Pages might be devoted to a discussion of the reasons for their formation. That cholesterin, their principal component, should more readily deposit in such a way as to produce these calculi, and more often in some individuals than in others, is hard to explain, but may be held to be largely due to its formation in excess in certain individuals and to concentration of those fluids which hold it in solution. Increase of cholesterin seems to be connected with catarrh of the membrane which produces it, and thus stagnation of bile may predispose. That bacteria have much to do with biliary calculi is now conceded, and a history of typhoid is obtainable in many cases. It has been shown experimentally that aseptic foreign bodies introduced into the gall-bladder remain indefinitely without becoming covered with precipitate, while virulent organisms set up disturbance, and only the attenuated or moderately infectious organisms produce calculi, and usually then only when some trifling foreign body is introduced at the same time. It will thus be seen that a nidus may be afforded by a clump of epithelial cells or débris.

It is not at present so much a question of what organisms are at fault, although they are usually the colon and typhoid bacilli and the ordinary pyogenic organism. It has been shown, moreover, that in typhoid fever the gall-bladder is often invaded, and that the typhoid bacilli may live there indefinitely, and that they tend to clump or agglutinate themselves in a very suggestive way into trifling masses which may serve as minute foreign bodies. Thus each predisposing factor reacts upon the other, and by a vicious circle either an acute lesion may be established or calculi may be formed in varying numbers.

Gallstones have been found in the newborn, but are relatively infrequent below the age of twenty-five, and are most common in the later years of life. The condition is by four to one more frequent in women than in men. The only predisposing habit seems to be such lack of exercise as gives no expulsive movement to the gall-bladder by action of the abdominal muscles. They are more common in the gouty and in those predisposed to uric-acid diathesis, while abundance of nitrogen seems rather protective. Biliary calculi have never been found in the wild carnivora.

McArthur has formulated the following conclusions of interest in this connection:

• 1. Not all gallstones originate within the gall-bladder.
• 2. The origin of a cholesterin stone is probably the gall-bladder, with subsequent accretion, either in passing through, or in the duct, where it may have lodged.
• 3. Bilirubin calcium is the principal constituent of the smaller intrahepatic duct stones.
• 4. Calculi in immense numbers may exist for months in the ducts without producing serious symptoms.
• 5. Under these circumstances the surgeon need not reproach himself if there be recurrence of symptoms after common duct drainage.

Biliary calculi are serious menaces to a patient’s welfare, not alone because of the obstructive symptoms which they may produce, but because of the acute or chronic conditions to which they indirectly give rise. These have been in some degree already mentioned. Thus cholecystitis and cholangitis of all degrees of severity, from the milder chronic forms to the phlegmonous and fulminating varieties, may be at least associated with the presence of such calculi and seem to be to a greater or less extent due to their presence. Around such foci of excitement there will always occur local peritonitis, which will result in adhesions, and the consequent tenderness with referred as well as local pains to which it necessarily gives origin. The viscera suffer not only in this direct way, but functional disturbances are produced, and are usually covered under those vague terms “dyspepsia” and “indigestion” with which patients crudely describe their discomforts, and under which physicians too often conceal their failure to appreciate the actual condition.

Furthermore there is always a possibility of cirrhosis resulting, because of distention of the hepatic ducts and backing up of the hepatic secretion. Thus the liver becomes larger and more dense, is colored green, its edges become more rounded, this occurring especially in the right lobe, or at least attracting more attention in that location because more easily recognized from without. Again the more acute inflammatory conditions sometimes cause paralytic ileus, or at least paralysis of the lower bowel, and thus lead to conditions almost identical with, and difficult to distinguish from acute intestinal obstruction.

Of equally great and growing importance is the fact that, according to Schroeder, some 14 per cent. of gallstone sufferers develop cancer, the presence of these irritating foreign bodies in the biliary passages having much the same relation to cancer of the liver as does the existence of previous ulcer to cancer of the stomach.

Symptoms.

—There is scarcely any morbid condition which is at one time characterized by such significant symptoms and at another by none at all as cholelithiasis. In rehearsing the list of the ordinary symptoms produced by the conditions exceptions should be made, for no matter how complete the list something may be omitted which has been noted in some particular case.

Gallstones confined within the gall-bladder proper may produce few or no symptoms, this being particularly true so long as the ducts are free and there are no persistent consequences of previous acute trouble. A stone may grow in the gall-bladder to a large size and cause little or no distress until it begins to work its way by the ulcerative process. Doubtless small concretions pass with little or no disturbance, or only that which would be considered a “temporary dyspepsia.”

