biliousness if you like, are always associated | where a second operation has been needed for with a greater or less amount of septic infection. the removal of gall stones, and inasmuch as in Evidence obtained from the clinical condition almost every case either the gall bladder has and from the examination of cases surgically been stitched well up into the abdominal wound treated bears this out. Not only do we find an or surplus material removed or the whole acute inflammatory condition of the mucous bladder or its lining membrane removed, it membrane, but in a large majority of cases, would seem that this in itself has a marked ulceration as well. In more severe cases still influence over the prevention of stasis of bile peritonitis is set up, and adhesions are formed in what is left of the gall bladder, and in a way between the peritoneum covering the gall presumably influences the prevention of the bladder and that covering adjacent surfaces. fresh formation of gall stones. The pathological cycle, in fact, is not by any I have not been able to obtain any definite means very unlike that of appendicitis.

evidence on this point but in cases where there Naunyn has shown that cholesterin and was a probability that stones had formed in the calcium, the chief constituents of bile, are ducts, it would be of some interest to know formed in the mucous membrane of the bile whether pockets did not exist in which stones passages. Gilbert and Fournier, too, are of could gradually be formed. opinion that gall stones derive their origin from Let us look at the pros and cons of surgical this source, and that the mucous abundantly versus medical treatment. Gall stones are secreted, and the desquamated and degenerated almost always formed in the gall bladder. The epithelium unite with pigments to form insol- operative treatment in good hands shows uble compounds. So that although gall stones one per cent. of deaths. Recurrence must be a second stage in the pathogenic cycle may very rare, I certainly do not know of a single again cause attacks of cholecystitis and biliary case. If the stones pass into the ducts colic, these attacks are often present when no operative treatment gives us as much as ten per gall stones can be found.

cent. of deaths, though I think that this will It is only when patients experience intense probably be greatly lowered. While gallstones pain that we look upon the case as one of remain they may give no trouble, but they are biliary colic, but it is more than probable that always liable to and frequently do give rise to many cases of acute dyspepsia, or what are septic attacks and malignant disease, and more termed attacks of the liver or biliousness are rarely to perforation. All of these prove really attacks of cholecystitis possibly, at times, themselves to be a great menace to life. associated with gall stones, or occasioned by an I cannot, from my own experience give ascending catarrh originating in a gastro- precise data as to the frequency with which duodenal catarrh.

gall stones cause cancer. Within the last two Naunyn who is if anything an advocate of years I have met with six patients under my medicinal treatment admits that in the great own observation who died of cancer of the gall majority of so-called cures, one has to do with a bladder following on cholelithiasis. Two of cure for the time of the septic complications these I thought I had cured with olive oil only. Kehr and Mayo hold similar views, and six or seven years ago. Klob and later Frerichs, so I am sure must anyone who has given to Klebs, Hilton Fagge and others have testified this subject his thoughtful consideration. to cholelithiasis as a cause. Courvoisier found

It is true that patients sometimes go on for gall stones in 74 out of 84 cases. Brodouski a considerable length of time after an apparent found gall stones in 40 consecutive cases of cure of an attack of cholecystitis, but this is by cancer of the gall bladder. It is true that no means a guarantee that he has been cured. cholelithiasis is no newly discovered disease I grant, too, that these cases do not warrant and for that reason there is great difficulty in our recommending interference where such a convincing men that it is not the common place prolonged abeyance of symptoms exists, simply painful but comparatively harmless disease wo because we are not in a position to say whether once thought it. Jaundice, which was so often gall stones or some such possible sequela of looked upon as the only feature wanting to cholecystitis exists.

clinch the diaqnosis is considered by Naunyn Although it is admitted that gall stones may to be present to the extent of giving a urinary form in the bile ducts, the bulk of evidence goes reaction in only one-half the cases, and this to show that the vast majority are formed in the probably means that occasionally cases have had gall bladder. This is what one would expect, repeated attacks of biliary colic sufficient to for a running strean such as one finds in the give some stones at all events an opportunity of bile ducts would not be so favourable to their getting into the bile ducts. development. Again, so far, I know of no case Kehr is very emphatic in stating that 80 per

a

If upon.

one.

