day. It is
astonishing to what a degree of uncleanness even the
better class of people will allow their teeth to go. Patients
with gastric ulcer and its complications seem to suffer
especially from bad teeth, and, indeed, the point is worth
raising as to the degree in which oral sepsis may be a
factor in the causation of gastric ulcer. If the patient is in

286 Preparation for Operations

very feeble health, the niirse is instructed to clean the
patient's mouth by frequent wiping with gauze or lint,
and the patient subsequently rinses the mouth out. It
is possible, as the excellent work of Dr. Harvey Gushing
has shewn, by careful attention to the condition of the
mouth and by the sterilisation of all foods, to render the
alimentary canal comparatively aseptic. All patients
from the moment they are received into hospital are fed
on fluid diet, and everything given is sterilised, and the
feeder or vessel from which the food is taken is also boiled.

I am disposed to think that the occurrence of parotitis
and of pneumonia after abdominal operations are both
largely, if not solely, due to infection from the mouth.
In some cases so foul a condition of teeth and gums may
be accidentally discovered as to make a little delay in
operating imperative. In one patient I found quite
by accident a degree of suppuration in the mouth and a
fcetor of breath that warranted a diagnosis of Riggs*s
disease. In such a case, and even in bad cases of carious
teeth, an aspiration pneumonia is not unlikely to occur, or
an extension of inflammation up Stenson*s duct, unless
a thorough and repeated cleansing is observed.

The skin of the abdomen needs, and must receive, very
careful preparation. The hair is first shaved away from
the whole abdominal wall and from the pubes. It is
evidence of careless work to see a patch only shaved, one
half of the pubic hair, for instance, remaining untouched.
It is well to limit the operative field, of course, but the
preparation of the skin must extend wide beyond it.

A free washing with soap and hot water frequently
changed is first necessary. The best material wherewith

Preparation of the Patient 287

to wash is sterile gauze in large pads. These are moist-
ened with hot water and rubbed with soap till a good
lather is obtained. This washing should be continued for
a quarter of an hour, the water and the gauze being fre-
quently changed. An antiseptic compress is then applied
and left on for twenty to twenty-four hours, or until the
movements of the patient begin to displace it. The
compress consists of lint of two or three thicknesses,
soaked in one per cent, formalin, i in 60 carbolic, or i in
2000 biniodide lotion. I prefer the former, in the belief
that there is by its means a deeper penetration of the
skin and of the glands.

At the end of twenty-four hours there is a second
washing, and a second similar compress is applied. This
is removed immediately before the operation, when a third
cleansing is made. The skin is now rubbed with spiritus
saponatus — a solution of soap in spirit — a swab wet with
1 : 1000 biniodide solution being used to make a fine lather.
This is wiped away with biniodide lotion and finally the
skin is wiped over with sterile salt solution.

Some patients' skins are very tender and will not bear
this preparation. If not, the second washing is omitted,
for it is supremely important that the skin should not be
roughened or chapped, and that any irritative rash should
not ,be caused. Overpreparation to the extent of damag-
ing the skin is almost as bad as no preparation at all.
If there are any small furuncles or septic cracks on the
skin within the operation area, these must be carefully
disinfected. The only satisfactory method of doing so is
by means of the actual cautery, the point of the hot metal
being kept in contact with the infected spot until all the

288 Preparation for Operations

septic matter is destroyed. When it is realised that the
yellow spot in a furuncle may contain a pure culture of the
staphylococcus pyogenes aureus, the complete annihila-
tion of such a colony is seen to be a desirable thing.

If the skin of the patient should be very rough, scaly,
chapped, or cracked, its adequate preparation is almost
impossible. In these conditions the ** rubber dam"
introduced by Dr. J. B. Murphy of Chicago will be fotmd
of the greatest service. It consists of a strong, very
adhesive material, which is stretched and then placed on
the abdominal wall, to which it clings most closely, be-
coming, in fact, for the time, an inseparable part of this
wall.

Through it the incision is made, and the hand lying
outside, or any viscus escaping from the abdomen, lies
not upon the abdominal wall, but upon this sterile rubber
dam.

As a general rule, no more preparations than those
indicated are necessary, but in some few the general con-
dition of the patient may be so enfeebled that special
precautions are needed. It is a matter of the highest
importance in all cases to ensiu'e that the heart and the
kidneys are acting well. Inefficient kidneys are among
the most serious obstacles to success in any major opera-
tions, but especially in any abdominal operations. A
routine and most exact examination of the urine for two
or three days is, therefore, necessary. If the patient be
feeble, or the heart so weak as to be a cause of anxiety,
much good may be done by hypodermic injections of
strychnine and digitaline for a few days before the opera-
tion. Five minims of the liquor strychninae may be

Operation 289

given three or four times daily. If the patient has been
accustomed to alcohol, his usual quantity may be al-
lowed him. All patients who are submitted to any
abdominal operations are clothed in a suit of gamgee
pajamas made for them by the nurse. After being made,
of appropriate size, the suit is well warmed and is put on a
few hours before the beginning of the operation. It is
worn until all risk from the operation is past, and is then
removed limb by limb.

OPERATION.

The operation, if possible, should be performed in a
room specially furnished for the purpose. In a public
hospital a well-equipped operation theatre is always
provided. In a niu-sing home or in a private house it is
sometimes necessary to operate in the patient's bed-
room. The advantage of this is that it is less of an ordeal
to the patient, who is sometimes alarmed at the prospect
of being taken to a special room, and that there is less
of lifting or of carrying after the operation. These
trivial advantages are, however, greatly outweighed by
the disadvantages, which are, that in the conversion of a
bedroom into a theatre there is much traffic, many
tables, instruments, etc., having to be taken into the
room ; that it is not possible to have all the needed ap-
pliances to hand with the same certainty, and that finally
the smell of the anaesthetic clings to the room for many
hours. An ordinary room in a nursing home can readily
be converted into, and equipped as, an operation room,
to the great convenience of the surgeon. The operation
19

290 Preparation for Operations

table should have the foot towards the light, and should be
of good height. Many of the tables are about three inches
too low. If the table is high, it is more convenient and
more comfortable for the surgeon, and if, for any brief
manipulation, it is necessar\' for the surgeon to be at a
rather high level, a plain metal or wooden footstool can be
used.

AFTER-TREATxMIENT.

No small portion of the success in all abdominal opera-
tions depends upon the after-treatment. When the
patient is returned to bed, she is generally propped up
slightly, by three, four, or five pillows. If a drainage-tube
is left in the wound, its outer end is fitted into a bottle of
about ten ounces capacity, which is fixed by a safety pin
to the side of the dressing. During the first few hours
bile may flow in very small quantity, especially in cases
where the action of the hepatic cells has been in part sup-
pressed by the tension and sepsis in the. common and
hepatic ducts, as a result of the occlusion of the duct
by a stone. The bile that first flows may be muddy or
turbid, but after a few days the bile flows in greater quan-
tity and it becomes gradually clearer. The patient is
allowed no sip of water until the ether sickness and the
feeling of nausea are over. In all cases the abdominal
bandage is applied tightly, so that if vomiting should
occur, the wound may thereby receive some support. If
thirst is great, the mouth may be flushed frequently with
water or soda water, and an enema of salt solution, from
ten ounces to twenty ounces in quantity, may be given.
If the pain is severe, ten grains of aspirin may be given

After-treatment

291

by the mouth, or twenty grains by the rectum. Morphia "
is never given during the firet twenty-four hours and
very rarely, indeed, afterwards. In some cases, espe-
cially in old and enfeebled patients who have slept but
little or not at all during the first night, and who do
not seem likely to sleep during the second night, a
small dose of morphia, one-sixth of a grain for exam-
ple, may safely be given if the patient is otherwise
in a satisfactory condition. On the third or on the
fourth night it may be given under like circumstances,
A good night's rest often is a great help to a patient
who is enfeebled by a long-enduring disease and dis-
tressed by the anxiety of a serious operation. Under
these rare circumstances, therefore, morphia may be
given, but it must not be repeated.

Saline injections, about six ounces every four hours, are
given for the first two or three days. If the pulse is
poor or the patient at all collapsed, an occasional hypo-
dermic of five or ten minims of liquor strychninas is
given .

As soon as the sickness is over a few teaspoonfuls of
fluid are given by the mouth. Water, or tea made to the
patient's liking, is the best ; on the second day milk and
soups may be given ; on the third the same, with milk
puddings and a little bread and butter.

The condition of the mouth receives constant attention.
The teeth are cleansed three or four times a day by the
patient or by the nurse, and a wash of some weak and
fragrant antiseptic is frequently employed.

Drainage-tubes are left in until the stitch which fixes
them loosens spontaneously. This occurs about the

292 Preparation for Operations

seventh to the tenth day. The tube is removed and the
wound is then dressed daily. While the tube is still in the
wound it is not necessary to change the dressings unless
they are soiled by leakage of bile by the side of the
tube. If gauze packing is employed, it may be left
from four to eight days. The stitches are removed
about the eighth day.

If the patient is old and feeble, she is allowed to sit
up out of bed within three or four days. In all such cases
through and through stitches will have been employed,
and there is consequently little or no risk of damage to
the wound.

CHAPTER X.

OPERATIONS UPON THE GALL-BLADDER AND

BILE-DUCTS.

HISTORICAL.

The history of the surgery of the bile passages is full
of interest. Langenbuch, in a paper read before the Ger-
man Congress of Surgeons in 1896, has given a detailed
account of the various steps by which the treatment by
surgical methods of cholelithiasis and of its many com-
plications has been laboriously built up ; and in the follow-
ing account I have borrowed freely from his paper.

The first record of the removal of a gall-stone from a Hv-
ing patient is found in the year 1618, the operator being
Fabricius Hildanus. In 1630 Zambeccari, an ItaHan,
performed cholecystectomy upon a dog. The animal
recovered, and two months later was killed. At the
examination it was found that the omentum and bowels
were adherent over the stump of the cystic duct. In
1667 a student, Teckof, in Leyden, removed the gall-
bladder from several dogs. Ettmiiller, referring to the
work of Teckof. says : " As we now know, the gall-bladder
can be removed from dogs without detriment to life or
health. I was first informed briefly of this by a friend
who told me that a student of Leipzig had removed the
gall-bladder from a dog three months before, and had
closed the abdominal wound at once. This animal still
lives and fulfils all the functions of life without the least
disturbance."

Further experimental work was done by Malpighi,

294 Operations on Gall-bladder and Bile-ducts

Taubrin, and others and by Seeger, by whom it was shewn
that ligature of the cystic duct gave rise to hydrops of the
gall-bladder.

Gall-stones were removed by operations performed, in
1687, by Stalpart van der Wiel; in 1738 by Amyand, and
in 1742 by Miiller. These operations were in all cases the
result of accident, rather than deliberately planned and
purposeful operations.

The first surgeon who carefully devised and deliberately
carried out an operation for the removal of gall-stones was
Jean Louis Petit, in 1743. His procedure was limited to
those cases in which it was thought that the gall-bladder
was adherent to the abdominal wall. This adhesion was
diagnosed when a tumour of the gall-bladder was present
which was not movable from side to side, or when an
inflammation over the gall-bladder seemed on the point
of bursting through the skin. In one case certainly, the
patient being a woman, he operated with success at
several sittings. He writes: "How many people have
died because this disease was not recognised, or because no
operator could be found who would undertake to rid them
of their disease by means of an operation ! ' '

Petit*s work was, however, ignored by many of his*
contemporaries and successors, though it was recognised
by Haller, and ojx^rations were performed by Morand and
Sharp.

Herlin, in 1767, jxTformed a number of experiments
upon dogs and found, as Teckof before him had found,
that the gall-bladder ctnild be safely removed. He
advised extirpation of the gall-bladder as a remedy for
cholelithiasis.

The next advance was made by Bloch of Berlin in
1774, who attempted to create an artificial adhesion of
the gall-bladder Xo the ]Xiriotal peritoneum by means of
the ai>plication of irritant materials to the skin. In
three cases he oiXTated successfully.

Historical 295

August Gottlieb Richter, the famous German surgeon,
first suggested that adhesion of the gall-bladder to the
parietal peritoneum was not an essential preliminary
to an operator. He wrote; "Is then an escape of bile
into the belly cav-ity to be feared when the gall-bladder is
not adherent to the peritoneum if the trocar be used, and
be left in the wound after the gall-bladder is empty?
Have we not cause to hope that the cannula will cause the
gall-bladder to adhere to the peritoneum, preventing
it from moWng away by the creation of adhesions?"
As a step further than this may be mentioned the pro-
cedure adopted by Sebastian, Carr6. and Fauconneau-
Dufresne, in which the abdominal wall was incised down
to the parietal peritoneum, and into the wound irritating
substances were placed to promote adhesions. Kocher
in 1878 opened the abdomen and packed around the gall-
bladder with Lister's gauze, and six days later, when ad-
hesions had formed, he opened the gall-bladder and
emptied it : the patient recovered completely.

The next advance is due to Thudichum, who, in 1859,
suggested that the operation of cholecystotomy should be
performed in two stages, the gall-bladder beifig stitched
to the abdominal wound in the first stage, and in the
second, the gall-bladder being opened. The advocacy
of this method, however, found no favour, and for eight
years there is no record of any operations having been
performed upon the gall-bladder or the bile passages.

In the year 1867 Bobbs, an American surgeon, per-
formed cholecystotomy in one stage. After opening the
abdomen the gall-bladder was brought up into the ab-
dominal wound, opened and emptierl, and then sutured
to the parietal peritoneum. The operation was based
upon an inaccurate diagnosis ; it was thought that a large
fluctuating tumour was an ovarian cyst ; on exploration
it proved to be a dropsical gall-bladder. This opera-
tion attracted so little contemporary notice that several

296 Operations on Gall-bladder and Bile-ducts

operators, Daly (Lancet, 1876), Maunders (Brit. Med.
Joum., 1876), Handfield Jones (Med. Times and Gazette,
1878), Brown (Brit. Med. Joum., 1878) all believed that
their methods were original. In 1877 Marion Sims and
Keen performed cholecystotomy after the method em-
ployed by Bobbs. Marion Sims' patient suffered from
calculous obstruction of the common duct, and died of
haemorrhage. The credit of performing the first in-
tentional and successful cholecystotomy, in two stages,
belongs to Konig, who operated in 1882. The year 1882
was the most memorable of all in the development of gall-
bladder surgery, for it was in this year that Langenbuch
first performed the operation of cholecystectomy. To
Langenbuch, as much as to any surgeon, belongs the
credit of establishing the surgery of the gall-bladder upon
a firm footing. His operative work is the work of a
pioneer, and his book upon the diseases of the liver
and the gall-bladder is probably the soundest and most
authoritative treatise we possess. Langenbuch, on July
15, 1882, after long practice of the operation upon the
cadaver, performed cholecystectomy upon one of his
patients, and a speedy and successful result followed.
Other similar operations were performed by Langenbuch
himself, by Courvoisier, and by Riedel.

The year 1882 saw the first performance of another
operation upon the bile passages, the operation of chole-
cystenterostomy, which was carried out in six stages by
von Winiwarter. The suggestion of the operation is
due to Nussbaum. \'on Winiwarter united the gall-
bladder to the colon. Cozi, after many experiments
upon dogs, suggested that the anastomosis should be
made with the duodenum. This was done by Barden-
heuer and Terrier. In 1885 Roth, a Swiss surgeon,
suggested that in blockage of the common duct the
cystic duct might be implanted in the duodenum.

The year 1884 saw the first attempts in surgical inter-

Historical

297

ference with the common duct. The operations of
choledochotomy and of duodeno-choledochotomy were
both suggested by Langenbuch, and the possibility of
their performance demonstrated by experiments upon
the cadaver, Duodeno-choledochotomy was first per-
formed by MacBumey, then by Pozzi and Kocher.
Choledocho-duodenostomy was first performed by Riedel
unsuccessfully, by Sprengel successfully.

The first surgeon to attempt choledochotomy was
Kiimmel ; the result was unsuccessful, Courvoisier per-
formed the first successful operation. In 1891 Hochen-
egg, after removing a stone from the common bile-duct.
did not introduce sutures, but drained the wound with
gauze; his patient recovered. The operation of chole-
docholithotripsy was performed by Langenbuch. Cour-
voisier, Lawson Tait, and others. Rehn was the first
surgeon to perform cholecystectomy and choledochotomy
successfully.

In the year 1884 Kuster performed the first operation
for acute ulcerative perforation of the gall-bladder. The
first hepatotomy was performed by Korte.

In the year 1883 Sir Spencer Wells recommended the
operation of ideal cholecystotomy, or cholecystendysis.
Two unsuccessful results were recorded by Meredith, and
were followed by a successful operation performed by
Courvoisier.

In 1884 Riedel operated successfully for the relief of
a fistula of the gali-bladder, communicating with the
colon and with the right pleural cavity. Kronlein in
1886 closed a fistulous track which extended from the gall-
bladder to the bladder, and one year later von Bergmann
evacuted gall-stones from a distended patent urachus
which communicated with the gall-bladder.

In 1886 Landerer performed cystolithectomy through
the liver substance, and Lauenstein hepatolithectomy
in two stages.

^

298 Operations on Gall-bladder and Bile-ducts

In 1890 Hochenegg was the first to remove a malignant
tumour of the gall-bladder, and in the same year Terrier
removed a growth which involved the gall-bladder and
the adjacent portion of the liver.

The use of omental flaps and grafts for walling off
incisions in the bile passages was advocated first by
Courvoisier and by Mayo Robson. The first operations
for peritoneal adhesions which crippled the action of the
gall-bladder and the stomach were performed, according
to Langenbuch, by Riedel and Lauenstein. In England,
Mayo Robson, and in France, Terrier, both recognised
the harm done by adhesions affecting these organs, and
the great relief afforded by the free division of them.
The operation of cysticotomy originated with Kiister.