When, however, gallstones produce symptoms these usually include more or less paroxysmal pain, occurring unprovoked and at irregular intervals, referred not alone to the upper abdomen, but radiating to the rest of the trunk, as well as in the direction of the right shoulder-blade. (The shoulder pains of biliary and renal lesions are due to the connection of the pneumogastric nerves with the ordinary sensory nerves above, and below with the sympathetic ganglia.) Attacks of pain are usually followed by nausea and vomiting, and if extremely severe by more or less depression and collapse. At times there will be a sensation as of distention in the region of the gall-bladder. Tumor in this location may or may not be present, and jaundice is an uncertain symptom, not occurring unless the ducts are occluded. The stomach so far sympathizes that digestion is at least temporarily disordered. In proportion as angiocholitis is produced by the passage of calculi we may meet with more or less septic features. The pain produced is uncertain in severity and duration, and is often relieved by the relaxation which may accompany or follow vomiting. After subsidence of severe pain there remains a dull ache for several days, lasting perhaps until another acute paroxysm. These pains are sometimes referred to the left side and over the stomach, in which cases it will usually be found that the gall-bladder is adherent to the stomach, while when the pain is felt in the right side of the thorax it is usually because there are numerous adhesions between the lower surface of the liver and the viscera below it. Such pain may even simulate angina pectoris or may involve the genitocrural distribution. In fact it may be referred to almost any part of the body.

Vomiting which is at first paroxysmal and colicky may become persistent, continuous, and even dangerous. It is essentially an expression of pneumogastric irritation. The vomited matter may contain bile or even, by retrostalsis, fecal matter. The depression which at first occurs may merge into complete collapse; it may even be fatal. It will necessarily be more marked when the paroxysms are more frequent.

A significant feature in nearly every case is muscle rigidity, especially of the upper abdominal muscles on the right side, but not necessarily confined to these. This muscle spasm is a symptom common to many serious conditions and is not of itself indicative. It simply implies a serious condition within. Tumor or enlargement in the region of the gall-bladder may be met with, but are by no means constant. These may become more pronounced with each attack, being reduced between times because of the escape of bile between paroxysms. It is a valuable symptom when noted, but no importance should be attached to its absence.

The presence of gallstones in the stools is, of course, indicative, but most valuable time is often wasted when waiting for their discovery. Moreover, a number of hours, or even days, may elapse, the time depending on the activity of peristalsis, between the escape of calculi into the duodenum and their appearance in the stools. A convenient way to search for them is to let the stool be stirred with a 1 per cent. solution of formalin and then strained through a sieve which has about sixteen meshes to the inch. The question of the wisdom of operation can practically always be decided without reference to the appearance of calculi. In this way the surgeon may feel that his diagnosis is corroborated by it, but in no sense weakened without it.

Jaundice is always a significant sign when present, but is absent in at least four-fifths of cases which nevertheless should be subjected to operation. Its occurrence is a matter of interest along with the previous history of the case. It is, however, of great value if it were noted in connection with the first pains or cramps. In chronic obstruction by stone in the common duct it is important to determine the intensity of the jaundice, since this may indicate whether we deal with calculous disease or obstruction from tumor. In chronic obstruction by stone the color changes are less marked, and often clear up entirely, while when produced by tumor they become gradually more intensified.

Deep and persistent jaundice is suggestive of malignant disease. The degree of cholemia rather predisposes these patients to hemorrhage or persistent oozing during operation. Jaundice gradually deepening with each attack of pain is also very suggestive. Such attacks, coming on with symptoms like those of malaria, chill, sweating, and pyrexia, are extremely suggestive and always call for surgical intervention, i. e., drainage. In brief it may be said that jaundice, with enlargement of the gall-bladder, is at least suggestive of cancer, while a history of gallstone colic, without much enlargement of the gall-bladder, is indicative of stone in the common duct. Although this statement is probably true for the majority of cases there are occasionally marked exceptions to it, as, for instance, when a gall-bladder is distended with hundreds or even thousands of small calculi, or to such an extent that it may form even a pear-shaped tumor hanging down within the abdomen.

In addition to these features thus rehearsed there might be made a long list of possible “extras,” by which the original condition is complicated and made to appear in unusual aspect or even life endangering. Such a list would include nearly every imaginable lesion of the upper abdomen. Suffice it to say that the liver, stomach, and the pancreas especially may suffer, while other viscera and the larger veins, with the surrounding tissue, may any or all of them become involved.