cent. of gall stone cases do not suffer from above normal, the secretion of bile is prevented, jaundice. This leaves a large percentage of so that cholagogues can only act as ordinary cases difficult to diagnose, and which were once brisk aperients. attributed to bilious attacks, gastritis, dyspepsia, My own impression as to the best method of malaria, and other diseases associated with treatment is this. During the attack give acute abdominal conditions. The grave sequelæ opium and belladonna in order to relieve the which are apt to supervene are well exemplified pain and spasm. As soon as possible give in the series I present to you, and I think that large doses of salines, preferably, or any other the most conservative physician can hardly aperient by the mouth, or, if they are not reinsist that he is right in allowing a condition of tained, give them by the rectum. Salines affairs to remain in a patient's abdomen which produce free watery evacuations and in this may at any time produce intra-abdominal, local, way deplete the inflamed part. If the salines or general sepsis.

be given warm so much the better. The appliThe state of affairs is this. If a patient has cation of heat externally is soothing, and gall stones there is a 1 per cent. of risk open to leeching also appears to be of service. him if they are removed from his gall bladder, The surgical treatment I have already touched and practically no chance of recurrence.

The operative treatment of cases of they are left he must be prepared to take the cholecystitis and cholangitis is at times very various risks with which we are acquainted. simple, but he who attempts to operate on the On the other hand you might remark how often gall bladder and bile ducts must be prepared can any of us say positively that gall stones are for anything, and at times, if he do his duty, present ? Very rarely indeed, but we do not he will find that he is face to face with one of necessarily operate for gall stones, but for a the most difficult tasks in surgery. cholecystitis which is deemed to be sufficiently I have heard of cases of congenital absence severe, either from the severity of this one of the gall bladder, but I have never met with attack or the frequency of the attacks to need I am inclined to think that greater exoperative interference.

perience or a more effective search would very Biliary colic is almost always due to cholecy- much increase their rarity. stitis. Cholecystitis is a septic condition some- Before concluding, I would like to ask-Is times amenable to medical treatment. If, not- it not patent that the majority of us in dealwithstanding treatment, attacks recur, then, ing with cases of cholecystitis and cholangitis whether we think gall stones are present or have shown too little thoroughness, and have not, the bile passages should be examined, the profited too little by our knowledge of the cause if possible discovered and rectified. If misery and mortality which follows so often in there be any obstruction to cystic or bile ducts the wake of these cases, and have we not clung it should be removed. If the gall bladder be too long to the crude and unscientific treatment affected the lining membrane or the whole of our fathers ? bladder should be removed just as we should After all, what is it we must seek to do for remove an appendix, for the pathological condi- our patients ? Is it not to restore them to tions are very similar.

health as completely, as speedily and with as I shall be brief on the question of the little risk to life as possible? methods of treatment. Preventive treatment If surgery can claim such a large percentage should confine itself to keeping in check those as 99 in early cases, and can, so far as we know, causes which are likely to produce gastro-promise complete amelioration, then what duodenal catarrhs.

object is gained by temporising at times for Olive oil I have used greatly, and at times days and even weeks with a poor wretch who is in with good results, that is to say this oil, in constant pain, and who, even if he does recover, conjunction with podophyllin, gave frequent recovers with the pleasant prospect that some motions, and both the patient and I were day he may have it all over again. Even these delighted to find a lot of green lumps we called few cases show what great risks several of the gall stones. The fasting and purging relieved patients ran, and what a small shred of hope the inflammatory conditions, and the attack the operator often clings to when struggling to passed off. The patient called it a cure. I was bring the case to a successful issue. The after a time not quite so sanguine. Cholagogues, dangers of operative treatment have hitherto with a view to increase the flow of bile, can be no doubt deterred many men from recommendof little service. It is not increase in quantity ing their patients to submit to surgical measures, of bile we need, but increase of pressure. If but improved methods and experience in this the pressure is increased in the ducts very little class of work have made such treatment in

or

was

Careful hands, infinitely preferable to the many Present condition.—Temperature irregular, uncertain, tedious, and more painful methods occasional rise to 101° or 102o. adopted by those whose conservatism Digestive System.-Tongue dry, furred ; no inherited convictions will not allow them to vomiting or nausea ; always thirsty ; appetite take advantage of the more efficient line of fair ; bowels very confined ; no melæna, stools treatment which such cases merit.

clay-coloured ; abdomen moderately easy to A thorough examination into the already examine, slightly tender beneath right costal active pathological processes in the living sub-margin. Liver dulness from fifth space to ject will not only solve many a clinical riddle, but costal margin, 4ļin. Stomach resonance lower will give to us the means of saving many a life. than normal. Flanks resonant, spleen not