In England, the first surgeon to operate deliberately
and with success for gall-stone diseases was Lawson
Tait. No small measure of credit for the successful per-
formance and advocacy of the surgical treatment of
diseases affecting the gall-bladder and bile-ducts is due
to two surgeons attached to the Leeds Infirmary, McGill
and Mavo Robson. McGill was undoubtedlv one of
the pioneers in this branch of our art, and, possessed as
he was of the very genius of surgery, he would, if his
brilliant career had not been prematurely cut short, have
achieved in it a great and enduring reputation. What
Mayo Robson has done for the surgery of the abdomen in
general, and perhaps especially for the surgery of the gall-
bladder, is well known to all. His little work, published
in 1892, followed by his Hunterian lectures, and three
editions of the work based upon them, are a record which
we, at his hospital, are proud to remember.

General Observations 299

GEPJERAL OBSERVATIONS.

In all operations upon the gall-bladder or ujxin the
bile-ducts a considerable advantage will be derived from
the use of a sand-bag placed, under the patient's back at,
or a little above, the level of the liver. The liver by this
means is made to present in the wound and easy access

—Shewing ihe position of the sand-bag in operations upon
the gall-bladder and btte-ducts.

is obtained to the cystic and common ducts. The in-
testines fall away into the pelvis, and the whole operation
area is made more accessible. In addition to this use of
the sand-bag it will be found a convenience to be able

slightly to tilt the table so that the head of the patient
is raised and his feet lowered about four to six inches.

It is to Wheelock Elliot of Boston that we are indebted
for the first demonstration of the great advantage to be

300 Operations on Gall-bladder and Bile-ducts

derived from the placing of the patient in this position.
He writes (Annals of Surgery, 1895, vol. 22, p. 97):

**The patient is hung by straps under the arms on an
inclined plane at an angle of something less than forty-
five degrees. A sand-bag is placed under the back, so
that the patient is bent over it. In this position the
intestines gravitate to the lower part of the abdomen, so
that when the liver is held up by a retractor, the air
sucks in between the liver and intestines much as it
enters the pelvis in the Trendelenburg position.

The only disadvantage of this position is that, when a
vertical incision is employed, the edges of the wound are
necessarily very tense, owing to the pushing forward of
the rib margin and the consequent tightening of the
abdominal muscles. This solitary disadvantage is done
away with when Mayo Robson*s incision, to be presently
described, is used. This position of the patient is, as a
fact, indispensable for easy work upon the ducts.

The best incision is a vertical one, made at first about
four to five inches in length through the right rectus near
its outer border. The upper end of the incision starts at
the costal margin and extends vertically downwards. If
more room is needed than this incision gives, it may be
obtained by prolonging the incision downwards, or by
carrying the upper end obliquely upwards and inwards,
dividing the fibres of the rectus about one-half of an inch
from the costal margin. There is rarely any need for a
further increase of the incision than these. The incision
near the outer margin of the rectus, with the upward and
inward extension, is that first suggested by Mayo Robson.

General Observations

301

^-S^s-

f-..v

Great convenience may often be gained, especially in
stout patients with an abdominal wall three inches or
more in thickness, by making the skin incision two or three
inches longer than the incision in the rectus. The sides
of the wound then fall away and allow the more ready
access of the hand. The longer incision in the skin and
subcutaneous fat does not in any way weaken the ab-
dominal wall, as a longer in-
cision in the muscles would .>. y .-;:; ,.

certainly do.

Dr. Arthur Dean Sevan of
Chicago has suggested (An-
nals of Surgery, vol. 30, p. 17)
the use of an S-shaped inci-
sion, the lower end of the ver-
tical incision being carried
outwards, and the upper end
obliquely upwards- and in-
wards. Dr. Sevan claims that
by means of his incision less
damage is done to the vessels

and nerves of the abdominal wall than by other incisions,
and that a better view can be obtained of the bile-ducts.
The incision of Mayo Robson is practically the same as
the upper part of Sevan's incision.

Kocher uses an oblique incision four inches in length ,
about one and one-half inches below the costal margin.
The centre of the incision is a little outside the outer
margin of the rectus muscle. This is a very useful in-
cision, giving ready access to the gall-bladder and ducts,
being readily enlarged either inwards or outwards, and

Fig. 59. — Mayo Robson's in-
cision.

302 Operations on Gall-bladder and Bile-ducts

doing little damage to the nerves or muscles of the ab-
dominal wall. Very little weakness of the parietes
remains after the operation, and there is little chance of
a hernia developing. This incision and the vertical inci-
sion, with Mayo Robson's extension, are the only ones
. I have adopted. So far as I am aware, I have not had
a single case of post-operative hernia. This I attribute
in part to the method of making the incision (a large skin
wound and a small muscle wound), but chiefly to care in

stitching up the wound. Courvoisier's incision is eight
to ten inches in length, and runs almost parallel with the
costal mai^in. Kehr makes use of an incision even longer
than this.

Such phenomenal incisions as these two latter are never
necessary'. With a vertical incision five or six inches
in length, and at the most an oblique upward and in-
ward prolongation of this just below the costal margin,
any operation can be performed upon any |)art of the gall-

General Observations

303

bladder or the cystic or common or hepatic ducts. Pro-
vided the ducts are brought within easy reach, then the
smaller the incision the better, for the intestine can the
more readily be packed away with swabs or sponges.
A long incision is troublesome in that it allows the escape
of intestines from the wound and makes the retention of
the bowels within the abdomen a matter of constant
attention. As soon as the abdomen is opened and a
preliminary exploration has been made, a large flat swab
is packed down towards the upper part of the right kidney

a

Fig. 62. — Gall-stone scoop (a) and forceps (6).

pouch. The proper placing of this swab is a matter of
the greatest importance. It should fill the upper part of
the right kidney pouch, fitting in between the common
duct and the duodenum on the inner side, and the ab-
dominal wall on the outer side. When fixed in its correct
position, it forms an adequate protection against any
leakage from the opened bladder or ducts. When the
operation is completed and the swab is removed, there
should have been no soiling of any part of the peritoneum
which it covers.

5iie

-' .■• ♦

* ^

- • •

* ^r*

'Wr/^jr*'. 'i\ ot.vrr •/.r'.e'. tr.^y are exieeiir.^-v M-Jigc.

jfitri^^iV; ar.'! '!:::/.">. V/ *^o^ravr. The creates: ci^re ani

th/: ^J^j^^yj^rTiurr.. ^tz *:':(:r^ tr.e ston^ach. mav r^ t':»m, an«i
h'jikixyft irorn th#,-vr viv;era nriav contaminate the whole
fu^M. A Tou'/h vrparation of the omentum may cause
a f/Tofi]'/! h;rrriorrha;(e, and the torn vessel, retracting.
rnav can-A: a larL'^: h;f:mat^>ma to f'^irm in the substance of
th<: orni'Titum, In the stripping of all these adhesions
yji'ii\, \\*'\\* will \fi'. found in the use of ^auze. which wrapped
I'ironnd tin- finj.^Ts slowly jxrels the arlhesion away. It is
rrKr-^t csM'fitial that all the ducts and the gall-bladder
should \)i' fn-cd and laid bare l>efore the operation pro-
ceeds U\v\\\i'V.

L'nh-ss all the bile-tract can }>e explored, there is a great
risk of a small calculus, or even of many calculi, being
left behind. Adhesions, even the very firmest, will
yield to time and i)atien((r and dexterity. No operation
need ever br abandoned because the adhesions are sup-
|)o;;rd lf» present an insui>eral)le ol)Stacle. I have, on

General Observations

305

many occasions, seen adhesions that at first were utterly
bewildering in their infinite complexity, but gentle per-
sistence in separating first one spot and then another has
gradually cleared all difficulties away.

Fig Gj. — Liver rotated through Mayo Robson's incision When
the gall-bladder is pulled upwards in this way, the ducts are straight-
ened and put upon the stretch. Access to them is then quite easy.

When all is quite clear, then the gall-bladder with the
liver around it is seized in the hand covered with gauze,
and gently dragged downwards from under the shelter of
the ribs. If this can be effected, it will be found easy to
rotate the liver, turning the gall-bladder upwards, so that

3o6 Operations on Gall-bladder and BQe-ducts

what was its under surface now faces upward and forwards.
Bv this n^-anoeu^Te the cvstic and common ducts are
brought almost into a straight line, and the common duct,
which at first seemed so deeply hidden in the abdomen,
can now be brought forwards till it lies almost or actually
on a level with the skin. In this way the ducts can be
mfjst thoroughly explored and the surgeon may satisf\'
himself of the certainty of being able to remove all the
stones.

It is not necessar\' in all cases to bring the liver and
gall-bladder forward in this way, but in case of any
doubt, it is certainly advisable to do so. In thin patients
this may be done through the usual vertical incision, but
in the stouter patients the upward and inward prolonga-
tion of the incision will first be necessar\'.

In sUmt people it is sometimes difficult to make the
liver rotate, and thus to bring the ducts forward, but
even if the manrjeuvre cannot be completely effected, it
can often be done to such an extent as to make the steps
of the oi>eration much easier. If the patient be thin, and
if, as in spare women, the liver lies with its edge well
below the costal margin, it is perfectly easy to bring the
common duct well up to, or even outside, the abdominal
wound, and there to incise or suture it.

During the operation it is advisable in all cases, but
more esi)ecially in those patients suffering from chronic
jaundice, to ligature every bleeding point.

After the intra-al)d()minal portion of the operation is
comi)lcte(l it is necessary to remove the sand-bag from
bencatli tlic ])atient's back before stitching the woimd.
The i)crit()neal stitch is excessively (liflicult to introduce

General Observations

307

while the epigastrium is made tense and prominent by
the sand-bag.

The preliminary treatment of patients who are to be
operated upon for gall-stone disease is the same as in all
abdominal operations. In cases of chronic jaundice
Mayo Robson, acting upon the experimental observations
of Wright, has administered chloride of calcium, either
by the mouth or by the rectum, in the hope that the
coagulability of the blood might thereby be increased.
I have never been convinced that this drug had any
effect whatever in this direction, and though I formerly
gave it a fair trial, I have now ceased to administer it.

In some few cases I have given gelatine subcutaneously
with the same hope — but this also I have abandoned as
being useless.

The abdominal wound is closed in the following
manner :

The parietal peritoneum is seized on each side with
two or three pairs of clips which hold the cut edge of the
peritoneum and also the posterior sheath of the rectus
muscle. The clips are given to an assistant, who holds
them away from the abdominal wound with sufficient
force to facilitate the ready introduction of the stitch.
Too forcible a drag must not be made, or the clip will be
pulled away. A continuous catgut suture is now intro-
duced, beginning at the lower end of the wound. It takes
up on each side the posterior sheath and the peritoneum
together. If the rectus is very thick, a portion of this may
also be included. This is much better than the practice
usually followed of seizing only the peritoneum, for if
there be any tension on the stitches, the needle may cut

3o8 Operations on Gall-bladder and Bile-ducts

thr^Axgr*. or the stitch, after being tightened, may break
awav. This stitch is continued from the lower end of
the incision to the top if the wotmd is to be closed com-
pletely. If a drainage-tube is left in the wound, the
stitch is continued up to the tube. The same stitch
having reached the upper end of the wound, or the
tube, is now introduced from above downwards, seizing
the rectus muscle and the anterior sheath : when the lower
end of the wound is reached, the end of the suture is tied
to that end which was left long when the stitch was
begun. The stitch is carefully introduced and accurate
apposition ensured. In thin patients this suture is quite
enough to ensure a firm cicatrix, but in stout patients,
or in any patients whom, because of old age or feebleness
or old-standing chest disease, I may w-ish to get out of
befl within three or four days of the operation, I first in-
trrxluce a series of deep silkworm-gut sutures. These are
introduced about one-half of an inch from the margin of
the wound ; they pass through all the structures of the
abdominal wall except the peritoneum, being brought
out on the one side and re-introduced on the other between
the iJ<jsterior rectus sheath and the peritoneum. These
sutures are placed about three-fourths of an inch apart.
They are not tightened until the catgut suture has been
passed, as already described. When this catgut suture
is completed and its ends cut short, the silkworm-gut
sutures are knotted. It is not necessary — it is, in fact,
harmful -to draw them very tight. As long as they draw
the opposing walls comfortably together, that is all that
is n('(!dc(l. Tension is to be avoided. A continuous
stitch of thin Pagenstechcr thread is now introduced close

Cholecystotomy 309

to the wound edges to ensure accurate skin apposition.
However carefully interrupted sutures are passed there
is a risk of having overlapping of the skin edge, and,
therefore, delay in the sound and perfect healing of the
wound. For this suture a triangular pointed straight
needle is used.

THE OPERATIVE TREATMENT OF STONES IN THE GALL-
BLADDER.

When stones are present in the gall-bladder, they may
be removed by cholecystotomy or by cholecystectomy.
The operations well be separately considered.

CHOLECYSTOTOHY.
Indications for the Performance of the Operation of
Cholecystotomy. — Cholecystotomy is the operation most
commonly practised at the present day for stones which
are found in the gall-bladder, Under certain circum-
stances it has been replaced by the operation of cholecys-
tectomy. As to the conditions which demand the latter
operation, and as to those in which it will probably be
the operation of choice, I propose to speak later. There
are, however, certain cases for which cholecystotomy
will always remain the only satisfactory operative pro-
cedure. Though the experience of many surgeons
seems to be urging them to perform cholecystectomy
far more frequently than before, there will always
be some cases for which cholecystotomy must be per-
formed. The need for this particular operation will
be determined in part by the conditions found when

3IO Operations on Gall-bladder and Bile-ducts

the abdomen is opened and the bile passages ex-
plored, but more often by the general condition of
the patient. In not a few gall-stone operations, es-
pecially in older people sufTering from a severe infec-
tion, that operation is the most desirable which gives
the speediest relief. It is not a permanent cure of the
disease that at such a moment is the surgeon's chief de-
sire, but rather some quick and assured means of giving
relief to urgent and threatening symptoms, so that the
patient may be brought safely through a time of great
peril. When the danger is past, then a further step
towards the permanent cure of the condition may, if
necessary, be safely taken. Broadly speaking, there-
fore, cholecystotomy will be demanded where there are
the acute infective conditions for which instant relief
is necessary and in patients whose powers of withstand-
ing the shock of any detailed operative procedures are
small. That surgeon will have the best results who does
not always follow any method, but, taking a just measure
of his patient's powers, chooses that measure of relief
which seems to him, in each case, to be the best ; one in the
practice of which he is the most expert. This is more
especially the case in gall-stone surgery, for so many con-
ditions, each one a menace to the patient's life or comfort,
may be present at the same time. A stone in the am-
pulla, infectious cholangitis, cholecystitis with ulceration
of stones into the liver, for example, were present in two
consecutive cases of my own. For the gall-bladder con-
dition alone, cholecystectomy would have been correct.
But whether in such circumstances it should be done in
the presence of the other conditions will depend upon the

Cholecystotomy 3 1 1

patient's condition, the difficulties or the ease of that
particular operation, the surgeon's former experience, and
so forth. In these two, I performed transduodenal
choledochotomy and cholecystectomy, and after taking
away the cystic duct, I left a tube in the common and
hepatic ducts. Both patients recovered. To have at-
tempted such an operation in old or weakly patients
would have been worse than folly.

One point which requires further investigation is as to
the frequency and the character of the after-results of
cholecystotomy, It is desirable that we should know of
the frequency of recurrence of gall-stones (and this should
be distinguished from the spurious recurrence which is
the sequel of incomplete removal of stones), and of the
symptoms that ensue when adhesions have formed to a
chronically inflamed gall-bladder, even after all stones
have been removed. Of the former some evidence is
forthcoming, though no doubt it is not all available ;
of the latter there is also evidence, and Furbringer
(Arch. f. phys. u. diat. Therap., July, 1903) has said
that " post-operative adhesions to the gall-bladder
embitter the lives of many patients."

The majority of surgeons will agree with Dr. Maurice
Richardson when he says (Med. News, May 2, 1903, p.
817): "The end-results in simple cholecystotomy are
certainly as gratifying as end-results have ever been in
any class of abdominal operations."

Operation. — The operation of cholecystotomy has
been practised in two ways: In one, the gait-bladder,
after being opened and cleared of stones, is stitched
up and returned within the abdomen ; this method

1^ .rM

tTwji^, zn

Hm -atie-mcs

er.rr^^.

f. "g^

a^^

:e :?n

•«•:.

-» ^<<'

"^v^ V". m r!. izt'jk/zii T'Jz

-T

Hit 12a

^ r f ri^-^ r . r

rue

^ ' * » ...