Diagnosis.

—Diagnosis has to be made mainly from non-calculous obstruction; from the acute gastric conditions, ulcer, etc.; from renal colic; from the acute or subacute pancreatic affections, duodenal ulcers, renal lesions, localized peritonitis from some other cause; from cancer, lead colic, angina pectoris, pneumonia, pleurisy, and even hysteria. Not so rarely pneumonia and pleurisy begin with pains which are referred to the upper abdomen and are suggestive of gallstone disease, while they seriously perplex the medical attendant. Much stress is to be laid on the first location of the pain, especially if this be in the direction of the right shoulder, and upon concomitant vomiting and jaundice, if present, as well as on the location of the greatest tenderness and muscle rigidity. Recurrence of more or less similar attacks is also suggestive. Diaphragmatic pleurisy may cause pain, referred especially along the esophagus, and intensified during the act of swallowing or vomiting. Affections of the appendix and gall-bladder may co-exist, as well as be easily mistaken one for the other. The former is so true that when operating for one condition it is always advisable to explore in regard to the other. When the appendix is placed high, especially behind the colon, confusion may confound. Biliary colic is usually free from the associated ordinary symptoms which are so often met with in renal colic, while in the latter the urine will contain no bile pigment and the pain will usually be referred to the external genitals. In lead colic the characteristic line upon the gums and the habitual constipation which always accompany it will be suggestive. When the stomach is at fault and the pylorus obstructed this viscus will usually be dilated, and the vomit is of a different character, while, at the same time, actual stomach movements may or may not be made visible. With gastric or duodenal ulcer pain it is more regular and associated with food taking after a definite interval, longer in the latter case.

Chronic pancreatitis is so often associated with cholelithiasis that it is impossible to disassociate their symptoms, but the referred pain is rather midscapular or even on the left side. It will be particularly suggested by rapid loss of flesh. In acute pancreatitis the symptoms are usually more excessive, the distention earlier and greater. Cancer of these various organs does not commence with pain, but has a more gradual, distinctive downward course, with cachexia. These are some of the considerations which may aid in differential diagnosis.

The detection of bile pigment in the urine and blood will have corroborative value.[63]

Treatment.

—The general subject of cholelithiasis and its associated lesions constitutes an important topic in the so-called “border-land” between medicine and surgery, where views and advice regarding prognosis and treatment will depend on the experience and the training of the medical attendant. Surgeons now recognize, and physicians are being gradually converted to their view, that gallstone disease is essentially a surgical disease, i. e., one to be combated by surgical intervention. While it is not to be gainsaid that many patients live and die with gallstones who are never conscious of their presence, and while others who have had serious attacks live to die of some other disease, nevertheless the general statement may be boldly made and easily defended, that when the disease is well marked and when patients suffer more or less constantly from it the only successful method of treatment is the surgical, and that, in other words, operation offers the only prospect of permanent relief. Regarding its associated dangers it may be said that danger comes from delay rather than from operation, and that here, as with many other conditions, patients often wait too long, partly from lack of proper advice, partly from timidity, and that a septic and moribund patient, allowed to become so for lack of earlier application of the resources of surgery, is a reflection on the one who waits rather than on the surgeon, who, endeavoring to save, still unfortunately loses his patient.

This is not the place to discuss non-operative measures—i. e., medicinal and dietetic treatment—valuable as they may be in certain cases. Most of the drugs which are supposed to be effective in their power of solution of gallstones or of facilitating their escape are disappointing, and at best are vague and uncertain in their action. The hydrotherapeutic treatment, such as carried out, for instance, at Carlsbad, will do good in many cases, especially for those who have been indulgent in their appetites and careless in their habits. Cases of any description not too far advanced would be benefited by a careful regimen of this character, but that Carlsbad or any other waters will certainly cure cholelithiasis is now absolutely disproved. As a preparation for operation a sojourn at some such place may be advised; as a substitute for it, never. Large doses of glycerin (50 to 150 Cc.) often temporarily relieve the pain of biliary colic.