I am afraid that I have told you nothing enlarged. Circulatory, respiratory, and other new to-night, but I shall be content if I have systems are normal. She

tender on been able to place these few cases before you in deep pressure, and the muscles stood on guard, such a way as to induce you to look upon this and it was impossible to feel the gall bladder, subject with some increase in your appreciative so we concluded it was not very distended ; interest.

this pointed to gall stones as the cause of the

obstruction, and Dr. Jamieson was of opinion CHOLECYSTOTOMY, FOLLOWED BY CHOLE- that the trouble was due to a stone impacted CYSTO-COLOSTOMY-RECOVERY.

in the common duct, though the sudden onset,

without any attacks of biliary colic and the By R. Steer Bowker, M.R.C.S., L.R.C.P.,

steadily increasing jaundice not being intermitHon. Surgeon, Sydney Hospital.

tent, was rather against cholelithiasis. How

ever, we agreed as to the mode of treatment, and M. R., vet. 42. Living in Sydney ; was ad- decided to cut down and explore, the patient mitted to Sydney Hospital on 6th June, 1900. herself being very anxious for the operation. She was a miserable looking woman, appearing She was put on calcic chloride gr. xxx, t.d.s. many years older than her stated age, having 13th June.--She was given a hypodermic evidently lost a deal of weight, being very injection of morphia and atropine, and ether jaundiced, almost to a mahogany colour; the was the anesthetic used. I could now distinctly conjunctive were deeply jaundiced, giving her feel a linguiform prolongation of the liver, with the appearance of a woman with malignant a distended gall bladder. An incision was theredisease of the liver. Her history was as fol- fore made over the tumour, and a very dislows :—She was well up to January, 1900. On tended gall bladder found, the walls of which February 1st she was suddenly seized by violent were very thin in places and thick in others; pain across the lower part of the abdomen. ahard greyish nodule was found on the surface which lasted for about 12 hours, she vomited of the liver, and on the under surface were also freely and felt relieved; the pain was not seen several lines of fine yellowish nodules accompanied by fainting, sweating, or collapse. running in the direction of the lymphatics; all She went to bed and remained there for three round about the common duct was matted, and or four days, and still felt weak and ill. She the duct hard to palpate, but no stone could be had an irritation of the skin, and shortly be felt. What was at first thought to be a stone came jaundiced ; this jaundice has gradually was found to be an enlarged gland in the curve increased in intensity. She has had all along between the cystic duct and the gall bladder. dull aching pains all round the upper part of I removed a small nodule from the liver for the abdomen, never acute. No attacks of biliary microscopic examination. There was such a colic, and she only vomited on the one occasion. lot of matting that I could not make out the She has lost weight; she was about 11 stone in parts near the duodenal opening of the duct; January, now is about 8 stone. There has been the gall bladder was then packed round and an no hæmatemesis or melæna; bowels confined, exploring syringe introduced into its lower motions very pale ; no pain or frequent micturi- end, and a quantity of pus withdrawn. The tion, urine is dark. She has no cough, but bladder was freely opened and explored, but no slight dyspnea on exertion ; feet used to swell. stone could be found ; it was then stitched in

Past History.—Previous to onset of illness, the usual way to the wound. she was very drowsy for some weeks. There is 14th June. -- Microscopic examination showed no history of alcoholism or of the use of strong the growth removed to consist of young fibrous condiments. She had an attack of inflamma- tissue only. I was glad of this, as I was afraid, tion of bowels when 12 years of age.

by the appearance of these nodules, that the Family History. —Good.

cause of the obstruction was malignant.

a

try it.

10th July.—Patient recovered well from the 18th October.- Temperature 98-4°, pulse 74, operation ; jaundice gradually disappeared, and no distention, slept well, is very sleepy. she gained in flesh, health, and strength; but 26th October. - Doing well, but has considerthe discharge of bile from the fistula was of able diarrhea. course very great, as the obstruction still 1st November.—Diarrhæa has stopped. remained there.