^.^ ,...,. A ^^,, .<,":!^ i. f : :?t , -,-;;- c •? -. .•^-.'-T^-
^/» It.. .AV. .*.• . . ,^:'^...-^ ,, i^. . ,»^.'^i ki -T —IT L'lilC

'/f th#: rr/j/'//^'t :^rr-,:>-^:r*jr stor.e-forrr.ir.z catarrh which
7/;i'.; x*".\tt,xx\\\}\t', ir. th^r first instar.ce for the forma-
Unu tt\ yjiW WfTii'h. " Ideal cholecystotomy" is any-
ifiin;< f/iit, id*-al in practice, and is an operation
Ui/it i<v fri<-ntioned now onlv that it mav be une-
/liiivor;ilIv rondrrnned.

r4ioIr(y«,t/;t/;friy is jxrrformed in the following manner:
WImmi I.Im' ;d>dofncn lias been o7>ened in the manner al-
M'/idv d<".(rilw'r|, and tli(! ^all-bladder and ducts and the
iM'iid ol llir |»,'incn'as thoroti^lily explored and freed from
nil ndlir'.inu:;. Ilir operative area is ])acked round with
j|ini/r r.wab'. wiMin)f out. of hot sterile salt solution. If

Cholecystotomy 3 1 3

the gall-bladder is of moderate or large size, it will be
found quite easy to draw the fundus up into the wound.
An aspirating needle is now thrust into the fundus of
the gall-bladder and all the fluid contents drawn away.
While this is done, the fundus should be seized with a
Spencer Wells clip on each side of the puncture, to steady
the gall-bladder and to hold it forward when it is empty
and perhaps collapsed, so that it does not slip away when
the needle is withdrawn. The fluid removed from the
gall-bladder should be considered septic. The needle,
therefore, which has been within the bladder should
not be touched, nor should any drop of exudate from the
puncture be allowed to soil the hands or any portion of
the wound. The swabs used to mop the puncture, or
those which in a later stage are soiled with the fluid from
the bladder, should at once be thrown away. The
puncture in the fundus is now enlarged with a snip of
the scissors until an opening about one-half of an inch or
even longer is made. The clips which hold the fundus at
each side of this incision are now removed and reapplied
so that the edge of the incision is seized. By their means
the wound can now be held opened, or when they are
crossed over, can be securely closed. Through this open-
ing a large gall-stone scoop is introduced, and the stones
removed. If there are many stones, it is advisable to
remove only a few at a time; if the scoop be overfull,
it is difficult to withdraw from the gall-bladder and some
of the stones may fall away into the swabs, and will have
to be sought. It will often be found that if many stones
are present in the gall-bladder, the smaller ones will be
near the fundus and one or more larger ones will lie in the

314 Operations on Gall-bladder and B3e<lucts

pelvis, near to but not occluding the opening into the
cystic duct. When all the stones that can be felt with
the scoop are removed , the dips on the edge of the opening
are crossed so as to pull the edges together, and the fundus

Fig. 64. — Shewing the drainage-tube fixed in the gall-bladder by
a single catgut suture and the method of infolding the edges of the
wound in the gall-bladder.

of the gall-bladder is wrapped in gauze. The swabs which
lie beneath the bladder are then removed or pushed
aside, and while the left hand holds the gall-bladder,
the fingers of the right hand are slipped along the under
surface and the ducts are again explored. If a stone or
stones be felt in the cystic or hepatic ducts, an attempt is

Cholecystotoniy

315

made to "milk" them backwards into the gall-bladder.
If any difficulty is experienced with a stone in the pelvis
or in the cystic duct, the scoop may be re-introduced,
and may be worked within the bladder in concert with
the fingers outside. In this fashion a stone which is
seemingly imprisoned may be dislodged. When all stones
are, so far as can be seen, entirely cleared away, a final
examination of the duct
is again made, and if
they are found to be
clear, the swabs may be
removed from the kid-
ney pouch and from
above the stomach, one
swab only being left be-
neath the centre of the
wound. A tube is now
introduced into the gall-
bladder. The size most often tised is about one-
third of an inch in diameter. About two to three
inches are laid within the gall-bladder, so that the
end of the tube reaches approximately to the pelvis.
The tube is now fixed by a single catgut stitch which
passes, on the one hand, through all the coats of the
gall-bladder except the mucosa just beyond the edge of
the opening, and, on the other, through the tube. This
is tied, and the tube thereby is fixed firmly. The incision
and this stitch are now buried in one of two ways : either
by taking a purse-string suture around the wound and
tightening this, as the tube is pushed deeper into the
gall-bladder, as is done in Senn's method of gastrostomy.

Fig, 05.— Gall-li
around drainage-tube by 1
purse- string suture.

3i6 Operations on Gall-bladder and Bile-ducts

or a continuous stitch is taken from side to side of the in-
cision, taking all the coats except the mucosa, so that on
drawing this tight the edges are infolded, as in Kader's
method of gastrostomy. The stitches in either case
are made to embrace the tube closely so that no leakage
can occur by its side.
The swab within the
abdomen is now re-
moved, and the ab-
durainal wound closed
in the usual manner.
The gall-bladder may
be allowed to fall back
within the abdomen,
or, preferably, it may
be fixed to the parietal
peritoneum in the fol-
lowing way : The con-
tinuous suture, of cat-
gut which is first in-
troduced to suture the
peritoneum and the
posterior sheath of the
rectus is begun at the
^'■- lower end of the

wound. When it
reaches the middle or a little above the middle, the
needle is passed through the wall of the gall-bladder,
avoiding the mucosa, as it crosses from the left to the
right edge of the wound. The stitch then returns to the
lower end of the wound, taking the anterior sheath of the

_L,

m

Fig. 66 ^Drainage-tubes: a. Split
rubber tube with gauze wick; b. the
rolled tube of gauxe and dental rub-

operations for Stone in Cystic Duct 317

rectus. The upper part of the wound, that which Ues
above the tube, is similarly treated, the stitch now begin-
ning at the top of the wound and working downwards
to the middle until the gall-bladder is reached, when, as
before, a single suture is passed through it. The gall-
bladder is then held by two stitches, one above, one
below. There is no need to fix the gall-bladder by
interrupted sutures closely placed together, or even by a
continuous suture. The two stitches passed in the
way described suspend the gall-bladder quite sat-
isfactorily.

THE OPERATIVE TREATMENT OF STONE IN THE CYSTIC

DUCT.

When a stone is present in the cystic duct, it may be
loosely fixed, being contained in a pouch or diverticulum,
and interfering very little with the passage of bile and
mucus, or it may be tightly wedged in the duct and in this
way may cause a condition of hydrops or of empyema,
or. in the latest stage, of cysto -intestinal fistula. A stone
wedged in the pelvis of the gall-bladder is not to be
distinguished from a stone in the cystic duct, for, when
it has been long stationary, the gall-bladder may narrow
behind it, forming an " hour-glass gall-bladder," the
pouch in which the stone is lying then resembling a
dilated cystic duct.

When the stone is found in the cystic duct, it may be
dealt with by crushing, cholelithotriiy, by incision of the
duct, cysticotomy, followed by suture of the duct or
drainage, or by cholecystectomy, the gall-bladder and

H

3i8 Operations on Gall-bladder and Bile-ducts

cystic duct being removed in mass or by cholecystoU
omy.

Of the operation of cholelithotrity, whether for stone in
the cystic or for stone in the common duct, I have not
had, and I do not anticipate that I shall have, any ex-
perience. The method seems to me to be one that was
only fitted for, perhaps compulsory in, the earliest days
of the operative treatment of gall-stones. But at the
present time it is rarely if ever necessary, and should only
be reserved for those cases where any other method of
removal seems impossible or extremely hazardous. The
disadvantages of the method are that it is likely to
damage the duct, and therefore,. perhaps, to lead to rup-
ture, ulceration, or stenosis, that it is uncertain, — other
stones being overlooked and left untreated, — and that
some fragments of the crushed stone may remain behind
to form the nucleus of other stones. It is, in fact, a crude
and imperfect method. The needling of a stone or stones
through the duct wall finds no place in the surgery of
to-day.

Cysticotomy. — The removal of stones from the cystic
duct through an incision which is subsequently sutured,
or into which a drainage-tube is introduced is an operation
that is occasionally, though rarely, necessary. The
operation was first performed by Lindner in 1891 upon a
patient from whom he also removed the gall-bladder.
Kehr in 1892 removed a stone from the duct and closed
the opening by suture, draining the gall-bladder.

The neck of the gall-bladder and the cystic duct are
exposed by the method of rotation of the liver already
described. When the duct is exposed, it is incised, the

Cysticotomy

319

stone or stones removed, and a further exploration of the
duct made at once. If the bile passages are found to be
clear, the wound may be closed by a continuous catgut
suture which misses the mucosa. This will close the
incision satisfactorily, but a second supporting layer of
sutures, either of catgut or preferably of thin celluloid
thread, should also be introduced. A drain is then
placed in the gall-bladder and the abdominal wound is
closed in the usual way.

When the stone is tightly wedged in the duct and
hydrops or empyema -has resulted, the operation to be
practised will depend very much upon the general condi-
tion of the patient and upon the especial conditions found
when the field of operation is exposed. As a rule,
cholecystectomy should be performed. It is the operation
I perform as the routine procedure, in the absence of
special circumstances which would add an undue risk
to its performance. I have removed the gall-bladder and
the cystic duct upon several occasions for these condi-
tions, and the results have been remarkably good. In
seven cases of empyema I have lost one patient, on the
eleventh day, from suppression of urine, and of five cases
of hydrops I have not lost one, and in one case of gangrene
of the gall-bladder the patient reco%'ered.

If, however, the condition of the patient is poor and her
power of bearing any operation is but small, or if the
gall-bladder be adherent, or the mechanical difficulties
of the operation, owing to thickness of the abdominal
walls, be considerable, cholecysiotomy should be per-
formed.

It will be found helpful, then, to aspirate the contents

3IO Operations on Gall-bladder and Bile-ducts

the abdomen is opened and the bile passages ex-
plored, but more often by the general condition of
the patient. In not a few gall-stone operations, es-
pecially in older people suffering from a severe infec-
tion, that operation is the most desirable which gives
the speediest relief. It is not a permanent cure of the
disease that at such a moment is the surgeon's chief de-
sire, but rather some quick and assured means of giving
relief to urgent and threatening symptoms, so that the
patient may be brought safely through a time of great
peril. When the danger is past, then a further step
towards the permanent cure of the condition may, if
necessary, be safely taken. Broadly speaking, there-
fore, cholecystotomy will be demanded where there are
the acute infective conditions for which instant relief
is necessary and in patients whose powers of withstand-
ing the shock of any detailed operative procedtu^es are
small. That surgeon will have the best results who does
not always follow any method, but, taking a just meastu^e
of his patient's powers, chooses that measure of relief
which seems to him, in each case, to be the best ; one in the
practice of which he is the most expert. This is more
especially the case in gall-stone surgery, for so many con-
ditions, each one a menace to the patient's life or comfort,
may be present at the same time. A stone in the am-
pulla, infectious cholangitis, cholecystitis with ulceration
of stones into the liver, for example, were present in two
consecutive cases of my own. For the gall-bladder con-
dition alone, cholecystectomy would have been correct.
But whether in such circumstances it should be done in
the presence of the other conditions will depend upon the

Cholecystotomy 31 1

patient's condition, the difficulties or the ease of that
particular operation, the siirgeon's former experience, and
so forth. In these two, I performed transduodenal
choledochotomy and cholecystectomy, and after taking
away the cystic duct, I left a tube in the common and
hepatic ducts. Both patients recovered. To have at-
tempted such an operation in old or weakly patients
would have been worse than folly.

One point which requires further investigation is as to
the frequency and the character of the after-results of
cholecystotomy. It is desirable that we should know of
the frequency of recurrence of gall-stones (and this should
be distinguished from the spurious recurrence which is
the sequel of incomplete removal of stones), and of the
symptoms that ensue when adhesions have formed to a
chronically inflamed gall-bladder, even after all stones
have been removed. Of the former some evidence is
forthcoming, though no doubt it is not all available;
of the latter there is also evidence, and Fiirbringer
(Arch. f. phys. u. diat. Therap.. July, 1903) has said
that "post-operative adhesions to the gall-bladder
embitter the lives of many patients."

The majority of surgeons will agree with Dr. Maurice
Richardson when he says (Med. News, May 2, 1903, p.
817): "The end-results in sim(51e cholecystotomy are
certainly as gratifying as end-results have ever been in
any class of abdominal operations."

Operatioii. — The operation of cholecystotomy has
been practised in two ways: In one, the gall-bladder,
after being opened and cleared of stones, is stitched
up and returned within the abdomen; this method

322 Operations on Gall-bladder and Btle-ducts

gall-bladder and the cystic duct together may be removed,
as in the cases under mv own care to which reference has
already been made.

CHOLECYSTECTOflY.

Indications for the Performance of Cholecystectomy. —

In 1902 I read a paper entitled **A Series of Cases of
Cholecystectomy/* before the Yorkshire Branch of the
British Medical Association. I gave then the following
indications for the performance of this operation:

1. In injuries of the gall-bladder, rupture, stab or

bullet wounds.

2. In gangrene of the gall-bladder.

3. In phlegmonous cholecystitis.

4. In membranous cholecystitis.

5. In chronic cholec\''stitis with dense thickening of

the walls of the gall-bladder and cystic duct, with
or without stenosis of the cvstic duct, and in
chronic cholecystitis, when the gall-bladder is
shrivelled and puckered and universally ad-
herent. In such cases it is no longer a receptacle
for the bile.

6. In distension of the gall-bladder, hydrops of empy-

ema, due to blockage of the cystic duct by calculus,
stricture, growth or external inflammatory de-
posits; or in cases of mucous fistula following
c)])eratic)ns for these conditions.

7. In cases of fistula between the gall-bladder or the

cystic duct, on the one hand, and the stomach,
duodenum, or colon, on the other.

8. In multi])lc ulcerations of the gall-bladder or the

cystic duct when gall-stones have eroded their

Choi ecyste cto my

3^3

way through the walls into the Hver, the duo-
denum, or other protective adherent masses.
9. In primary carcinoma of the gall-bladder.

The result of my early cases was so satisfactory that I
was led to put the operation to a more extended proof,
and as my experience increases I am tempted to ask
whether it would not be the better treatment in many
gall-stone operations to remove the gall-bladder entirely.

The experience of every surgeon who has worked ex-
tensively in this field of surgery is that the chief purpose
and the main indication in any operation for gall-stones
is the drainage of the gall-bladder and bile-ducts. Of
the validity of this experience there can be no question.
We know that gall-stones are rendered troublesome by
the cholecystitis or the cholangitis which they are the
means of amusing. In many cases it is because of the
inflammatory consequences that an operation is de-
manded. The essential part of any operation would,
therefore, seem to be the drainage of the gall-bladder,
prolonged for such a time as to allow a complete subsid-
ence of the inflammatory process. But in the very great
majority of cases the secondar>' inflammation has its
origin, and runs its course entirely within the gall-bladder ;
an infection of the hepatic or common ducts does not
occur. In many cases, therefore, in removing the gall-
bladder, we are doing away with the necessity for drain-
age by removing that structure, the drainage of which
seemed imperative. It is within the gall-bladder that
the great majority of stones are formed ; it is within the
gall-bladder that the secondary inflammator\' troubles

r^-j^^j^s.^

\2x ■Jj>cjar«:* oz

C*>^ ^Ti'iv Tirih ibe reeri ::r fr^.^.-.^e I* riencSers less
Hkfely trje f-irrr^ii'.*! :c g^-5^:ce^. 2;nl h r^eoieffs less

If. r/7K'ever. the rkeei f:r irrt^,r,2re is arisohxte, it is
jyAfiible- in fact cui:^ eas}-. Vj ir^in the i:acts after the
gall'bladder h^s been renx/ved. After the division of
the cystk: du-ct the stiin:? of the duct may ^le slit Tip until
the hej>at2c duct is reiiched. or the cystic duct may be
cut off flu-sr. -A-ith the comiTion duct- It is then quite a
simple matter to explore upi^ards and downwards with a
gall-st/^e sc-^x/p or with the finger to make certain that
the ducts are clear of calctili, and then to stitch in, bv a
single catgut suture , a rubber drainage-tube. The presence
of sUmes in the common duct does not debar one from
removing the gall-bladder. In two cases I have removed
sU^nes from the ampulla of Vater by duodeno-chole-
d^x:hoU>my and have then at once removed a chronically
inflamed gall-bladder full of stones which were ulcerat-
ing int^') the Hver, and after dividing the cystic duct
U> the common duct, have stitched in a rubber drainage-
tube. Uoth patients recovered without the slightest
intttrruption. The x^lea, therefore, that the need for
drainage is o]jposed to the routine removal of the gall-
bladder is answered by the facts that when the gall-
bladder is rem(;ved, the need for drainage does not often
(rxist, as that need was due to the presence of the gall-
bla(l(U*r and that if desirable or necessary, it can be car-
rit'(l (Hit without the smallest difficulty.

An examination into the recorded cases of carcinoma of

Cholecystectomy 325

the gall-bladder and of the adjacent portions of the liver
shews that in approximately 95 per cent., the malignant
change is due to the chronic irritation of gall-stones. If
the gall-bladder is removed, there will, of course, be no
chance of this malignant growth occurring. This is not,
however, a point of much importance, for the cases of
carcinoma are, as a rule, those in which no operation has
been done; by the time the surgeon sees the cases the
growth is already there. To make the argument for
cholecystectomy a strong one from this point of view, it
would be necessary to shew that malignant disease oc-
curred after cholecystotomy, and, so far as I know, this
had not been done at the time my paper, already referred
to, was written. Since then, however, my colleague,
Mr. Lawford Knaggs, has recorded an exemplary instance
of this. The case is given at length in the chapter dealing
with the "General Pathology of Gall-stone Disease."
A similar instance is recorded by Mr. Mayo Robson. The
patient was a lady aged fifty-seven, upon whom chole-
cystectomy was performed in February, 1902, A good
recovery followed, and the patient remained well up to
August, 1903, except for pain in the gall-bladder. On
examination, a tender lump could be felt in the gall-
bladder region. On opening the abdomen a second time
in October, 1903, the gall-bladder was found the size
of a small hen's egg, full of solid material. On incising it
the swelling was found to be new growth which was in-
filtrating contiguous parts of the liver. The gall-bladder
and adjoining part of the liver were removed successfully.
Cases such as these strengthen materially the plea for
cholecystectomy.

326 operations on Gall-bladder and Bile-ducts

In the very jfreat majority of operations for gall-
bt^^neii there is ample evidence of long-standing in-
nainniation in and ulxmi the gall-bladder. The normal
smoothness of the gall-bladder is gone, its deep blue
eolour is lost, its once supple walls have become thickened
an<l tough. A glance at a gall-bladder during other ab-
donunal ojn^rations will tell one in a moment whether
sttnies are lying there. If the gall-bladder is blue, it is
healthy ; if ojnuiue and grey or yellow, there are, or there
I'er.tainly have been, stones and a chronic inflammation
amused by them,

\\\ some I ases, therefi^re, it will be conceded that chole-
rysteiituuy is the miuv ilesirable operation, but before
its nn\ti\)e adoption is advwated it is necessar\' to shew
that the ^all bladder is useless, and that its removal does
U\M advl auv risk v^s \.\>m{\\rt\l with oholecystotomy. In
the abstrav t, v^ue nxii^lu Iv inelim\i to think that the loss
v^t a ^\le vv\MU\vMV vMUiMo v^t env^^tvin-: on demand would
iv a Novivnis iwi'.tor u^ :he inviivv.ual. vT .it the least, a
d.wl^l*,\',\ rV-o ivvuvtu^r. o: the !r.^vhan:sm of digestion
>iv^ ^vav^valA toM ^v :\i\n1o\v wouVi s<vn: to require

i« I « ,x« »•••

« * * • ^^^•■**

,\ \ \\ ..»-,s. v—^ ^\» ,. >^ V ■• , . V.-. , • . ^;, ■. . jL-^« «^xr ^ .^^^ «^
...'-..,..; ■ ,- ^->» - "*, * "'•\ ^» ' ' •■«.,-»....•». . .» j^ -.jj.^* » -«•. •*'\-^^r-

. . ' V ..vv '^.. , ^ V >.{j^ .... .>vi , . ... x — *.> *. — .trTTr

■ .-. ., V- ■,-,•: ' •^■,-. ■ ■ : \.: :-:e in.~

Cholecystectomy

327

has the same duodenal digestion as an ordinary healthy
individual. The gall-bladder, therefore, if not useless,
can quite well be spared.