In general, then, it may be said that cases which give a history of recurring attacks of biliary colic, with or without recurrent jaundice, and with those varied concomitant symptoms which are usually grouped under the term “indigestion,” in which there is definite tenderness over the region of the gall-bladder, with or without muscle spasm, and with the other referred pains so often present in this condition, should be regarded as legitimately surgical, where operation is more than justifiable and usually decidedly advisable, even too often imperative. The same is true of those cases of distended gall-bladder with obstruction of the duct where perhaps no calculi are present, but where the patient suffers in much the same way as though they were present. Biliary drainage is equally called for, and the presence or absence of calculi is but a minor feature upon which too much stress should not be laid nor too much disappointment expressed if they be not found.

Many cases of chronic cholelithiasis have become more or less toxemic, as well as cholemic. It is a well-recognized fact that cholemic patients are more likely to cause inconvenience to the surgeon from free hemorrhage or persistent oozing, because of the slowness with which coagulation of their blood takes place. When time is afforded for preparation it is of great value in these cases to administer calcium chloride, of which several doses may be given each day, in considerable water, the former varying in amount from 1 to 2 Gm. When time suffices, too, it is always of value to prepare these patients for the operation by measures already discussed, improving their elimination, reducing the degree of their toxemia, and fortifying their circulatory systems by well-known measures. The value of such preparation is perhaps more apparent in such instances than in most others. On the other hand, many cases calling for operation are almost as imperative as those of acute appendicitis, where every hour’s delay is to the disadvantage of the individual. The operations which are practised upon the biliary tract will all be discussed together in a section by themselves.

TUMORS OF THE GALL-BLADDER.

This expression refers rather to actual neoplasms of the gall-bladder itself than to distention of the sac by which an intra-abdominal tumor may be formed. The latter subject may be dismissed with the mere statement that the gall-bladder may become distended with bile, with mucus, with pus, with concretions, or with the products of such disease as echinococcus, actinomycosis, etc. In this way it may be so much enlarged as to be easily felt through the abdominal walls or to be even mistaken for other conditions. In the latter case it may have to be differentiated between such a condition and a movable right kidney, a tumor of the kidney itself or of its capsule, as well as from tumors of the stomach, especially the pylorus, of the liver, or of the intestine and from the enlargement of the right lobe which often accompanies cholelithiasis, or from fecal impaction. It would be best to abstain from the use of the aspirating needle in these cases, as more harm might be done by the escape into the abdomen of deleterious fluid than would be atoned for by the information which the procedure would afford. Even when the abdomen is open the gall-bladder should rarely be punctured in this manner, unless one is prepared at the same time to open it and drain. In other words, there is less risk about a small exploratory incision than in puncture.

Nearly all varieties of malignant and many of benign tumors have been reported as occurring in this location. It will be sufficient in this place, however, to say that cancer of the gall-bladder, which, of course, may extend in various directions, is by no means an uncommon affection, and is usually a complication of gallstones. In fact, it may be doubted whether primary cancer of the gall-bladder ever occurs in the absence of such a source of irritation. These cancers vary in type between the round-cell and the squamous, most of them, however, being of the former character. Although Musser has put the percentage at 65 and Zenker as high as 85 of instances where gallstones are found within cancerous gall-bladders, it does not follow that the above statement may not be true regarding their almost universal association and causal relation, for any gall-bladder found empty at a given time may at some other time have contained a calculus. This frequent association is justly among the valid arguments which surgeons may now use in making a plea for earlier operation, and for making it a more standard procedure.

Cancer may be suspected in cases of progressive and unintermittent jaundice, especially when there can be felt in the region of the gall-bladder a distinct tumor or an enlargement of the liver. Pain is a frequent but by no means a constant or reliable symptom. As the disease spreads the adjoining textures will become matted together, and a low grade of local peritonitis may still further cement them into a mass which will occupy a considerable portion of the upper part of the abdomen.

But few cancers of the gall-bladder which are so apparent as to be recognized without exploration can be considered as still amenable to surgery, which for them can hold out but little prospect save perhaps a temporary relief by biliary drainage. It is the cases in their earlier stages, when the condition is made out by exploration, and by it alone, which still afford prospects of more or less permanent relief. The very impossibility of detecting the condition in these earlier stages without exploration affords one of the strongest arguments for such a procedure in every vague case of the kind. That cases of this character are not necessarily hopeless is instanced by an experience of my own, where on opening the abdomen of a large and fleshy woman I found a distinctly cancerous gall-bladder containing two large calculi, and removed the entire mass, with a considerable portion of the surrounding hepatic tissue, the removal being effected with the actual cautery. At present date of writing, nearly six years after the operation, the patient is apparently perfectly well and doing her own housework.

OPERATIONS UPON THE GALL-BLADDER AND BILIARY PASSAGES.

The small area included under the above title has been made the field for a variety of operations, dignified with formidable names, the entire list of which might be made quite long. In order to simplify their arrangement and illustrate their purposes they may be referred to as (1) operations upon the gall-bladder proper; (2) those upon the ducts; and (3) the more complicated operations upon one or both of these in connection with some other part of the intestinal tract; or, to catalogue them somewhat definitely, the operations upon the gall-bladder include cholecystotomy, cholecystostomy, and cholecystectomy, according as the surgeon opens the gall-bladder and closes it, makes a more or less permanent opening, or completely removes it. Again, upon the ducts he may make cholangiotomy or cholangiostomy, or, using their practically equivalent synonyms, choledochotomy or choledochostomy, these terms referring to operations upon the cystic and the common ducts; while when similar procedures are applied to the hepatic duct they have been spoken of as hepaticotomy and hepaticostomy. Cholecystenterostomy refers to an anastomosis between the gall-bladder and the upper bowel, while when this is effected between the common duct and the bowel it is referred to as choledochenterostomy. When a stone lies partly in the common duct and partly within the wall of the duodenum, and it becomes necessary to incise the latter, it may be spoken of as duodenotomy. The operation of merely crushing biliary calculi, hoping that the fragments will be passed on with the flow of bile, and spoken of as cholelithotrity, is now almost abandoned, and the term has historical rather than present value.

To even attempt to epitomize directions for these various operations into space available here would be impossible, for large volumes have been devoted to this subject alone. The main thing for the student and the junior practitioner is to appreciate the indications for their performance, at which he should certainly have assisted before attempting to perform them himself. General directions, however, may be given as follows, the usual preparations having been made both of the patient and the environment: A woman who has borne children and who has, in consequence, relaxed abdominal walls, makes a more favorable subject for operation than a muscular man whose abdominal muscles cannot be relaxed until a profound degree of anesthesia has been obtained. In many instances exposure is made better by placing a sandbag behind the region of the liver, especially on the side to be operated, by which the costal angle is more outlined and the parts pushed forward.

A preliminary incision should be made of, say, three inches in length, and is best placed a little to the inner side of the outer border of the rectus, whose fibers are separated and its tendinous intersection divided. This incision may be extended upward and curved toward the middle line, as recommended by Bevan, or downward, as the exigencies of the case may require. The beginner especially should provide himself with sufficient space for manipulation. The posterior sheath of the rectus and the peritoneum are best divided together. Sufficient opening being thus made, a finger may be inserted for the purpose of exploration. In the presence of adhesions, and especially in acute cases in which pus is likely to be present, this should be done with great caution. When no adhesions are present gauze pads may be inserted and so disposed as to permit exposure to view of the lower surfaces of the liver. The operator should be prepared for any and all conditions—one of dense adhesions or their complete absence, as well as for cobweb-like adhesions which surround foci of infected exudate or of pus. The more reason he may have for suspecting the presence of pus the more carefully should the region be walled off with protective gauze. Adhesions are most likely to form between the omentum and the colon, in front and below, and with the stomach, duodenum, and colon below and behind. Those who have had experience with abdominal operations will appreciate whether these adhesions are recent and likely to cover purulent foci, or old, and will proceed accordingly. Occasionally tissues will be so matted that even an experienced operator will scarcely be able to differentiate them.

The endeavor should be, if possible, to expose the gall-bladder itself, both to touch and sight, in order that after orientation concerning its actual condition its duct may be followed into the common duct, and this into the intestine. This is sometimes an exceedingly easy matter, and again impossible. The presence or absence of pus will of itself indicate what should be done. When, for instance, the gall-bladder is found black or partly gangrenous the surgeon will content himself with doing the least possible amount of separating, endeavoring rather to provide the widest outlet for drainage. It might be better to make simply a small opening and permit the escape of fetid débris, and to postpone until a later day further attempt to remove the calculus, which presumably has produced the difficulty. Local indications, then, should be considered along with the general condition of the patient.

The lower surface of the liver will afford the guide to the location of the gall-bladder, and when the latter is nearly obliterated its discovery sometimes taxes the resources of the surgeon. When not contracted it is usually easily exposed, and so far freed that it may be even drawn up into the wound. After having thus isolated and perhaps secured it, it must be decided by further exploration how it shall be treated. It is of great importance to liberate the ducts from surrounding adhesions.