The removal of the gall-bladder in cases judiciously
selected does certainly not involve a greater risk than the
operation of cholecystotomy. I have, in fact, in several
cases been convinced that the removal of the gall-
bladder made the operation simpler and shorter than it
would have been if a multitude of small stones had been
removed. By carrying out the operation in the manner
described below it will be found a safe, speedy, and simple
procedure. During the last three years I have in-
clined more and more to the performance of cholecys-
tectomy, and after some hesitation and some trepida-
tion, which experience has removed, I am strongly dis-
posed to advocate the frequent, though certainly not the
invariable, adoption of this operation in preference to
cholecystotomy. Its advantages are that the operation
removes the chief source of the disease, that it thereby
prevents in great measure a recurrence either of stones or
of the inflammation which betokens their presence, that
growths in the gall-bladder or adhesions around it are
subsequently impossible, and finally that the wound, if
drainage is not required, may be caused to heal through-
out by first intention. The gall-bladder is devoid of any
strikingly useful purpose, and its removal does not add
appreciably to the danger of the operation. If drainage
of the ducts is necessary, it can be carried out quite
satisfactorily. The presence of a stone in the common
duct does not prohibit the operation, but drainage of the
duct, ^fter removal of the stone in the duct or in the
ampulla, is necessary.

328 Operations on Gall-bladder and Bile-ducts

The one disadvantage that may justly be iirged against
cholecystectomy is this: that if a late operation should
become necessary — for stones can, and do, form in the
hepatic and common ducts — such an operation would
be more difficult and almost certainly more dangerous.
The possibility of a further operation being necessary
cannot be denied, but the likelihood of it is negligible.

Dr. W. J. Mayo, of Rochester, Minnesota (Annals of
Surgery, vol. 38, p. 454), gives the following account of
his opinion with regard to drainage in gall-stone opera-
tions :

(i) If the gall-bladder contained bile, and the organ
was distensible, if the gall-bladder was removed, bile
drainage was provided for by cutting the cystic duct
across and leaving it open. If such a patient was very
obese or had degenerative lesions of other organs, he
preferred cholecystotomy. (2) If there were symptoms
of cholangitis, even of mild grade, he provided for bile
drainage, and if the condition was acute, the drainage
must be free. (3) If the gall-bladder contained cystic
fluid, but no bile, and the patient had symptoms of
cholangitis, he removed the organ and cut the cystic
duct below the obstruction to permit of bile discharge.
If necessary, the cystic duct was split down to the common
duct. (4) In a few cases he had directly opened the
common duct for the purpose of securing liver drainage ;
but it was very rare that this was necessar\', unless there
were or had been stones in the cc^mmon duct, and it was
dilated. The cystic duct ordinarily could be advantage-
ously used for the i)urpose ; although in a few instances he
had found it necessary to cut it off flush with the common
duct, leaving a lateral defect in its wall for drainage
purposes. This brought up the question as to how much

Cholecystectomy

329

danger of peritonitis there was as a result of bile leakage
into the peritoneal cavity. If there was free gauze
drainage, with or without tubage, there was but little
danger of peritoneal infection from the bile. He had
never seen a case of death from this cause ; but the drain-
age should be attached to the proper point by a catgut
suture to prevent its floating away by the bile discharge
or displacement by the action of the diaphragm upon the
liver. If the common duct was greatly dilated, and after
removal of the calculi there was considerable detritus,
the end of a rubber drainage-tube was inserted into the
duct opening and secured by a catgut suture. If this
condition did not exist, tubage of the common duct was
unnecessary.

To sum up: Cholecystectomy was to be preferred if
the patient was otherwise in good condition. If the
cystic duct was obstructed and the gall-bladder con-
tained only cystic fluid, ligation of the cystic duct, without
provision for hepatic drainage, was safe. If there was
any infection of the hepatic ducts, bile drainage was
essential.

Dr. Maurice Richardson (Med. News, May 2, 1903) gives
the following indications for extirpation of the gall-blad-
der:

"(i) Certain lesions in themselves demand removal
of the gall-bladder whenever possible. Such are new-
growths and gangrenes. (2) Certain other lesions of
the gall-bladder are better treated by cholecystectomy.
These are the contracted and inflamed gall-bladders,
with thickened walls. All gall-bladders which do not
permit easy and efficient drainage should be extirpated,
for in such gall-bladders the risks of drainage are quite as
great as the risks of extirpation; and the one great

A

330 Operations on Gall-bladder and Bile-ducts

advantage of retention is impossible — retention of the
biliary reservoir to fulfil the functions of that reservoir,
and to permit, if necessary, renewed drainage in future
years. (3) Drainage is preferable in the dilated and in-
fected gall-bladder, which, however, is neither gangrenous
nor to any great extent changed — the slightly thickened
gall-bladder containing gall-stones and infected bile. This
gall-bladder will, after drainage, become normal, and,
therefore, capable of fulfilling the functions of a gall-
bladder. Through it the biliary passages will become
effectually drained, after subsidence of the temporary
swelling about the cystic duct. (4) As a rule, drainage
rather than extirpation is demanded in acute cholecys-
titis with severe constitutional symptoms, when the gall-
bladder is dilated, or at least not contracted, and when it
is not gangrenous. (5) In chronic cholecystitis, with
dilatation and thickening of the gall-bladder, especially
when a stone is impacted in the cystic duct, extirpation
is the preferable operation, unless the stone can be dis-
lodged backwards into the gall-bladder, in which case
drainage is, if not preferable, quite as advantageous as
extirpation. (6) In simple gall-stones, without visible
evidence of infection or chronic changes incompatible
with restoration of function, simple drainage of the gall-
bladder is indicated. ( 7 ) In chronic pancreatitis, whether
associated with gall-stones or not, drainage through the
gall-bladder is .indicated. Cholecystectomy is unjustifi-
able, for immediate drainage is essential. Furthermore,
reopening of the biliary passages may, in the future, be
required.*'

The Operation. — Cholecystectomy was first performed
by Langenbuch on July 15, 1882.

The operation is performed in the following manner:
Mayo Robson's incision is made, the abdomen opened, the

Cholecystectomy ;iT, i

adhesions separated, and the liver rotated in the manner
already described. The gall-bladder may be removed
from before backwards, or from behind forwards; that
is to say, the cystic artery and duct may be first cut
across and the gall-bladder stripped up towards the
fundus, or the peritoneum around the fundus may be first
divided and the gall-bladder stripped up towards the
cystic duct. I have adopted both methods, but prefer
the former, .as the only difficult part of the operation, the
ligature of the pedicle, is accomplished first.

The liver being held upwards, the cystic duct and its
termination in the common duct are defined. A circular
peritoneal incision is now made around the cystic duct
about half an inch from its tennination, and a peritoneal
cufE is stripped up towards the common duct. In this
way the cystic duct is cleared to the view. Two clips
with a curved beak are now placed on the cystic duct, and
the duct is divided between them. The chp on the
gall-bladder side prevents any leakage during the further
steps of the operation. The stump of the cystic duct is
ligatured with catgut, and the clip on its divided end is
removed. The frayed end of the duct is trimmed away
with scissors. The cystic artery and vein are now de-
fined. They lie above and to .the inner side of the divided
duct, and may be readily seen by gently stripping with*
gauze that part of the pedicle which remains. Two clips
are applied and the vessels are divided between them.
The proximal end of the vessels is now ligatured with
catgut and the clip which secures them is removed.
Occasionally, another vessel than the cystic artery may
need to be clipped and ligatured ; it is a separate branch

I

33^ Operations on Gall-bladder and Bile-ducts

of the hepatic which passes to the common and cystic
ducts. If there is no inflammation of the common duct,
and if, therefore, there is no need for drainage, the stump
of the cystic duct may be covered completely by its
peritoneal cufit, which is fixed over it by one or two
sutures of fine Pagenstecher thread. A small flat swab
is then placed over the common duct, and the separation
of the gall-bladder from its fossa is begun. This is most
easily and expeditiously effected by working upwards
towards the fimdus with the index finger, which is in-
sinuated at first between the pel\-is of the gall-bladder
and the liver. The finger may be covered with gauze
so as to make the separation easier. A little patience
will soon secure that the gall-bladder is stripped cleanly
away, and is left attached only by a peritoneal fold
aroimd it. This fold is then divided about one-half to
three-fourths of an inch away from the liver, and the
gall-bladder then comes away. A raw surface fringed
by a collar of loosely hanging peritoneum is now left.
From this raw surface there may be some oozing. This
is checked by the pressure of a swab \\Tung out of hot
sterile salt solution. Rarely a suture may be necessary"
if any vessel bleeds. This is passed with a curv'ed
intestinal needle and tied gently. When all the oozing
has stopped, the peritoneum around the denuded surface
is closed over it by a continuous suture of catgut which
passes from the liver edge to the cystic duct. A final
cleansing of the operative area is needed and the abdomen
may then be closed.

If, however, drainage of the common duct is necessary,
it may 1)e secured in one of two ways, either immediately

Cholecystectomy

333

or after the lapse of a few days. If immediate drainage
is desired, the cystic duct is not ligatured in the manner
described. When that stage in the operation is reached,
the clip is removed from the stump of the cystic duct,
and the cut edges are seized with fine French vulsella.
The duct is slit up and an opening is made into it at
its junction with the hepatic duct, of sufficient size to
permit of the introduction of a rubber tube. This is
fixed in the duct by a suture of catgut which picks up
the wall of the common duct a little distance away from
the cut edge. To the outer side of this tube a second one,
which is split and has a gauze wick, passes backward into
the kidney pouch. This second tube may come through
the abdominal wound or be made to project from a stab-
wound in the loin, preferably the former. If it is thought
desirable to postpone the drainage for a few days, the
following plan which I have found convenient may be
adopted. The chp on the cystic duct is removed and a
small clip placed so that the open end of the duct is just
seized. Around this a single thin catgut ligature is
placed. The peritoneum is not stitched over the stump
of the duct. A rubber tube is now passed down to the
ligatured duct, and it may be fixed by passing a stitch
through it and through the peritoneal cuff. The perito-
neum is not sutured over the divided end of the duct. The
catgut ligature which closes the duct soon gives way. in
three or four days, and bile then begins to flow through
the tube. By this time an impermeable rampart of
adhesions will have formed around the tube, and will
effectually prevent any leakage into the general peritoneal
cavity.

334 Operations on Gall-bladder and Bile-ducts

Drainage may or may not be necessary after cholecys-
tectomy. If cholangitis be present, as in those cases
where a stone is also removed from the common duct or
from the am'pulla, it is certainly necessary. If, however,
the inflammatory changes are limited to the gall-bladder,
drainage need not be provided, the whole abdominal
wound being soundly closed.

LUMBAR CHOLECYSTOTOMY OR CHOLECYSTECTOHY.

In a certain small proportion of cases the opening or
the removal of the gall-bladder in the loin may be deemed
necessar>% as, for example, when a mistaken diagnosis
of renal tumour has been made and the gall-bladder has
been exposed. W. F. Manton (Amer. Med.. Oct. 4.
1902) describes a case of extirpation of the gall-bladder
through a lumbar incision. The diagnosis in this case
was nephroptosis with probable cystic metamorphosis
of the kidney. When the kidney was brought out of
the lumbar wound the gall-bladder, containing a num-
ber of stones, could be easily palpated, and was so thor-
oughly shut off from the general peritoneal cavity either
bv adhesions or V)ecause of its anomalous situation that
the operator was able to remove it, with the cystic duct,
without much difficulty. The gall-bladder and the cystic
duct contained nineteen stones.

CHOLECYSTOTOMY PERFORMED UPON THE LEFT SIDE-

Carl Beck (Annals of Surgery, vol. 2q, ]). 503) records
a case of cholecystotomy in which, owing to trans])osition

Hepaticotomy 335

of the viscera, the liver lay in the left side of the abdomen,
and the incision had, therefore, to be made through the
left rectus muscle.

THE SURGERY OF THE HEPATIC DUCT.

When calculi are arrested in the hepatic duct, they
may be removed through incisions made into the gall-
bladder, into the common duct, or, rarely, into the hepatic
duct itself, or they may be crushed and the fragments
pressed onwards into the common duct. In the very
great majority of instances stones which are felt in the
hepatic ducts can be milked downwards and removed
during cholecystotomy or during choledochotomy. In
very exceptional instances, however, the performance of
hepaticotomy, that is, incision of the hepatic duct, may
be necessary.

Hepaticotomy. — The operation was first performed by
Kocher on Nov. 8, 1889, unintentionally and unknow-
ingly. In the hepatic duct, which was closely adherent
to the gall-bladder, a stone was tightly wedged. The
duct was opened and the stone was removed. Shortly
afterwards the abdomen was re-opened, as symptoms
of peritonitis were present. Bile was found in the general
peritoneal cavity. The patient died.

Other operations were performed by Cabot (1892),
Elliot (1894), Czerny two cases, Kehr, and recently
Delageni^re and Rogers. Cabot's case was one in which
many calculi were removed from the gall-bladder. A
large stone was then felt in the hepatic duct deep under
the liver. The duct was opened with ver\^ great difficulty

336 Operations on Gall-bladder and Bile-ducts

and the stone extracted. The duct and the gall-bladder
were drained and the patient recovered.

Elliot (Annals of Surgery, vol. 22, p. 86) gives the
following account of his case:

** On September 4 I opened the abdomen by an incision
in the upper right linea semilunaris. The gall-bladder
was found empty and flaccid, the ducts were palpated,
and a stone was felt deep under the liver in the hepatic
duct. The stone could not be pushed along the duct
nor crushed with the fingers. No other stone was felt in
the common or cystic duct. After separating numerous
adhesions, the stone was seized between the thumb and
forefinger of the left hand and pulled up from its deep
position. Adhesions and duodenum were pushed aside
until the stone appeared between the fingers with only
the peritoneum and the wall of the duct covering it.
The field of operation was packed with gauze to prevent
contamination with bile, the duct was incised, and a
stone the size of a robin's egg extracted. The duct was
closed at once with catgut sutures, a second row of silk
sutures including the peritoneum being placed outside.
The duct was held with the fingers, and very little bile
escaped. A drainage-tube and gauze were packed down
to the sutured duct. A rapid and complete recovery
followed. The duct did not leak, and on the second day
the gauze drain was removed. On the fourth day the
abdominal wound was completely closed by provisional
sutures. The jaundice had partially disappeared, and
the stools were natural in colour. The patient was w^ell
in three weeks. Eight months after operation he was
known to be in ])erfect health."

In Czerny's case and in one oi Kehr's the duct w^as
ruptured during the manipulations attendant upon the
removal of stones, and the wound was closed by sutures.

Hepaticostomy 337

An interesting case of hepaticotomy is related by Leonard
Rogers. A full account of it is given in the chapter
dealing with stone in the hepatic duct.

The operation of hepaticostomy, or the opening of the
hepatic duct and the suture of the duct in the abdominal
wound, was first performed by Knowsley Thornton in
1888. He removed 412 stones from a dilated hepatic
duct which formed a swelling closely resembling the gall-
bladder. The duct was stitched to the abdominal wall
and drained. The fistula closed in fourteen days.

A remarkable case is recorded by H. V. Chapman. An
abdominal tumour about the shape and size of a large
kidney was felt in the abdomen ; it was connected with the
liver. The abdomen was opened over the tumour by an
incision 13 cm. in length between the umbilicus and the
anterior superior spine. There were numerous adhesions
which were readily freed. The tumour was seen to con-
sist of a portion of the liver near its anterior margin ; at
the lower part the wall was thin and seemed likely to
burst. A trocar was plunged in, and 480 c.c. of lightly
bile-stained fluid were withdrawn. Then with a round
needle the tumour was stitched to the abdominal wall, ,
and a few days later was opened and ii; calculi were
removed therefrom. The case is described by Pantaloni
as "transhepatic hepaticosto»iy." An example of "sub-
hepatic hepaticostomy" is recorded by Nicolaysen of Kris-
tiania. The patient was a little girl, aged eight, in whose
abdomen a cyst 17 cm. long and 15 cm. broad was felt.
The swelling descended about three fingerbreadths below
the umbilicus. A year before there had been jaundice
for three months; from this the patient recovered, and

338 Operations on Gall-bladder and Bile-ducts

attended school to within three days of her admission to
hospital. At the operation the cyst was fixed to the
abdominal wall, and six days later was aspirated. Death
occurred on the following day. The cyst was found to be
formed by a dilatation of the whole of the hepatic and of
a part of the common duct. The hepatic duct had been
stitched to the abdominal wound. There was no tumour,
and no stone could be found. Nicolaysen considered
that the deformity was congenital in origin.

Leonard Rogers (Brit. Med. Joum., vol. 2, 1903, p.
706) records a case in which the hepatic duct was opened
under the impression that it was the gall-bladder; it
was brought to the surface and -drained. The patient
died the next day; it was then found that the hepatic
duct, and not the gall-bladder, had been opened. The
duct was immensely dilated behind an impacted stone.

Access to the duct may be readily obtained, as was
first shewn by Elliot, by placing a sand-bag under the
patient's back at the level of the liver. The manoeuvre
of rotation of the liver already described makes it a simple
matter to expose the duct to view and to easy handling.

The operation of hepaticolithotripsy, or the crushing
of a stone in the hepatic duct, is at times the safest and
the speediest method of dealing with such an obstruc-
tion. It was first suggested by Kocher in 1890 and has
been j)erformed by Mayo Robson, Delageniere, and re-
cently by Marcel Baillet (Bull, et Mem. Soc. de Chir.,
vol. 29, ]). 1194). Tlie last case was one in which chole-
dochotomy and suture of the common duct had been per-
formed. The svniptoms were not relieved, and nine davs
later the abdomen was re-opened and a stone, found
in the hepatic duct, was crushed. The result was good.