Cholecystotomy.

—Cholecystotomy, sometimes fallaciously spoken of as ideal, consists in simply opening the gall-bladder, emptying it of calculi or other contents through a small incision, and closing this by sutures. The operation is ideal in but one way, but conditions which permit it rarely justify it, for any gall-bladder so diseased as to call for operation needs either removal or drainage.

Cholecystostomy.

—Cholecystostomy includes provision for drainage over a considerable length of time. A distended gall-bladder which permits of easy manipulation and isolation may be sufficiently long and large to justify uniting its surface to the peritoneum and deep margins of the wound, in such a way as to permit discharge of its contents through the latter. The old method was to unite it to the skin. This should never be done, as fistulas thus resulting are more likely to be permanent. If the gall-bladder be thus affixed to the parietal peritoneum the better way is to insert a drain, its arrangement being left somewhat to the choice of the operator. For my own part I prefer a rubber tube, not too flexible, inserted two or three inches into the gall-bladder, through a small opening closed around it, with invaginated edges, by a purse-string suture of chromic gut, by which it is intended to prevent leakage into the abdominal cavity. By another suture of common gut the tube may be so fixed as to avoid danger of being lost in either direction. If the gall-bladder be sufficiently long to permit additional fixation to the depths of the abdominal wound the operation is made still more ideal; but in the case of a short and contracted cavity the tube may be left to follow it into the abdominal recesses. Within forty-eight hours the exudate which has been thrown out around it will have become sufficiently organized and well ordered to form a canal in which the tube shall rest, and which shall serve later as a conduit to conduct bile to the surface after removal of the tube itself. Into such a tube, after the application of the dressings, may be conducted another more flexible tube, whose upper end shall connect with a receptacle of some kind, which may later be a bottle held within the dressing, to receive the discharge, and thus avoid soiling.

This operation has been done occasionally in two sittings, the gall-bladder being brought into the upper part of the wound and fastened to the peritoneum by sutures, which should not perforate its walls, as that leakage would occur which the method is intended to avoid. After waiting a day or two for adhesions to form the cavity is then opened with a knife or scissors and drainage thus accomplished. This method has been practically abandoned, for the reason that it permits no digital exploration by combined manipulation.

Cholecystectomy.

—Cholecystectomy includes the removal of the whole or the greater part of the gall-bladder. It has already been stated that this is a reservoir, convenient and advantageous, but not needed in a way, and not essential to life. It figures as a superfluous organ, then, similar to the appendix, and there is no reason why, when diseased and troublesome, it should not be extirpated. Its removal will sometimes be a matter of choice, and at other times a necessity. The former is the case when the surrounding conditions lend themselves to its dissection from the lower surface of the liver without too much violence to other tissues; the latter when it is involved in malignant processes or when its interior is seriously infected. An incomplete method of treating the gall-bladder under the latter circumstances might include the scraping or removal of its thickened mucosa, without removing the entire thickness of its structure. In this case, however, drainage would be required. That the gall-bladder may be completely separated and thus isolated, with comfort and speed, requires that its wall be sufficiently strong to stand the ordinary manipulation. This may not be true of the perfectly normal gall-bladder, but in such case no one would think of removing it, whereas the cyst, which is diseased sufficiently to justify removal, will usually permit of the necessary manipulation. Even if somewhat torn in the process the procedure may be effected without much added difficulty. This procedure consists essentially in separation of the overlying peritoneum and enucleation of the gall-bladder from its bed or the depression in the liver in which it lies, which, as already indicated, may be narrow or wide and deep. Actual separation from liver tissue will be followed by oozing and at least two or three vessels in the surrounding structures and at the neck of the gall-bladder will require to be secured. Removal should not be attempted in cases which do not permit of it, but may be practised in those cases not too infected, when after emptying the sac (full of calculi, for instance) it can still be established with the probe that the common duct is patulous. These are ideal cases for such complete work. The gall-bladder having thus been isolated down to its cystic termination, the surgeon proceeds much as though it were the appendix, by firmly ligating the duct with chromic gut, guarding against escape of contents while it is divided on the distal side of the ligature thus applied. The stump of the duct is then cauterized with pure carbolic, after which oozing is checked by tamponing for a few moments. It then is often possible to bring together the peritoneum beneath the torn liver surface and almost completely cover it anew. The liver tissue will bear a ligature or suture not too tightly drawn. If the case have been one otherwise surgically clean, and the operation properly conducted, the abdominal wound may be closed without drainage. If, however, doubt be felt a small cigarette or a tubular drain may be placed, to be left not more than thirty-six hours. Every infected gall-bladder, if not removed, should be thoroughly cleansed, its interior being mopped with gauze, preferably with the addition of hydrogen dioxide. An important step, next to attention to the gall-bladder proper, is to demonstrate the patency of the ducts. This is done by gently passing a probe, which should be bent to suit the case, along the duct and into the intestine. This, of course, cannot be done if calculi are discovered by manipulation, neither can it always be done when calculi are not present. Gallstones in the duct can usually be distinguished by the fingers with which the exploration is made, and failure to thus pass a probe may be brought about by stricture rather than by calculous obstruction. The importance of this determination will be seen in removing the gall-bladder, as to remove it in an obstructed case is to leave no outlet for bile except into the abdominal cavity, whereas to fail to drain such a case is to plainly neglect to meet the indication.

Cholecystendysis.

—The term cholecystendysis, now almost obsolete, implies practically a cholecystotomy with drainage, the gall-bladder having been opened for the purpose of removal of one stone or more and then united to the abdominal wound.

Of the operations upon the ducts there is something to be said in addition to the directions already given. Inasmuch as they lie more deeply they are more difficult of access, and variously shaped retractors, with walling off the cavity with gauze, are more often required, while in proportion as deep adhesions have enwrapped the structures they are made more difficult of exposure. At present surgeons have less hesitation in leaving duct incisions unclosed than was formerly felt. It was formerly held that every incision into a duct should be closed with sutures. It has been later found that satisfactory results ensue when the end of the drainage tube is left resting, or even fastened, within the duct opening, the operation being thus made shorter and simpler and the difficulties of deep suture thus obviated. As elsewhere noted the common duct may become enormously dilated, and may be almost mistaken for the small intestine. The passage-way between this duct and the gall-bladder may be so obstructed that double drainage will be of advantage, or this may be a case where partial removal of the gall-bladder may be effected, with drainage of the common duct. Such cases should be judged upon their merits. The more infectious the existing condition the more is free drainage demanded. When a stone is impacted in the ampulla of Vater there should be no hesitation in dividing the walls of the duodenum in order to extract it. In such a case the duodenum is sutured, but the duct or the gall-bladder must be drained (Fig. 629).

These deep operations require free incision, several inches in length, and it will astonish the beginner to see how the liver may be delivered from the abdominal cavity through such an opening. Much assistance will here be gained by a large pillow or sandbag placed beneath the back. Bleeding vessels need to be secured, at least temporarily, with forceps, and usually with sutures or ligatures en masse. The exposed or torn surfaces of the liver will ooze freely at first, but bleeding usually ceases with the pressure of a gauze tampon. From the uninflamed gall-bladder the peritoneum is usually easily separated, with but trifling hemorrhage. For deep work traction on the middle portion of the duodenum makes more prominent the junction of this part of the bowel with the gastrohepatic omentum, at which point the peritoneum may be incised and separated along the free border of the duodenum until this portion is free from external peritoneal covering. There will be exposed here the second portion of the common duct where it lies upon the pancreas, it being more or less embedded in the latter further along. When it is necessary to cut away more tissue it is better to sacrifice a portion of pancreas rather than of duodenum itself. Blunt dissection alone should be made here. When it is necessary to cut it will be better to use the thermocautery.

These various cutting operations have superseded the previous methods of endeavoring to crush stones within the duct and force the fragments along by pressure. The Mayos have recommended the use of two fine parallel sutures, introduced longitudinally into the duct, between which the incision should be made, and which may be used as tractors, or subsequently for purposes of closure.

Practically every gall-duct case should be drained with a tube extending down to the deepest portion of the site of the operation. This may be done with what has been called a “dressed tube,” made by surrounding an ordinary rubber drain with a few layers of gauze and covering this with oiled silk. The lower end of the tube is then bevelled or trimmed in fish-tail fashion. This may be passed into the depths, or it may be used for gall-bladder drainage as well.