CHAPTER XI.

OPERATIONS FOR OBSTRUCTION OF THE COHHON

DUCT.

CHOLEDOCHOTOJilY.

A stone may be impacted in the common duct in any
point of its course. The stone may be solitary, or there
may be, and commonly are, more stones than one. A
stone may be fixed in the ampulla and a second stone,
or several, may be wedged in the upper part of the duct,
or even in the hepatic duct.

Access to the duct may be obtained in three positions,
corresponding to the three divisions of the duct already
described.

1. As the duct lies in the free edge of the gastro-

hepatic omentum; the supraduodenal portion.

2. As the duct lies behind the duodenum ; in the retro-

duodenal portion.

3. As the duct lies within the wall of the duodenum;

the transduodenal portion.

The operation of choledochotomy consists in the open-
ing of the duct in any of these three positions.

First. — Choledochotomy performed upon the first por-
tion of the common duct. The operation was first
suggested by Langenbuch in 1884, first performed by
Kiimmell in the same year, and first performed success-

339

340 Operations on Common Duct

fully by Knowsley Thornton in 1889. This is the simplest
operation, and in my experience has been that which I
have been most frequently called upon to perform.

The position of the patient during the operation is a
matter of great importance. All the steps of the opera-
tion, up to the suture of the abdominal wound, are simpli-
fied by placing a large sand-bag under the patient's
back behind the liver, as already described. The table
may be slightly tilted so that the feet of the patient are
lowered four or five inches, and the head correspondingly
raised. Mayo Robson's incision is made, — that is, a
vertical incision about five inches in length near the outer
border of the rectus, — and an oblique upward and in
ward prolongation from this about one-half of an inch
from the costal margin for about two inches, or more if
necessary. The abdomen is opened, the kidney and
stomach swabs carefully placed in position, all adhesions
carefully separated by gauze stripping or divided and
ligatured, the bleeding points being carefully sought and
at once ligatured in this, as in all stages of the operation.

The gall-bladder and the edge of the liver are now
grasped in the hand, being first covered by gauze, so that
a firm grip may be obtained. They are dragged gently
but firmly downwards from under the costal margin,
and the liver is then rotated so that the posterior surface
of the gall-bladder now looks forwards and upwards, and
the common duct is stretched and V)rought much nearer
to the abdominal wall. In thin patients the common
duct is brouij^ht quite on a level with the skin wound;
in fat patients this is not possible, but in all the duct is
made easv of access. It is ])ossil)le to exi)lore it thor-

Choledochotomy 341

oughly, to incise, and if need be to stitch, it without, as
a rule, any difficulty.

The common duct now being exposed is surrounded
very carefully with swabs and the position of the stone
defined. It will often be found to slip about in the dilated
duct, and to be very elusive. This is from some points
of view a disadvantage, but it often enables the surgeon
to move a stone impacted low down in the duct into the
upper and more accessible portion. The stone is now
grasped between the index finger and thumb of the left
hand, and the duct incised over the stone, the cut being
of such size as to permit the easy removal of the stone.
With a pair of forceps or with a gall-stone scoop the
stone is now dislodged. Immediately after it bile will
flow, and this the assistant wipes away at once, before
there is time for it to soil the parts around. Such bile
is always, or almost always, infected by the bacillus coli
communis, if not by other organisms. Any other visible
stones are removed, and the scoop is passed upwards
and downwards along the ducts to explore. It will
always be found that the duct is of large size, partly as
the result of an old-standing cholangitis, partly perhaps
because of the increased tension of the bile therein. The
duct will, therefore, be large enough in most cases to
admit the finger — and in this way alone can a perfectly
satisfactory exploration of the duct be made. A stone
that will evade detection by the scoop is at once per-
ceived by the finger. The finger, therefore, should
always be passed both upwards and downwards along
the duct and a free exploration made. A stone even in
the ampulla may, by the conjoined manipulation of the

342 Operations on Common Duct

fingers on the duodenum and a finger within the duct, be
coaxed upwards into the duct and removed.

This digital exploration should always be resorted
to in common duct stone — but it must be remembered
that the duct is a septic tract. A glove finger may,
therefore, be put on before the exploration, or the glove
on that hand may be changed. After the duct is cleared
of stones two courses are open to the surgeon: he may
either close the duct by suture, or he may drain the duct
bv a rubber tube. Each case must be decided as seems
best, but, on the whole, it will be found both desirable
and necessarv to drain.

Drainage of the common duct may be direct or in-
direct — direct when a tube is introduced into the open-
ing in the duct made for the extraction of the stone,
indirect when the duct is sutured and a drain is left in
the gall-bladder, or in the stump of the cystic duct, left
after removal of the gall-bladder. In some instances one
method, in other instances the other, may seem the best.
But in nearly all cases (h*ainage V)y one or other of these
methods is imperative. If the common duct is closed
by suture and the i(all-bladder drained, it is prudent
though not ahvays necessary to leave in the wound a
wisp of gauze whose end lies against the sutured line.

If drainage is employed, a rub])er tube is passed up-
wards towards the hepatic duct for about an inch. If
the opening in the duct is very wide, it may be narrowed
bv a stitch or two of catgut, introduced l)v Lembert's
method. The tube is stitched in l)y a single catgut
suture, which ])icks up the wall of the c(.)nimon duct a
little outside the edge and passes through the tube. So

Choledochotomy 343

long as this stitch holds, and it holds about seven to ten
days, the tube will remain in place. In addition to this
tube another drain is necessary on the outer side of
the duct. For this I prefer a rubber tube, split longi-
tudinally, with a fine gauze wick. The tube lies to the
outer side of the duct in the kidney pouch; it may be
brcnight out of the abdominal incision, or made to present
in a stab wound in the loin, preferably the former. A
third tube to lie to the inner side of the duct is occasionally
necessary. The gauze wick projects about two inches
from the inner end of these tubes. These tubes are left
in from three to ten days, as seems necessary. There is
no advantage in removing them early.

If it is deemed prudent, the common duct may be
closed by suture. This is done by a continuous stitch of
catgut or fine celluloid thread taken from end to end of
the incision and introduced in two layers. It is import-
ant to avoid wounding or penetrating the mucosa, as any
suture which gains access to the lumen nf the tiuct may
form the nucleus of a calculus. When the wound is
securely closed, a split rubber tube with a gauze wick
may be passed down to the duct, as a matter of pre-
caution in the unlikely event of any leakage ensuing.

There does not seem to be any general agreement
among surgeons as to the propriety or advisability of
adopting drainage after the removal of a stone from the
common duct, A discussion was recently held at the
Soci6t6 de Chir. de Paris {Bull, et Mem. de la Soc. de
Chir. de Paris, vol. 29. p. 1194) in which several surgeons
gave their experience. Michaux in tweU'e choledochot-
omies had sutured the duct in all, and the results were

344 Operations on Common Duct

'ver-/ satis: ar.vjT'/." A drain was left in contact with
the suture Irr^e. and in "three or four" there was a slight
escape of bile. Ouenu had abandoned suture entirely,
as second operations. OT*-ing to blockage of the duct by the
infolde^! mucosa or blood clot, were sometimes called for.
Schwartz considered that suture of the duct might be
resp-^nsible for certain disasters, and he advised drainage
in all cases. Hartmann considered that suture of the
common duct was "alwavs unnecessary, and sometimes
harmful." In my own early cases I not infrequently
stitched the wound in the duct, but in a series of sixteen
consecutive cases I have drained the duct and all the
patients have recovered.

The whole f>peration area is now gently wiped with
sterile swabs wrung out of salt solution, and the liver is
replaced, and the abdominal wound closed in part, or
whollv, as mav be necessarv.

Second. The retroduodenal portion of the duct may be
reached from behind by a procedure similar to that
emplr)yed In' Kocher in the ** mr>bilising of the duodenum *'
as a ])reliminary to the performance of gastro-duodenos-
tomy. This method was suggested at the German
Surgical Congress in i8q8 by Haasler. It had been found
necessary three times in eighteen operations for stone
in the common duct. Oscar Block of Copenhagen has
described a similar operation to this. In the very great
majority of cases a stone which appears to be fixed in this
])ortioii of the duct can l)e moved upwards into the first
])ortion. The o])cralion to he now described is, therefore,
very rarely necessary.

The common duct is exposed in the manner already

Choledochotomy 345

described. The parietal peritoneum of the posterior
abdominal wall is now incised vertically about one and
one-half inches to the right of the duodenum. The
fingers are introduced into this incision and the peri-
toneum stripped up until the duodenum is reached. By
dragging gently on the second part of the duodenum, it
can be turned over to the left so that its posterior surface
is visible. A stone seated in the second portion of the
duct can now be felt, and the duct over it incised. This
part of the duct is either covered by, or lies in, a groove
within the pancreas. The gland must, therefore, be cut,
or be separated by blunt dissection. In Haasler's three
cases the former procedure was once necessary, the latter
twice. Vautrin has suggested the division of the pan-
creas by means of the thermocautery. After removal of
the stone the duct is explored and sutured, and a gauze
drain left in the posterior peritoneal wound. A sound
healing of the duct without leakage is not likely to occur,
the duct being here devoid of any peritoneal investment.
Third. The third portion of the duct including the
ampulla may be reached by what is known as diwdeno-
choledochotomy. The duodenum is opened and the ter-
mination of the duct in its second portion exposed,
and the stone or stones extracted therefrom. The
operation was devised and first practised by Dr. Mc-
Bumey of New York in 1891. The earlier stages of the
operation are those which have already been described.
The stone impacted in the lower end of the duct or in the
ampulla is often elusive, being recognised only after close
palpation, and shewing a tendency to slip easily away
from the fingers which grasp it. The duodenum is

346

Operations on Common Duct

exposed, and if deeply placed or not easily accessible,
it may be freed by a vertical incision in the peritoneum
to its right side, as already described. The stone is
fixed by grasping it between the thumb and the fingers
of the left hand. The duodenum is then opened by a
vertical incision about one inch or a little more in length.
The edges of this incision are grasped with fine vulsella
and held apart. The greatest care is taken to prevent

L

projecting thereinlo

any leakage from the duc»denum. The fluid therein is
mopped, up by swabs, which are at once thrown away.
As a rule, the ampulla, with the stone, is seen at once, and
the stone may even be v-isible through the patent orifice.
If so, an incision is straightway made through the mucosa,
slitting up the lower end of the duct, and the stone is
lifted out with a scoop, or the orifice of the ampulla may
be dilated by introducing a pair of forceps and widely

Choledochotomy 347

separating the blades (CoHins's method). If there is any
difficulty in locating the ampulla, search must be made
for the longitudinal fold, which is generally recognised
without difficulty. If the stone is above the ampulla,
the lowest part of the duct should be slit up from the
ampulla and a scoop introduced. This, with the aid of
the finger of the left hand, will generally dislodge the stone
at once. The clearance of the duct is recognised by the
immediate flow of bile. The duct should then be ex-
plored with a scoop or with the finger, and any other
stones removed. If any stones are felt higher in the
duct, they may be worked downwards by means of the
left forefinger and middle fingers passed through the
foramen of Winslow, behind the supraduodenal portion of
the duct, and the left thumb in front of the duct. Be-
tween the fingers and the thumb the duct can be " milked"
and any stones forced downwards into the duodenum.
There is no need to put any suture in the opened ampulla
or duct. The duct lies, at this point, actually in the
duodenal wall, and, therefore, there is no risk of leakage.
In fact, the leaving of a wide-mouthed termination to the
duct probably allows of free drainage of the duct for
some period. If, however, the stone lies in the second
portion of the duct, sutures must be introduced to fix
the opened duct into the duodenum, else will leakage
occur, and bile will be poured into the peritoneal cavity.
The duodenum is then closed by a double row of sutures,
the first taking all the coats, the outer one only the serous
coat. The strictest cleanliness is observed throughout
the operation, and any soiling from the duodenum thereby
prevented. Drainage of the abdominal wound is not
necessary.

34^ Operations oh Common Duct

It will be seen that two distinct methods of removal of
stones from the lower end of the common duct through
the duodentun may be practised. Jn the one» the axa-
pulla is dilated or incised, or the third portion of the duct
divided, and the stone removed therefrom ; in the otheTt
the lower part of the pancreatic portion of the duct im-
mediately above the ampulla is opened. In the former,
the third portion of the duct or the ampulla is opened;
in the latter, the lower part of the second portion of the
duct.

The opening of the ampulla is McBtimey*s method.
Since the duct immediately above the ampulla lies in the
wall of the duodenum, there is no opening up of any space
outside the duodenal wall by an incision upon a stone
lying therein. No suture, therefore, is necessary; the
slitting up of the ampulla merely results in the leaving of
a wider end to the common duct.

The opening of the second portion of the duct from the
duodenum was first performed by Kocher in 1894. In
this operation the wall of the duodenum is cut completely
through. Immediately outside the duodenum lies the
overdilated duct containing the impacted stone, which
causes the wall of the duct to be lightly pressed against
the duodenum. A part of the pancreas may intervene,
but owing to the encroachment of the stone upon the
duodenum, it has probably undergone atrophy from
pressure, and has become fibrous as a result of chronic
inflammation. In the majority of the cases recorded
the common duct seemed to lie immediately outside
the duodenum. When the duct has been opened by
this route, its closure may be effected by suture, or the

Choledochotomy 349

wall of the duct may be suttired to the wall of the duo-
denum in such a manner as to ensure the formation of a
choledocho-duodenal fistula. The operation was indeed
described by Kocher under the term choledocho-diio-
deiwstomy. During the manipulations necessary to ex-
pose the duct and to liberate the stone the duodenum,
duct, and stone, should be grasped between the fingers
and thumb of the left hand, in order to prevent the elusive
calculus from suddenly slipping away.

After the stone is removed, by forceps or by a gall-stone
scoop, bile will flow freely from the opened duct. The
scoop should be passed upwards and the whole duct
carefully explored, in order to see if other stones are
present.

After the completion of the suture line posteriorly the
duodenum is closed, and the abdominal wound dealt with
in the usual manner.

The following description of this operation is given
by Kocher. (Stiles* translation of Fourth Edition, p.

The operation is as follows:

The stone situated behind the duodenum is fixed with
the finger, and after the duodenum has been opened,
as above described, at a point opposite to the stone, an
incision is made down on to the stone. Whether the
incision should be transverse or longitudinal will be
determined by the position and shape of the stone. The
distended common bile-duct is more likely to be found
applied to the duodenum in the whole length of the
necessary incision, if the latter be made in the long axis of
the stone. In this case also we advise, as does Elliot,

350 Operations on Common Duct

for choledochotomy in general, that the wall of the
duodenum and bile-duct right down to the stone should be
seized with artery forceps as soon as incised, and, if
necessary, a stitch rriay be passed through the middle
of the entire thickness of both edges of the woimd, so as to
keep up the apposition of the two walls and facilitate a
choledocho-duodenostomy, as we have termed the opera-
tion, if this be required. After the stone has been ex-
tracted, the canal should be probed — ^with the finger if
possible — so that other stones may not be overlooked.
Whether the opening is now closed in the ideal way (by
a suture through the whole thickness of the wound, with
a secondary suture to approximate the mucous edges)
or not, must depend upon whether the opening in the
papilla is stenosed or not. As a general rule, it will be
found advantageous to make sure of a considerable open-
ing where there is a danger of the formation of new stones.
If the opening is not required, it will contract of its own
accord. A suture should, therefore, be put in all round
the opening through the whole thickness of both canals.
In Kocher's and Kehr's case, in which this method was
adopted, no bad consequences resulted from chance
regurgitation of intestinal contents.

The following case, in which Kocher's operation of
choledocho-duodenostomy was performed, is related by
Thienhaus (Annals of Surgery, vol. 36, p. 928) :

The patient was a woman fifty-three years of age who
had complained for five or six years of severe attacks of
epigastric pain. For twelve months, since an extremely
acute attack, she had been intensely jaundiced, and had
lost during that time 102 pounds in weight. From the
sudden onset, the unvarying jaundice, and the absence of
swelling of the gall-bladder a diagnosis of complete ob-

Choledochoiomy

35'

struction of the common duct was made, and operation
was undertaken.

"A large bag was put under the Hver of the patient,
and then the abdomen opened by a longitudinal incision
on the outer border of the rectus muscle. After freeing
some adhesions with the omentum, the gall-bladder and
a part of the cystic duct were found transformed into
a rocky-iike mass of the size of two thumbs, the gall-
bladder containing not a drop of fluid. After a large
incision into the thickened wall of the gall-bladder, this
mass, which appeared to consist of numerous gall-stones
welded together, was dug out, and a gauze sponge put
into the bladder to avoid oozing into the abdominal
cavity during operation. Then a transverse incision
through the rectus muscle and the suspensory ligament
of the liver was made to gain better access to the region
of the common duct. Putting one finger into the fora-
men of Winslow, and the thumb of the same hand above
the common duct, the choledochus was explored. Three
concretions were found movable in this duct, and besides
that, a hard mass in the retroduodenal portion of the duct.
As several manipulations to dislodge this concretion into
the supraduodenal portion of the common duct proved
futile, the duodenum was incised by a longitudinal in-
cision on the anterior wall. Then, as I could not find
the papilla immediately, an incision was made through
the ptisterior wall of the duodenum and choledochus to
this immovable concretion, after having brought the
movable stones downward to the impacted stone, holding
them tightly in this position by the index finger of the
left hand introduced into the foramen of Winslow, and
the thumb of the same pressing the upper portion of the
common duct.

■' With some difficulty the incarcerated stone was dug
out of its diverticulum, the other stones were easily
stripped into the duodenum, the duodenum and chole-

352 Operations on Common Duct

dochus sutured together with four silk sutures (chole-
dochoduodenostomis interna), and then the duodenum
on the anterior wall closed in the usual manner. The
gall-bladder was drained with a drainage-tube after
Poppert's method, and a strip of iodoform gauze put
around this tube and down to the suture of the duo-
denum. The patient made an uneventful recovery;
her pulse and temperature were never over loo ; the fistula
from the gall-bladder closed by itself five weeks after the
operation. She left the hospital six weeks after opera-
tion, her weight increasing rapidly (thirty-seven pounds
in four and one-half months)."

During the performance of operations for gall-stones
it may be difficult, it is, indeed, at times impossible, to say
whether a stone is present in the common duct. An
enlarged lymphatic gland lying in the free edge of the
gastro-hepatic omentum may be absolutely indistin-
guishable by touch alone from a calculus in the first
portion of the common duct. It causes a hard, rounded,
slightly mobile swelling, in all respects similar to a stone.
When, however, the method of rotation of the liver is
employed and the duct is brought to the surface, the
distinction between the two is readily made.

It is not so much in this first part of the duct that
difficulties are likely to occur. It is in the second and
third portions of the duct when a stone is present it may,
indeed, often is, surrounded by a dense thickening in the
head of the pancreas so that in the midst of this tough
mass no definite stone can be felt. Or, on the other hand,
so dense and resistant a swelling may there be felt that
the surgeon may have no doubt that a stone will be found.

Choledochotomy 353

Yet on cutting into the swelling, or on introducing a
finger into the duct, no calculus is felt. In some in-
stances a small chronic abscess in the head of the pan-
creas may be opened. Legueu, Schwartz, and others have
recorded cases of localised induration of the head of the
pancreas, incised in the belief that a stone was present,
and until I became familiar with the conditions of chronic
pancreatitis I made several such mistakes.

When a stone is impacted in the ampulla of Vater,
it may be so small as to be felt with difficulty, or being
felt it may be mistaken for a hard, inflammatory, or
perhaps malignant nodule in the pancreas. A growth in
the ampulla cannot be discriminated from stone until the
duodenum is opened. In the only case of carcinoma of
the ampulla that I have seen it was thought that the
small, hard, rounded lump was calculous, and it was only
after slitting up the ampulla that a growth therein was
disclosed. Difficulties, therefore, in the recognition and
discrimination of stone in the lower end of the duct may
arise from (a) stones being overlooked, a thickening felt
involving the duct and its surroundings being looked upon
as due to inflammatory deposit, (b) No abnormality
being recognised when a postmortem examination or a
later operation discloses the presence of a stone, (c)
A condition supposedly due to calculus being recognised
and the duct being directly incised, or the ampulla laid
open and the duct probed, with the result that no ob-
struction is found.

23

354 Operations on Common Duct

LUHBAR CHOLEDOCHOTOMY.

Access to the common duct may also be obtained by
the lumbar route, as was shewTi by Bratm in 1876. On
one occasion Tuffier has performed liwtbar cltoledochotomy
successfullv. The method, however, as a deliberate
procedure possesses no conceivable advantages, and
may usefully be relegated to obli\'ion.

Though these operations are described separately for
convenience, it must not be considered that thev are
performed in the academic method here portrayed. In
several instances I have simultaneously performed cho-
ledochotomy and cholecystotomy, choledochotomy and
cholecvstectomv, and duodeno-choledochotomv and chole-
cystotomy or cholecystectomy. One point cannot be
too frequently nor too strenuously emphasised, that is,
that drainage is the secret of success in gall-bladder
surgery; it is always an advantage, often imperative.
In cases of cholangitis, as made manifest by fever of
jaundice or both, and of pancreatitis, drainage must be
practised, and should be maintained for a considerable
time.

OPERATIONS FOR IMPERMEABLE OR IRREMOVABLE
• OBSTRUCTION OF THE COMMON DUCT.

When the common duct is occluded by stricture, or
growth, or rarely by inaccessible or irremovable calculus
(if indeed such a thing exists), it may be necessary to
divert the stream of bile by forming a communication
between the gall-bladder or the duct above the obstruc-

Cholecystenterostomy 355

tion and some part of the alimentary canal. Anastomoses
have been made between the gall-bladder and the stomach,
cholecystgastrostomy ; with the duodenum or any part
of the small intestine, cholecystenterostomy; or with the
colon, cholecystcolostomy. The common duct has been
united to the duodenum or other accessible part of the
small intestine, choledocho-enterostomv. The duodenum
is the portion of the bowel selected whenever possible,
but where adhesions are binding and inseparable, any
accessible portion of the stomach or small or large intes-
tine may be chosen. These operations are rarely prac-
tised at the present time. Since the longer incisions
have been made and the method of rotation of the liver
already descrijDed has been practised, the common duct
has been more readily accessible, and any obstruction has
been more easily overcome. There are very few indi-
cations for the operations.

CHOLECYSTENTEROSTOMY.

The operation of cholecystenterostomy was suggested
by Nussbaum and first performed by v. Winiwarter in an
operation which was performed in six stages on dates
from July 20, 1880, to November 14, 1881.

It has been generally agreed that for the purpose of
effecting the anastomosis a Murphy's button shotild be
used, and if any mechanical appliance is necessary, cer-
tainly none is so good as this. In one case, however,
Mayo Robson has found the anastomotic opening made
in this way narrowed almost to obliteration. I have only
once been called upon to perform the operation, in a

-;6

OcerazSons cc Coounon Duct

>» ' *^ •

:r.e

^ frsir^e c: the gall-bladder
t2:i5 c>:c:Cit>:n . I then adopted
'jre. the stitches being passed in

ex£u:tly the sam-e manner as in the 'ireration of gastro-
enter'-stcmv. The a f vantage cf sin-.rle suture is that the

Fig. 6S. — a, Cholecystenterostomy combined with exclxision of
the intestine and end-to-end anastomosis, a method I have once
adojjted; b, cholecystenterostomy combined with entero-anastomosis
as suggested by von Mikulicz and Maragliano.

Opening may be made of ample size, so that subsequent
narrowing or closure need not be feared. If possible,
enough of the gall-bladder and of the duodenum should
be drawn up into the wound to allow of the application of
small intestinal clamps. These will facilitate the opera-
tion considerably by keeping the viscera to be suttired

Cholecystenterostomy

357

close together without difficuit>', and by preventing
any leakage from the openings. The two portions to be
anastomosed lying side by side, a continuous suture of
fine Pagenstecher thread is now introduced along a line
at least one inch in length. This suture picks up only
the peritoneal and subperitoneal coats. In front of
this line of stitches an incision is now made into the gall-
bladder and into the intestine, the length being about
three-fourths of an inch. The edges of these incisions
are now united by a continuous suture of catgut which
begins at the one end of the incision, unites the posterior
edges of the wounds until the opposite end is reached, and
then returns along the anterior edges until the starting-
point is reached. The suture is a continuous one, and
unites the edges by a through -and-through stitch. The
ends of this suture are cut short, and the first needle
which has been temporarily laid aside is now resumed
and the serous coat united along the anterior margin of
the wound, to the point whence it started. Thus there
are two continuous sutures wliich completely siuround
the opening: an inner one of catgut which picks up all
the coats of each viscus, and an outer one of Pagenstecher
thread which unites only the serous and subserous coats.
If the duodenum is not accessible, the stomach may be
chosen. The records of seven cases of cholecystgastros-
tomy were collected by Perier in 1902, Of these, six
proved successful. The fact that bile is not injurious
to the stomach and does not in any way interfere with
digestion has been shewn by a case of my own recorded
in the British Medical Journal (vol. i, 1901, p. 1136)
and by the experiments of Stendel upon dogs.

358 Operations on Common Duct

If the small intestine is selected for the anastomosis,
some difficulty may result from the passage of the intes-
tinal contents into the gall-bladder. To overcome this
diffictdty the operation may be performed after the
method suggested by Mikulicz. A loop of the intestine
is isolated. The apex of the loop is tmited to the gall-
bladder; the sides of the loop, about four inches away,
are united to each other by a lateral anastomosis. The
intestinal contents are in this way short-circuited and
there is no risk of infection of the gall-bladder from the
intestine.

It would, doubtless, be an advantage in cases such as
this to perform intestinal exclusion, as well as cholecyst-
enterostomy. The small intestine at the point selected
would then be divided completely, the proximal end
would be united to the side of the distal end, about five
inches from the point of division, and the distal end would
be closed, or a lateral anastomosis made with the fundus
of the gall-bladder. I have operated thus in one case.

CHOLEDOCHOSTOMY.

The operation of choledochostomy, the opening of the
common duct and the suture of the margins of the open-
ing to the abdominal wound, is said to have been first per-
formed by Parkes. This, however, is incorrect. It was
drainage of the duct that Parkes adopted, the perform-
ance of choledochotomy without sutures. The opera-
tion of choledochostomy was first performed by Helferich
in 1887, subsequently by Ahlfeld, v. Winiwarter, and
others. The nature of the operation in the cases of

Choledochostomy 359

Helferich and Ahlfeld was only recognised at autopsy;
it was believed in both that the distended gall-bladder
was being opened. To v. Winiwarter belongs the credit
of first deliberately performing the operation knowing
what he did. In all the cases recorded the common duct
has been greatly, often enormously, dilated behind an
obstructing calculus. That the dilatation must be con-
siderable is recognised when we know that in two cases
mentioned and in several others the duct has been mis-
taken for the gall-bladder, or even for a pancreatic cyst.
Several remarkable examples of extreme dilatation of the
common duct have already been mentioned. The duct
may be opened, emptied, and forthwith stitched to the
parietal peritoneum and the aponeurosis, or the operation
may be done in two stages, the opening of the cyst being
deferred until union between the duct and the peritoneum
is complete.

In Helferich's case the biliary fistula bled and sup-
purated, and the patient died about one month after the
operation. Ahlfeld's patient died on the eighth day of col-
lapse. Von Winiwarter's patient died six weeks after the
operation, of gradual exhaustion due to the generalisation
of a malignant growth. The following case is worthy of
record as shewing the conditions likely to be met with
during operation.

It is recorded by Hamilton Russell (Annals of Surgery,
vol. 26, 1897, p. 692):

George S., aged eight, was admitted to the Mel-
bourne Hospital for Sick Children March 23, 1897.

On the 1 8th, five days previously, he became feverish

u of choltdocliustomy. Under surface of liver witfi
attached organs: a. Gall-bladder laid open: i>, cyst: c, duodenum
laid open: d. pancreas (Hamilton RusselL).

k

with the histor>' of having enjoyed excellent health up to
the onset of the present illness. Jaundice was general and
marked; temperature, 102° F. ; pulse, ij8. Examination
of the abdomen revealed the following : The right flank
was occupied by a large, tense, elastic tumour, dull on
percussion, being continuous with the liver dulness above;

Clioledochostotny 361

extending downward an inch below the iliac crest, reach-
ing inward nearly to the midline, and posteriorly oc-
cupying the entire lumbar region. There appeared
to be distinct tenderness on palpation of the tumour;
there was a slight increase of the liver dulness upward.
A second, smaller tumour projected visibly immediately
beneath the rib-cartiiage, about the right linea semilun-
aris; this tumour was rather larger than a pigeon's egg,
round, soft, elastic, and painless. Both heart and lung
sounds were normal.

The view taken as to the nature of the case was as
follows: The larger tumour was believed to be an
echinococcus cyst, which had escaped notice until the
onset of the present illness; the smaller tumour was
either a second cyst or possibly a distended gall-bladder.

Operation on x\pril 8th. The abdomen was opened by a
four-inch incision in the right Hnea semilunaris, extend-
ing downward from near the costal margin. The smaller
tumour at once presented, and was found to be the gall-
bladder distended with colourless contents ; there were no
adhesions, so that its entire contour could be readily
felt. Turning now to the larger cyst, this was found to
be retroperitoneal, and the colon was bound to the face of
it, being nearer the inner than the outer side of the cyst.
An exploring syringe was now used, and perfectly clear,
limpid fluid obtained, having all the physical appearance
of hydatid fluid. The cyst was next emptied in great
part by aspiration and then incised, when three surprising
discoveries were made: (i) in the fluid, as it flowed, there
came several blackish masses looking like cinders; (2)
there was no echinococcus cyst; (3) at the end of the flow
the fluid was observed to suddenly change in character,
and in place of the clear limpid fluid there came one or two
ounces of less clear and distinctJy mucinous fluid. It
was now ascertained that this mucinous fluid had come
from the gall-bladder, which was collapsed, having

le

i

362 Operations on Common Duct

emptied into the larger cyst. Thus it was evident that
this large retroperitoneal cyst had a commimication with
the common bile-duct, and the only conclusion I was able
to arrive at as the result of much speculation, with which
I need not weary the reader, ascribed to the cyst a
pancreatic origin ; the possibility did not occur to me that
in a child of eight, who had never suffered a day's illness
until three weeks previously, this enormous cyst could
itself be the dilated common bile-duct.

The dilated duct

The operation was completed by stitching the opening
in the cyst to the niusciilature of the abdominal wall, and
closing the abdominal wound. After the operation the
whole of the bile commenced to flow from the opening;
with the \'iew of ascertaining whether there was any
admixture uf pancreatic fluid with the bite, its digestive
properties were investigated by my colleague, Dr. Sta-
well, with a negative result, nnr was any excess of fat
discovered in the sti»>]s. The chilil died four days after

Choledochostomy 363

the operation, from haemorrhage, the result of uncon-
trollable oozing from the stitches and into the cyst.

Autopsy. The body was universally jaundiced, and
had the waxen appearance characteristic of death from
haemorrhage; the cyst was filled by a mass of normally
clotted blood, with some bile. On opening the body the
intestines appeared to be lightly smeared with blood,
and the points of contact of neighbouring coils were
marked by lines of blood; all the organs were healthy
with the exception of those concerned in the operation.
The liver with the system of biliary vessels, including the
cyst, the duodenum, pancreas, and spleen, were removed
in one piece and are portrayed in the accompanying il-
lustration. The cyst is seen to commimicate anteriorly
with the gall-bladder, the cystic duct being dilated so as
easily to admit an ordinary penholder. At the transverse
fissure the dilated hepatic ducts are seen opening into the
cyst. The duodenum and the head of the pancreas are
spread over the outside of the cyst. A careful search for
the terminal portion 6i the common bile-duct reveals a
small valvular opening on the interior of the cyst through
which a probe can be passed into the duodenum, on the
surface of which it appears through the usual papilla;
that this is the normal termination of the common bile-
duct is proved by passing a second probe through the
same duodenal orifice into the pancreatic duct; this can
be easily done. Russell adds, ** We may safely conclude
that the condition was congenital.''

Additional cases are recorded by Edgeworth and others.
See chapter on **The General Pathology of Gall-stone
Diseases."

364 Operations on Common Duct

CHOLEDOCHO-ENTEROSTOMY.

If the nature of the cyst formed by the dilatation of
the common duct can be recognised, it is certainly better
to perform an anastomosis between the overdilated duct
and the intestine. This operation, choledocho-enter-
ostomy, was first performed by Riedel in 1888. It was
Riedel's intention at first to cut across the duct completely
and to implant the severed end in the duodenum, but,
abandoning this idea, he united by lateral anastomosis
the dilated duct to the bowel. The patient died as a
result of the leakage of infected bile into the general peri-
toneal cavity. Kocher in 1890 operated upon a patient
in whose common duct two stones were impacted. The
duct behind the block was greatly dilated and it was his
intention to unite the duct to the duodenum lying in con-
tact with it, and sutures were introduced for the purpose.
The obstruction of the duct, however, was relieved by the
breaking up of the stones, and the opening, therefore,
was not made. Sprengel in 1891 reported the first
recovery after this operation, the patient being a woman
upon whom he had previously performed cholecystec-
tomy. During the first operation the greatly dilated
duct was mistaken for the duodenum, and a calculus felt
therein was pushed onwards.

Several operations have been done under the impression
that a cholecystenterostomy was being performed — the
exact conditions only being made clear at an autopsy.

The anastomosis has been effected either by simple
suture or by the aid of mechanical appliances, such as
Murphy's button, as in Czerny's'case, or Boari's button.

Choledocho-enterostomy 365

The method of lateral approximation has been always
adopted.

The following case is related by Swain (Lancet, vol.
I, 1895, p. 743):

On October 12, 1894, I was asked by Dr. Clay to see
a girl aged seventeen years who had been brought to him
for the first time on the preceding day. She had been
ailing more or less for two years. In January, 1894, she
became jaundiced, and a swelling formed under the liver.
She had been treated by two medical men with mercury
and other drugs; but in spite of their treatment the
jaundice deepened and the swelling under the liver in-
creased in size. They appear then to have told the
parents that nothing more could be done, whereupon Dr.
Clay was consulted. The condition of the patient when
I saw her was briefly as follows: She was very deeply
jaundiced ; the urine was the colour of porter. The stools
were white. She suffered no particular pain, had not been
sick, and throughout her illness neither of these symp-
toms had been present. She was much* emaciated. There
was a large abdominal tumour reaching from below the
liver to the brim of the pelvis and across the abdomen
obliquely, about three inches to the left of the umbilicus.
The whole swelling was absolutely dull on percussion, and
the merest tap on any part of it produced a thrill of
fluctuation. Taking the sum of her symptoms, we had
little doubt that it was distended gall-bladder, although
the possibility of a hydatid cyst was suggested. I as-
pirated the tumour with a full-sized aspirating needle,
and we immediately perceived the characteristic fluid
of distended gall-bladder. As if to make assurance
doubly sure, towards the latter end of the aspiration a
gall-stone struck the cannula repeatedly, and the click
of impact was heard by Dr. Clay, the father, and myself.