Of the anastomotic operations there is less heard now than a few years ago. There are now considered to be but a few conditions which are not better dealt with by biliary drainage as made above than by any other method. Occasionally, as, for instance, when the common duct is strictured or involved in pancreatitis or cancerous deposit, and bile is backing up into the gall-bladder, it may be of great advantage to effect an anastomosis between the latter and the bowel. At one time the colon was used for the purpose, but this prevented the utilization of the bile in the upper bowel, where it is most needed. Consequently it should always be made into the upper portion of the bowel, the duodenum, or one of the upper loops of the jejunum. For this purpose a small Murphy button is probably still the speediest and best expedient. This is true also when it seems necessary to drain the common duct into the bowel, since the field of operation in most cases lies too deeply to permit of accurate and satisfactory suturing. A further and more difficult as well as later application of this principle has been suggested for certain cases of permanent obstruction of the common and main hepatic ducts. Under these circumstances the operation last mentioned would be useless and a cholangiostomy would be objectionable, as it would constitute a permanent fistula. As practised by Kehr and others this hepato-cholango-enterostomy is performed by removing from the lower surface of the liver a strip of its tissue about 7 Cm. long and 2.5 Cm. wide. The hemorrhage is checked with the thermocautery, and with it an opening is made into the liver, of such a depth that several of the bile ducts are thus divided and opened. The uppermost loop of bowel which then can be utilized without tension is opened and sutured to the margins of liver wound. The method is still on trial, and yet in at least one successful case it was shown that the liver tissue tolerated this unavoidable contact with the contents of the upper abdomen (Fig. 630).

After-management.

—What to do with these cases of biliary drainage after it has been effected is sometimes a serious problem. No hard-and-fast rules can be laid down regarding the length of time during which drainage should be maintained. In instances where the gall-bladder has been removed the drain should be taken out within thirty-six hours, but in those cases where a tube has been fastened into the gall-bladder for so-called permanent drainage the term “permanent” may be regarded as elastic, and covering a period of from ten days to perhaps ten weeks. In the majority of instances three weeks or so of such drainage suffice to meet the original indication. In cases, however, of chronic pancreatitis a long period of easy outflow will be demanded, while in rare cases of cancer drainage once thus made cannot be abandoned.

When the gall-bladder has not been fastened nor allowed to adhere to the skin, but only to the peritoneum, the fistulas thus made will usually close and rarely need stimulation. Should, however, the granulation process by which closure is effected be too sluggish it may be stimulated by the application of nitrate of silver, either in solution upon a swab, or in solid form, as when melted into a bead upon the end of a suitable probe. Firm pressure will also assist in final closure.

It is not reasonable to expect that after so much intervention, within the rudely triangular potential cavity occupied by the gall-bladder and the ducts, adhesions will not form as a part of the reparative process. In fact it may rather be expected that as it becomes obliterated adhesion must necessarily follow. In consequence there may result an agglutination around the gall tract, and into a common mass, of the liver, the colon, and the pyloric end of the stomach. In spite of these adhesions bad symptoms rarely ensue, and when discomfort persists it is usually in those cases in which no stone was found or those in which stones have been overlooked. Andrews regards such postoperative adhesions as unavoidable and even desirable, and, having no faith in any measures to prevent their formation, differs from Morris in regard to the technique of their subsequent removal. It appearing from observation and experience that the stomach is the organ which suffers most by extensive adhesion to the liver, he has proposed to substitute the colon for the stomach in this necessary union of surfaces, and would even practise it in old cases after separation of old adhesions.

The operation suggested by Andrews, and which he calls cholehepatopexy, or colon substitution, is made with an incision through the middle line of the right rectus, avoiding any old scar, long enough to afford plenty of room. The stomach is then carefully separated from the liver, tearing liver tissue rather than that of the former, if something must be torn, and checking bleeding by hot sponges. The pylorus having been exposed the stomach is invaginated into it in order to demonstrate its patency. The freshly separated viscera will now fall again into immediate contact unless the transverse colon be pulled up and held in place between the liver and the pylorus, this not being so much of a displacement as would appear, as the bowel is not rotated and does not cross over the stomach. The colon is held in its new relation by attaching its omentum to the gastrohepatic ligament, to the liver surface, or to remnants of old adhesions in the angle between the pylorus and the liver. The looser the omentum and the more easily it can be interposed in this way the better. Andrews’ conclusions are that gall-tract adhesions are unavoidable, both in disease and after operation, that they are harmless except in a very few cases, and often beneficial, and that in the few cases where they do harm this comes from malposition rather than from adhesions per se. He even believes that certain vague gastric adhesions which might have been benefited by this operation have been previously treated by gastro-enterostomy.