366 Operations on Common Duct

The quantity of fluid withdrawTi was six pints and one
ounce. No evU restdts followed the aspiration, and I did
not see the patient again imtil October 1 7th, when I found
that the swelling was as large as ever. We then advised
that an operation shquld be performed, and for this pur-
pose she was removed to the private home for patients,
and on the following day I operated on her. An incision
about four inches long was made a little to the outer side
of the right linea semilunaris. The integuments were
very thinly spread over the tumour and the peritoneum
was rapidly reached and opened. The cyst, being ex-
posed and packed well round with small sponges, was
tapped with an aspirating needle. Fluid of the same
character as before was withdrawn, but to the amount of
seven pints and twelve ounces. On passing the hand into
the abdominal cavity the cyst was found to be firmly
adherent to the intestine in all directions, the transverse
colon being spread out over it. A small opening was
now made, sufficiently large to admit the forefinger. The
cyst wall was very thin, but tough. Externally, it
was of a dark chocolate colour ; the cut edge was rather
white, and the interior bile stained. On introducing the
forefinger after a prolonged search no gall-stone could be
found, although, as previously stated, the presence of one
could not be doubted. The finger passed upwards and
inwards towards the liver into a passage with a crescentic
opening, which I believed to be common bile-duct; but
a probe passed down far beyond the finger impinged on no
stone. Up to this time I had no doubt but that I was
dealing with a huge, dilated gall-bladder; but my as-
tonishment may be appreciated when I found, in the
course of further investigation as to the relations of the
parts outside the cyst, the gall-bladder in its normal
position, somewhat pale in colour, undis tended by bile,
and containing no gall-stones. The question now arose
as to what course was the best to pursue. To remove

Choledochectomy 367

the cyst was impossible. To stitch it to the parietes
seemed to condemn the patient to a perpetual fistula,
or, at any rate, to very prolonged drainage. I decided,
therefore, to accept the other alternative and to attach
the cyst to the intestine. Without much trouble I
succeeded in drawing up a good coil of jejunum close
to the duodenum. My great difficulty was to get a
good surface on the cyst. In order to do this I had to
tear through the two layers of the mesocolon, and even
then the surface obtained was limited. The cyst was
then rapidly attached to the bowel by Murphy*s button
in the manner described by him. The small original
opening made to explore the cyst was closed with Lem-
bert's sutures. The peritoneal cavity, which had been
thoroughly well packed with sponges, was now cleansed,
and the pouch to the outer side and beneath the liver
drained with a Keith's tube. The wound was closed
with silkworm-gut sutures.

A case is recorded by Terrier, in which, after the anasto-
mosis of a dilated duct to the upper part of the duo-
denum, the bile flowed backwards into the stomach and
was vomited in large quantities.

A case of choledocho-enterostomy is also recorded by
Brenner (Virch. Archiv, Nov., 1899, vol. 158, part 2).

The operation of choledocho-duodenostomy has been
already described.

CHOLEDOCHECTOMY.

Removal of a portion of the common duct with sub-
sequent suture was performed first by E. Doyen. The
case was one of stone impacted in the upper part of the
common duct ; in extracting the stone the duct was torn

36S

Operations on Common Duct

through. The frayed ends were trimmed and the ends
sutured over a rubber tube. The figures explain the
various steps of the operation.

Kehr records a case in which a stricture of the common
duct was excised. The posterior part of the duct alone
was united; through the anterior part a drainage-tube
was passed upwards to the hepatic duct. The patient

:'a case of choledocln;ctumy: a, SheiVi the stone
1 duct, just beyond the junction of Che hepatic and
cystic ducts; b, shews the duct ruptured after estraetion of the stone:
e and d, the duct sutured after removal of the frayed edges seen in b.

recovered, though the hepatic cells were so damaged that
no bile flowed through the tube at first; for several weeks
a very small quantity only was passed. The fistula
eventually closed.

W. J. Mayo (Med. Record, April 30, 1904) records
three cases in which portions of the common duct were
excised for malignant disease. In the first the gall-
bladder, cvstic (iuct, and one inch of the common duct

Operations Upon Biliary Fistulas 369

were excised. The ends of the common duct were
brought together in three-fourths of their circumference,
the remainder being left open for drainage. The patient
recovered. In the second case the proximal end of the
divided duct was united to the duodenum. In the third
case a malignant tumour of the common duct was excised,
with end-to-end suture. This patient died from shock.
Waring and Reynier have successfully performed the
operation of excision of a part and of the whole of the
common duct in dogs. The operation deserves to be
remembered, as in certain exceptional instances it maybe
necessary.

OPERATIONS UPON BILIARY FISTUUE.

External Biliary Fistula. — The treatment of external
biliary fistulas will depend entirely upon the conditions
which produce and maintain the patency of the external
opening. As a rule, with few exceptions, it will be found
that the passage of bile through an external fistula is due
to the fact that this is the direction of least resistance.
If the bile-ducts are clear and free from narrowing, the
bile finds its easiest course along them. After a cholecys-
totomy it is sometimes, as in cases of chronic pancreati-
tis, advisable to keep the opening patent for several weeks,
and to accomplish this is not seldom a matter of the great-
est difficulty. If, therefore, the bile-passages are free, an
external biliary fistula will close spontaneously.

One form of external biliary fistula mentioned by
both Riedel and Langenbuch is that in which a greatly
dilated gall-bladder has been drained after cholecys-
24

^jo Operations on Common Duct

totomy. The dragging of the gall-bladder fixed in the
abdominal wound produces a Idnk in the common duct,
and the passage of bile to the intestine is therefore pre-
vented. In such circumstances the gall-bladder may,
as Riedel advises, be freed and the opening into its fundus
sutured. A better plan would be to remove the gall-
bladder entirely.

If the fistula persist after the operation of cholecys-
totomy, it probably indicates that a stone is wedged
in the common duct. In this and in all cases it is ad-
visable to make a bacteriological examination of the bile,
and to delay any operative intervention imtil the fluid
discharged is almost sterile.

The treatment, therefore, of an external biliary fistula
necessitates at the first a very thorough examination of
all the bile tract and the discovery of the condition which
is responsible for the prevention of the normal flow of the
bile into the intestine. If a stone be found in the common
duct, it will be removed ; if there be a stricture of the duct,
it also may be removed or cholecystenterostomy may be
j)erformcd. If there be a growth or an inflammatory
tumour causing obstruction of the duct by pressure from
without, or hy blockage from within, the fistula may be
left as a permanent drain, or a cholecystenterostomy may
])e performed. If, after the removal of a stone in the
duct, it is quite certain that the duct is clear, the gall-
bladder may be removed. Kleiber, in 1892 (Dissert.,
(ireifswald). has collected the records of thirty cases of
fistula in which cholecystectomy was performed.

Internal Biliary Fistula.— The discovery of a fistula
between the bile passages and the intestine will generally

Internal Biliary Fistula 371

be made only during the course of an operation. If the
fistula connect the gall-bladder or the cystic duct, on the
one hand, with the stomach, duodenum or colon, on the
other, the two tmited viscera must be separated with the
utmost gentleness. The opening into the intestine is
then closed by suture, and the gall-bladder is, by prefer-
ence, removed, or a drain is introduced through the open-
ing. It is of the highest importance in all such cases to
make sure that the passage is clear for the bile. If there
is a block in the common duct, it must be removed. As
a rule, a stone will be found in the cystic duct, in the
common duct near the cystic duct, or in the common
duct low down. If choledochotomy is performed, it is
wiser to afford through the incision a direct drainage for
some days.

Cases of fistula between the bile passages and the uri-
nary tract or the lungs may also be dealt with success-
ftdly by operation, the stones which are blocking the
hepatic or common duct being removed and free drainage
established. Instances are recorded in the chapter
dealing with biliary fistulae.

i

,1

t
f

ll

INDEX.

Abdomen, skin of, preparation of,

for operation, 286
Abdominal distension in perfora-
tion of gall-bladder, 232
wound, closing of, 306, 307
Abscess, biliary, 87

from stone in hepatic duct,

176
of liver, 89
subphrenic, from occlusion of

common duct, 196
with chronic perforation of gall-
bladder. 249
Adhesions, stripping of, 304
Adipose gall-bladder, 67
Age, gall-stones and, 51
Albumin in urine in gall-stone

disease, 144
Alimentary canal, preparation of,

for operation, 285
Amorphous gall-stones, 32
Ampulla of Vater, 22, 26

stones in, operation for, 345
Anastomosis of common duct,

355
Anatomy of bile-ducts, 17

of gall-bladder, 17

Appendicitis, acute cholecystitis

and, 163

gall-stones and, 49

Assistants, preparation of, for

operating, 277

Atrophy of gall-bladder wall,

from gall-stones, 78

of liver from gall-stone disease,

107

Bacillus coli in acute cholecysti-
tis, 163
in biliary abscess, 87
in gall-stones, 36, 146
of Ebcrth in acute cholecystitis,

163
typhosus, gall-stones from, 36,

39
in bile, 38, 39

in biliary abscess, 87

Bacteria causing gall-stones, 43

entrance of, into bile passages,

47
into gall-bladder, 47

through common duct, 47

through portal circulation, 47

gall-stones from, 36

in bile, 37

in biliary abscess, 87

in gall-stones, 146

Bevan's incision, 301, 302

Bichloride of mercury, gall-stones

from, 36

Bile and urinary tracts, fistuhe

between . 217

bacillus typhosus in, 36, 39

bacteria in, 36

passages and female genitals,

fistulae between, 218

and pleura, fistulas between,

220

and thoracic organ, fistulae

between, 220

casts of, as gall-stones, 32

entrance of bacteria into, 47

retention of, gall-stones and, 43

373

374

Index

Bile, secretion-pressure of, 80
stasis of, gall-stones and, 43, 50
sterility of, 37
Bile-ducts, anatomy of, 17
cancer of, 100
carcinoma of, 100
common, 21. See also Common

duct.
cystic, 20, 21. See also Cystic

duct.
hepatic, 21. See also Hepatic

duct.
operations on, 293

anti-operative treatment,

307
Be van's incision for, 301, 302

closing wound, 306, 307
Courvoisier's incision for, 302
general observations, 299
history, 293
incisions for, 300
Kehr's incision for, 302
Kocher's incision for, 301,

302
Mayo Robson incision for,

300. 301
])osition of patient, 299
sand-bag in, 299
swabs in, 303
technique, 2qq
walls of, structure, 30
Biliary abscess. S7

from stone in hepatic duct,

176
of liver, S()
listuhe, 204
external, 205

operations for, .^60
internal, 206

operation for, 370
operation upon, 369
treatment, 321
infection in typhoid fever, 39
BiliruV)in gall-stones, mixed, 1,2
Bilirubin-calcium gall-stones ,
pure, 32

Bilirubin-calcium, origin, 35
Blood-serum test for jaiindice.

Calcipication of gall-bladder
from gall-stone disease, 74
from stones in cystic duct,
169
Calcitmi-bilirubin gall-stones,
piu-e, 32
origin of, 35
Canal of Wirsimg, 22
Cancer. See Carcinoma.
Carbolic acid, gall-stones from. 36
Carcinoma from gall-stones, 99
jaimdice in, 127
of bile-ducts, 100
of gall-bladder after choice ys-
totomy, 102, 325
gall-stones and, 324
Casts of bile passages as gall-
stones, 32
Catarrh, lithogenous, 36
Catgut, sterilization of, 280
Celluloid thread, Pagenstecher's.

for ligatures, 281
Chalk gall-stones, 32
Cholangitis, membranous, from
gall-stone disease, 89
suppurative, extension of, 88
from gall-stone disease, 86
from typhoid, 87
pneumococcus in, 87
with occlusion of common duct ,
195, 196
Cholecystectomy, 317. 322
advantages of, 327
digestion and, 326
disadvantage of, ^iS
drainage in, 324, 328, 332
for perforation of gall-bladder,

indications for. 319, 322

lumbar, 334

risk involved, 327

Index

375

Cholecystectomy, technique, 330
Cholecystendesis, 312
Cholecy stenterostomy , 355
Cholecyst gastrostomy, 357
Cholecystitis, acute, appendicitis
and, 163
bacillus coli in, 163
Eberth's bacillus in, 163
from stones in cystic, duct,
161
in gall-bladder, 147
gall-bladder in, 148
pneumococcus in, 163
staphylococcus in, 163
streptococcus pyogenes albus
in, 163
aureus in, 163
chronic, from stones in cystic
duct, 164
in gall-bladder, 148, 149
from gall-stone disease, 57

oedema with, 64
membranous, from gall-stone

disease, 89
phlegmonous, from stones in
cystic duct, 165
symptoms, 168
with perforation of gall-blad-
der, 248
Cholecy St otomy, 309

carcinoma after, 102, 325
closing wound, 316
drainage after, 314, 315
end-results, 311
fixing gall-bladder after, 316
ideal, 312

indications for, 309, 319
lumbar, 334
on left side, 334
technique, 311
Choledochectomy, 367
Choledocho-duodenal fistula; from

gall-stone disease, 215
Choledocho-duodenostomy, 349
Choledocho-enterostomy, 364
Choledochostomy, 358

Choledochotomy, 339

for stone in common duct, 198-

201
Itmibar, 354
retroduodenal, 344
supraduodenal, 339

closing wounds after, 343
digital exploration in, 341
drainage in, 342
position of patient, 340
transduodenal, 345
Cholelithiasis. See Gail-stone

disease.
Cholelithotrity, 317, 318
Cholesterin gall-stones, lamin-
ated, 31
pure, 31
origin of, 35
Cigarette drain, 283
Colic in gall-stone disease, 117

cause of, 122
Common duct, 21
access to, 28
anastomosis of, 355
and duodenum, fistula be-
tween, 84
changes in, from gall-stones,

79
diameter of, 28

dilatation of, 79

distension of, 80

diverticula of, 77

entrance of bacteria by, 47

fistulae into, 225

inflammation of, pericholan-
gitis from, 86

impermeable obstruction of,
operations for, 354

interstitial portion, 26

irremovable obstruction of,
operations for, 354

occlusion of, cholangitis with,
195, 196
cholecystenterostomy for,

355
choledochectomy for, 367

376

Index

Common duct, occlusion of, cho-
ledocho - duodenofitomy

for. 349
choledocho - enterostomy

for, 364
choledochostomy for, 358
choledochotomy for, 198-

30Z, 339. See also

Clu^^dochoiomy,
cholelithotrity for, 3x8
complete, 184
differential diagnosis, 20 z
difficulties of diagnosis,

duodeno - choledochotomy

lor, X97, 345
impermeable, operations

for, 354
jaundice in, 202
loss of weight from, 193
operations for, 339
pancreatitis and, differen-
tiation, 302
pancreatitis from, 197
partial, 185

cause of attacks, 195
chronic, 191
jaundice in, 189
steeple chart in, 133,

190
symptoms, 188
temperature in, 190
subphrenic abscess from ,

196
symptoms, 184
j)ancreatic portion, 23
perforation of stone into por-
tal vein from, 223
relations of, 22
retroduodenal portion, 23
stenosis of, 93
stones in. See Contmon duct,

occlusion of.
stricture of, 93
supraduodenal portion, 22
transduodenal portion, 26

(A>mmpn duct, .wide-mouthed

openmg of, 84
Constipation in gall-stone disease ,

M3
Corset liver, gall-stones and, 50

Courvoisier's incision, 303

law, 130

Cystic artery, 30

duct, 30, 31

access to, 38
blocking of, 84
stones in, acute cholecystitis
from, x6z
calcification of gall-bladder

from, 169
cholecystectomy for, 317
cholelithotrity for, 317.

318
chronic cholecystitis from,

164
cysticotomy for, 3x7, 318
dilatation of gall-bladder

from, 153
empyema from, 156
hydrops from, 154
jaundice from, 159
operations for, 317
peritonitis from, 165
phlegmonous cholecystitis

from, 165
pressure effects of, 169
rupture of gall-bladder

from, 158
sclerosis of gall-bladder

from, 169
symptoms, 151
ulceration of stones through,
229
Cysticotomy, 317, 318
Cysto-colic fistulae from gall-
stone disease, 212. 216
Cysto-duodenal fistula from gall-
stone disease, 207, 212

Diagnosis of gall-stone disease,
differential, 138

Index

3//

Diagnosis of gall-stones in com-
mon duct, differential, 201

Diet after operation, 290

Digestion, cholecystectomy and.
326

Dilatation of gall-bladder from
stones in cystic duct, 152

Diverticula from gall-stone dis-
ease, 75
of common duct, 77

Diverticulum of Vater, 22, 26
stones in, 76

Drainage after cholecystectomy,

324

after cholecystotomy, 314, 3^5

in cholecystectomy, 328, 332

in choledochotomy, supraduo-
denal, 342

in operations for gall -stones,
328

material, 282

cigarette drain as. 283
split rubber tube as, 283
IXict, common, 21. See also
Common duct.

cystic, 20, 21. See also Cystic
duct.

hepatic, 21. See also Hepatic
duct.

stricture of, from gall-stone dis-
ease, 93
Duodeno-choledochotomy, 345

for stone in common duct,
197
Duodenum and common duct,
fistula between, 484

stone in, 256

ulceration into, 85

Eberth's bacillus in acute chole-
cystitis, 163
Elliott's position for operation.

299
Empyema, enlargement of gall-
bladder in, 72

Empyema from stones in cystic
duct, 156
in gall-stone disease. 68
of gall-bladder. 68

Female genitals and bile passages.

fistulac between, 218
Fever in gall-stone disease, 132,
142
in partial occlusion of common
duct, 189, 190
Fistulie between stomach and
gall-bladder, 208, 212
between bile passages and
female genitals, 218
and pleura. 220
and thoracic organs, 220
and urinar>' tract, 217
between common duct and por-
tal vein. 223
biliary, 204
external, 205
internal. 206
operations, upon. 369
treatment, 321
choledocho-duodenal .215
cvsto-colic, 212, 216
cvsto-duodenal. 207. 212
intestinal obstruction and.

216
into common duct .223
into hepatic duct, 225
into uterus, 219
Floating lobe in gall-stone dis-
ease. 108
F(.ecal vomiting in intestinal
obstruction from gall-stones.

259
FiX'tus. gall-stones in. 46

Foramen of Winslow, 23

Forcei)S, gall-stone. 303

Foreign bodies, gall-stones from,

44
Frrenum caruncuhe. 22

378

Index

Gall-bladder, adipose, 67
anatomy of, 17
and stomach, fistula between,

208, 212
atrophy of wall of, from gall-
stones, 78
calcification of, from gall-stone
disease, 74

from stones in cystic duct,
169
carcinoma of, after cholecystot-
omy, 102, 325

from gall-stones, 99

gall-stones and, 324
contracted, gall-stone disease

and, 128
dilatation of, from stones in

cystic duct, 152
dilated, 70

distension of, jaundice and, 127
diverticula of, from gall-stone

disease, 75
empyema of, 68

from stones in cystic duct,

156

enlargements of, 70
in empyema, 72

entrance of bacteria into, 47

fixinj^, after cholecystotomy,
316

freeing of, from adhesions, 304

i^anj^rcne of, 167

ha?niorrhagc from, 04

hour-glass, 65

hydroj^s of, from stones in
cystic duct, 154

hypersensitiveness of, in gall-
stone disease, 112, 116, 150

hypertrophy of muscles of,
from gall-stones, 57

in acute cholecystitis, 14S

intlammatory changes in, 57

niultilocular a])pearance of, 66

o])erations on, 203

anti-operative treatment, 307
Be van's incision, 301, 302

Gall-bladder, operations on, clos-
ing woimd, 306, 307
Courvoisier's incision, 302
general observations, 299
history, 293
incisions for, 300
Kehr's incision, 302
Kocher's incision, 301, 302
Mayo Robson incision for.

300, 301
position of patient, 299
sand-bag in, 299
swabs in, 303
technique, 299
ossification of, from gall-stones,

74
papillomata from, 99
passage of stone from, to duo-

denimi, symptoms, 140
perforation of, 165, 167, 226

abdominal distension in. 232

acute, 230

cholecystectomy for, 233

chronic, with abscess, 249

diagnosis, 231

from stones in cystic duct,

158

into peritoneal cavity, 2,50
operation for, 232
pain in, 231
peritonitis from, 230
phlegmonous cholecystitis

with, 248
through neck, 229
treatment, 232
mixture of, 165, 167, 226. See
also Gall-bladder, pcrjoraiton

sclerosis of, from stones in

cystic duct, 169
secondary. 76, 227
size of, in hydrops, 70
sloughing of, 165
stones in, acute cholecystitis
from, 147

cholecystotomy for, 300

^H Index 379

^^1 Gall-bladder, stones in. chronic

Gall-stone disease, cholecystitis

1 cholecystitis from, 14B, 149

from. 57

1 death from pressure of, 150

membranous, 89

1 ordinary, .51

cedema with, 64

symptoms from, 145

cholecystotomy for, 309.

tenderness of. in gall-stone dis-

See also Cholecyslotomy .

ease, 111, iia, 116, 150

choledochectomy for. 367

tumour of, in gall-stone dis-

choledocho - duodenostomy

ease. 134

for. 349

inflation of stomach in diag-

choledocho -enterostomy for,

nosis, 136

364

ulceration of, 67, 319

choledochostomy for, 358

walls of. structure. 30

choledochotomy for, 339.

thickness of, in gall-stone

See also Choledochotomy.

disease, 64

cholelithotrity for. 317, 318

Gall-stone disease, acute chole-

chronic cholecystitis in. from

cystitis in, from

stones in cystic

stones in cystic

duct, 164

duct. 161

in gall-bladder. 14S.

in gall-bladder, 14;

U9

albumin in urine in, 144

arrestment of stones, symp-

cause' of. 122

toms from. 145

consequences of, 304

atrophy of gall-bladder wall

constipation in, 143

from, 78

contracted ■gall-bladder and.

of liver from, 107

13S

biliary abscess in, from stone

cysticotomy for. 317. 318

in hepatic duct. 176

diagnosis, differential. 138

fistula in, treatment. 33 1

dilatation of gall-bladder in.

calcification of gall-bladder

from stone in cystic duct.

in. 74
from stones in cystic

■5"
diverticula from, 75

duct, 165

duodeno - choledochotomy

cancer from, gp

for. 345

of docts from, 100

empyema in, 68

carcinoma from, 99

from stones in cystic duct.

of gall-bladder and, 334

■56

changes in common duct in.

enlargement of liver in, 137

79

fistula; from, between bile

cholangitis from, membran-

passages and female

ons, 89

genitals, 318

cholecystectomy for, 317,

and pleura, aio

333. Sec also ChoUcyslte-

andthoracic organ, »3o

lomy.

and urinary tract, 3*^

cholecystentt-rostomy for,

between common duct and

1

355

jiorta! vein. 313

38o

Index

Gall-stone disease, fistulae from,
between stomach and
gall-bladder, 208, 212
biliary, 204. See also

Biliary fistula.
choledocho-duodenal, 215
cysto-colic, 212, 216
cysto-duodenal. 207, 212
into common duct, 225
into hepatic duct, 225
into uterus, 219
fever in, 132, 142
floating lobe in, 108
frequency of, 109
haemorrhage in, 94
hepatic abscesses from, 89
hei)aticolithotripsy for, 338
hepaticostomy for, 337
hepaticotomy for, 178, 335
hydrops in, 68

from stones in cystic duct,

154
hypcrscnsitiveness of gall-
bladder in, 111,112, 116,

150
hypertrophy of muscles of

gall-bladder from, 57
intestinal obstruction in, 216,

252. See also Intestinal

obstruction from gall-stones.
irregular, 140
jaundice in, 125, 143.' See

also Jaundice in gall-stone

disease.
linguiform process of liver

in, 108
liver changes in, 106
malignant disease from, 98
nausea in. 123
operations for, 293

after-treatment, 290

catgut for. 280

celluloid thread for liga-
tures, 281

diet after, 290

drainage in, 328

Gall-stone disease, operations for,
drainage in, material for,
282
garments for patient, 289

for surgeon, 270
gloves for, 275
Pagenstecher's celluloid
thread for ligattires, 281
preparations for, 270
of assistants, 277
of hands, 273
of nurses, 272, 277
of patients, 284
of surgeon, 270
room for, 289
rubber dam in, 288
suture material for, 280
swabs for, 278
ossification of gall-bladder

from, 74
pain in, 1 11, 141
local. III
referred, 115

stomach diseases and. 114
pancreatitis in, 197
papillomata from, 99
pathology of, 57
perforation of gall-bladder in,
165, 167, 226. See also
Gall-bladder, perforation of.
pericholecystitis in, 72
phlegmonous cholecystitis in .

165
symptoms, 168

pressure effects of stones in
cystic duct, 169
symptoms. 112, 150

pulse in, 143

recognition, 109

regular, 140

Riedel's lobe and, 107

rigors in, 132, 142

rupture of gall-bladder in , 1 6 5 .
167, 226. See also Gall-
bladder, perforation of.
of hepatic duct in, 181

Index

->
J

8i

Gall-stone disease, sclerosis of gall-
bladder in, from stones in
cystic duct, 169

signs of, 109

sloughing of gall-bladder in,

165
steeple temperature chart in,

133. 190
stenosis of common duct

from, 93
stones in common duct. See
Common duct, occlusion

of.
in cystic duct, symptoms,

151
in gall-bladder, symptoms,

145
in hepatic duct, symp-
toms, 174
stricture of common duct

from, 93
subphrenic abscess in, 196
suppurative cholangitis from,

86
symptoms, 109

of arrestment of stone, 145
of passage of stone from
bladder to duodenum,
141
of stones in common bile-
duct, 184
in cystic duct, 151
in gall-bladder, 145
in hepatic duct, 174
pressure, 112, 150
special, 140
temperature in, 132
tenderness of gall-bladder in,

III, 112, 116, 150
tetany in, 142
thickness of gall-bladder wall

in, 64
tumours in, 134

inflation of stomach in
diagnosis, 136
typhoid fever and, S^

Gall-stone disease, vt)lvulus in,

255
vomiting in, 123, 142

forceps, 303

scoop, 303

Gall-stones, age and, 51

amorphous, 32

appendicitis and, 49

bacillus coli in, 146

bacteria causing, 43

bacteria in, 146

bilirubin, mixed, 32

bilirubin-calcium, origin, 35

pure, 32
calcium-bilirubin , origin, 35

pure. 32
chalk, 32
cholesterin, laminated, 31

origin, 35

pure, 31
concretions around foreign bod-
ies as, 32
constitutional conditions and , 50
corset liver and, 50
experimental formation, 41
formation of, 35

experimental, 41

time needed, 46
frequency, 109
from bacillus coli, 36

typhosus, 36, 39
from bacteria, 36
from bichloride of mercury, 36
from carbolic acid, 36
from foreign bodies, 44
from mercur>' bichloride, 36
from metabolic alterations, 5 1
from ricin, 36
from stai)hyUx:occus i)y()genos.

from typhoid bacillus. 36. 39
gall-bladder, ordinary
imi)action of. in duodenum, 256
in common bile-duct. 184. See
also Comnuynd$tci,(h:clusiof I r>/.
in cystic duct . ()i)erati<)ns for, 3 1 7

;82

Index

Gall-stones in cystic duct, symp-
toms, 151

in diverticula, 76

in foetus, 46

in hepatic duct, 174

in infancy, 53

in omental adhesions, 227

in portal vein, 174

intestinal obstruction from,
252. See also Intestinal ob-
struction from gall-stones.

intramucous. 59

intra-uterine, formation, 55

number of, 32

pressure of, death from, 150

rarer forms, 32

recognition of, 109

retention of bile and, 43

sex and, 51

size of, 34

increase in, 49

staphylococcus pyogenes albus '

in, 146 I

aureus in, 146

stasis of bile and, 43, 50

ulceration of, into jjortal vein,
230
through cystic duct. 229
through neck of gall-V)ladder,

22Q

varieties of, 31

volvulus from. 255

vomiting of, 210
Oangrene of gall-bladder. 167
(rarments for ]>atie!U, 2S9

for surgeon, 270
(rastric disturbances in partial

occlusion of common duct,

(renitals, female, and l,)ile pas-
sages, listuUe between, 218

Gloves for o])eration, 275
sterilization of, 275

lI.EMORRHAiiK from gall-stoues, 94
jaundice and, 94

Hamel's serum test for jaundice,

Hands, sterilization of, 273
Heister's valves, 20
Hepatic abscess from gall-stone
disease, 88
duct, 21

access to, 28

fistulae into, 225

rupture of, from stones, 181

stones in, 174

biliary abscess from, 176
hepaticolithotripsy for, ;^^S
hepaticostomy for, 337
hepaticotomy for, 178, 335
o|>erations for, 335
Hepaticolithotripsy, 338
Hepaticostomy, 337
subhepatic, 337
transhepatic, 337
Hepaticotomy, 178, 335
Hour-glass gall-bladder, 65
Hydrops from stones in cystic
duct, 154
in gall-stone disease, 68
Hypersensitiveness of gall-blad-
der in gall-stone disease, iii,
112, 116, 150
Hypertrophy of muscles of gall-
bladder from gall-stones, 57

Icterus. Sec Jaundice.
Ideal cholecystotomy, 312
Ileo-ca»cal valve, gall-stone ol>-

st ruction and, 257
Incisions for gall-bladder opera-
tions, 300
Incisura vesicalis, 17
Infancy, gall-stones in, 53
Instruments for operation, steri-
lization of, 280
Intestinal obstruction from gall-
stones, 216, 252
age and, 252
channel of stone, 252
fcTecal vomiting in, 259

Intestinal obstruction from gall-
stones, frequency of , 252
ileo-caecal valve and, 257
medical treatment, 266
operation for, 267
prognosis, 264
site of lodgment, 254
spontaneoxis recovery, 264
stone in duodenum, 256
symptoms, 257
treatment, 266
vomiting in, 258

Intramucous gall-stones, 59

Intra-uterine formation of gall-
stones, 55

Irregular cholelithiasis, 140

Jaundice, blood-serum test for,

125
from stones in cystic duct,

159
gall-bladder distension and,

127

haemorrhage and, 94

in carcinoma, 127

in gall-stone disease , 125, 143

causes, 126

character, 126

detection, 125

frequency, 125

serum test for, 125
in malignant disease, 127
in occlusion of common duct,

202
of cystic duct, 159
in partial occlusion of common
duct, 189

Kbhr's incision, 302

Kidneys, examination of, before

operation, 288
Kocher's incision, 301, 302

operation for stones in common
duct. 340

Ligatures, sterilization of, 280
Linguiform lobe of Riedel, 107
Lithogenous catarrh, 36
Liver, atrophy of, from gall-stone
disease, 107
changes in gall-stone disease,

106
enlargement of, in gall-stone

disease, 137
freeing of, from adhesions,

304
in chronic occlusion of common

duct, 191
linguiform process of, in gall-
stone disease, 108
rotation of, through Mayo
Robson incision, 305
Local pain in gall-stone disease,

III
Lumbar cholecystectomy, 334
choice ystotomy, 334
choledochotomy, 354
Lymphatic glands around bile
tract, 30

Mayo Robson incision, 300, 301
rotation of liver through,

305
Mercury bichloride, gall-stones

from, 36

Metabolic alterations, gall-stones
and, 51

Mikulicz's method of anasto-
mosis of common duct, 358

Mouth of i)ationt, preparation of,
for operation, 285

Moynihan's sterilization of cat-
gut, 281

Nai'SEA in j:jall-stone disease, 123
New-born, gall-stones in, 53
Number of gall-stones, 32
Nurses, preparation of, for opera-
tion, 272, 277

384

Index

Oddi's sphincter, 28

CEdema in cholecystitis from gall-
stones, 64

Omental adhesions, gall-stones in,
227

Operations for gall-stone disease.
See Gall-stone disease, opera-
tions for.

Ossification of gall-bladder from
gall-stone disease, 74

Pagenstecher's celluloid thread

for ligatures, 281
Pain in gall-stone disease, iii.
141
local. III
referred, 115
in partial occlusion of common

duct, 189
in perforation of gall-bladder,

231
Pancreatitis from stones in com-
mon duct, 197
occlusion of common duct and,
differentiation, 202
Papilla major of Santorini, 22
Papillomata of gall-bladder, 99
Patholog>' of gall-stone disease, 57
Patient, anti-operative treatment

of, 307
garments for, 289
position of, for operation, 299
in choledochotomy, supra-
duodenal, 340
preparation of, for operation,
284
Perforation of gall-bladder, 165,
167, 226. See also Gail-blad-
der, perforation of.
Pericholangitis from inflamma-
tion of common duct, 86
Pericholecystitis in gall-stone dis-
ease, 72
Peritoneal cavity, perforation of
gall-bladder into, 230

Peritonitis from perforation of
gall-bladder, 230
from stones in cystic duct,

165

Pleura and bile passages, fistulae

between, 220
Plica longitudinalis, 22
Pneumococcus in acute cholecys-
titis, 163
Portal circulation, entrance of
bacteria through, 47
vein and common duct, fistulae
between, 223
gall-stones in, 174
perforation of stone into,
from common duct, 223,
230
Position of patient for operation,

299
Pressure effects of stone in cystic
duct, 169
signs of gall-stone disease, 1 1 1 .
112, 116, 150
Pulse in gall-stone disease, 143
Purgatives before operation, 285

Referred pain in gall-stone dis-
ease, 115
Regular cholelithiasis, 140
Ricin, gall-stones from, 36
Riedel's lobe, gall-stone disease

and, 107
Rigors in gall-stone disease, 132,

142
Room for operation, 289
Rubber dam, 288

gloves for operation, 275

sterilization of, 275
tube, split, for drainage, 283
Rvipturc of gall-bladder, 165, 167,
226. See also Gall-bladder,
perforation of.
of hci)atic duct from gall-
stones, 181

Index

385

Sand-bag in operation on bile

passages, 299
Santorini's papilla major, 22
Sclerosis of gall-bladder from

stones in cystic duct, 169
Scoops, gall-stone, 303
Secondary gall-bladders, 76, 227
Sex, gall-stones and, 51
Signs of gall-stone disease, 109
Size of gall-stones, 34
Skin of abdomen, preparation of,

for operation, 286
Sloughing of gall-bladder, 165
Sphincter of Oddi, 28
Split rubber tube for drainage,

283
Staphylococcus in acute cholecys-
titis, 163
pyogenes albus in biliary ab-
cess, 87
in gall-stones, 146
aureus in biliary abscess, 87

in gall-stones, 146
gall-stones from, 36
Steeple temperature chart, 133,

190
Sterilization of catgut, 280
of gloves, 275
of hands, 273 •
of instruments, 280
of ligatures, 280
of swabs, 279
Stomach and gall-bladder, fistula
between, 208, 212
diseases, gall-stone pain and,

114
inllation in diagnosis of tumour
of gall-bladder, 136
Stools in partial occlusion of com-
mon duct, 191
Strangulation. See Intestinal ob-

struction.
Streptococcus pyogenes albus in
acute cholecystitis, 163
aureus in acute cholecystitis,
T63

Stricture of ducts from gall-stone
disease, 93

Subhepatic hepaticostomy, 337

Subphrenic abscess from occlu-
sion of common duct, 196

Surgeon, preparation of, for oper-
ation, 270 •

Suture material for operations,
280

Suturing abdominal wound, 306,

307
Swabs for operations, 278

placing of, 303
sterilization of, 279
S)nnptoms of gall-stone disease,
109. See also Gall-stone dis-
ease, symptoms of.

Teeth, cleansing for operation,

285
Temperature chart, steeple, 133,

190
in gall-stone disease, 132, 142
in partial occlusion of common
duct, 189, 190
Tenderness of gall-bladder in gall-
stone disease, in, 112, 116,

Tetany in gall-stone disease, 142
Thoracic organ and bile passages,

fistulae between, 220
Transhepatic hepaticostomy, 337
Tumours in gall-stone disease,

134
of gall-bladder, inflation of

stomach in diagnosis, 136

Typhoid bacillus, gall-stones

from, 36, 39

in bile, 36, 39

in biliary abscess, 87

fever, biliary infection and, 39

gall-stone disease with,

dangers of, 88

suppurative cholangitis from,

87

25

3«6

Index

Ulcbkation into daodemua, 85

ci gaU-bladder, 67
Urnutfy and bile tracts, fiitnle

between, 2x7
Urine, albttmin hi, in gaU-etone
disease, 144
examination of, before opcnra-

tion, s88
in partial occlusion of oommon
duct, 191
Uterus, fisttalsB into, from gall-
stone disease, 3x9

Valvbs of Heister, ao
VatvttUe connxventes, 32
Varieties of gaU-stones, 31

Vater, ampulla of, aa, 36
diverticulum of, as, a6
Volvulus from gaB-stones, 355
Vomtting In gaOhstooe disease,
IS3, X4S
in intestinal obstructiQn from
gall-stones, 338
f»cal, 359
of gall-stones, axo

Wbight, loss of, from stones in

conmHMi duct, X93
Winslow, foramen of, 33
Wsrsung, canal of, 33
Wound, closing of, 306, 307

}

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Nancrede's Anatomy and Dissection. cdHi^

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Martin's E^ssentials of Minor Surgery, Band-
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Essentials of Minor Surgery, Bandaging, and Venereal Diseases, By

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M547 Mojnlhan, B.G.A.M. 1
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1904 surgical treatment. |

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