27th November.- Went to the Walker Con2nd October.--Patient is a different woman.

valescent Hospital to-day ; wound quite healed She eats well, looks well, feels well, has gained has not returned the button.

and firm. Is very well and very grateful, but considerably in flesh, but complains of the fistula, which discharges an enormous quantity

I saw the patient recently, and she was then of bile each day, as being an intolerable ! very well indeed, her only trouble being a small nuisance to her, and begs to be freed from it ; she had become so enamoured of operations

hernia at the lower part of the wound, and so I explained to her the risk of a chole- that she wished to have this at once attended cyst-enterostomy, as I considered that the only

to. operation which could give her relief, and she determined to undergo it, to get rid of her

I advised her to leave it for a little, though infirmity, so, after consultation, I decided to the temptation to have a look at the seat of

anastomosis was considerable. 17th October, 1900.--Hypodermic injection

Remarks.-Now with regard to the diagnosis in this case.

Here we had a case of extreme of atropine and morphine was given, and, under ether, an incision was made surrounding pain in the epigastric region, and lasting for

, the old scar with an ellipse, the sinus was plugged with wool, and dissected from amongst colic ; the jaundice intense and increasing, and

12 hours; no attacks before or after of biliary the tissues, until its junction with the gall bladder was

reached and freed from the not intermittent, and by ordinary examination abdominal wall; this was clamped to prevent

no gall bladder to be felt; tenderness under the escape of bile during further manipulation. right costal margin, and the right rectus on The gall bladder was very atrophied, in fact guard, with a deep, dull, aching pain near the was little more than a tube, and was firmly

navel, almost constant. By the jaundice there fixed in a mass of omentum, and a great many duct; by the fact that this jaundice was con

was evidently some obstruction to the common adhesions had to be broken down, and another search for gall stones instituted, but none could stant, the obstruction was evidently fixed, that be found, a probe passed as far as possible

is not movable ; by the fact that there was no through the bladder, etc. The parts about the colic, evidently the gall bladder gave up the common duct and head of the pancreas were

fight of trying to overcome the obstruction, and very matted, and it was impossible to thoroughly considered it futile, that is its muscular walls palpate the common duct, a condition which was present at the former operation. At this

instead of contraction took place. Now all time I did not know of Weller van Hook's me

this happened suddenly to an otherwise healthy

She was five months in this condition thod of air distention, or should have tried that. The obstruction (now that we knew that the without gaining ground, but on the other hand growths on the liver were inflammatory) being diced, and had an erratic temperature, and

was losing weight, and becoming more jaunprobably due to interstitial

pancreatitis, the only thing left was to join the bladder always a deep-seated, dull, aching pain in the to the intestine. The adhesions about the epigastrium, and no tumour to be felt. duodenum were so great and so dense, and the The proper treatment, no doubt, would have ascending colon so ready to hand, that I deter- been to have examined her under an anæsthetic, mined to join the gall bladder to that viscus, for in all these cases it is important to know lying as it did almost in contact with its lower the condition of the gall bladder, and, mostly surface, so that I closed the opening in the without the aid of sleep, impossible to get this lower end of the bladder with catgut, made a

information, and in the diagnosis a deal defresh opening in it's lower surface, and joined pends on this, for there are certain aphorisms it by means of a small Murphy's button, to the laid down for our guidance, and generally pretty ascending colon just below the hepatic flexure ; correct :the abdominal wound was then closed with I. A distended gall bladder without jaunthrough and through sutures of silkworm gut,

dice points to obstruction in the cystic and dressed in the usual way.

woman.

II. A distended gall bladder with jaundice and also that one can have a good many gall

points to fixed obstruction (tumour) stones without any jaundice. One in his earlier
in common duct, stricture, etc.

days used to think of jaundice and gall stones III. A contracted gall bladder with jaundice as always running in couples, but this is far

to movable (not constant) obstruction from being the case.
such as a stone, in common duct, owing The fact is that when gall stones cause jaun-
to its ball valve action. (Fenger, Rob- dice the case is pretty serious, and requires
son, and others.)

very often a very serious operation indeed to
The gall bladder in this latter case tries to give relief, for I do not know of any more
dislodge the obstruction which is not con- formidable operation than a choledochotomy,
stant, and its muscular walls become hyper- with all the parts out of relation and matted
trophied, and there are constantly recurring together by inflammation, as the result of a
attacks of biliary colic, ceasing when the stone stone or stones which will not pass into the
falls back in the dilated duct, with inter- duodenum, even though the patient has taken
mittent attacks of jaundice, more or less, all the oil which has been ordered to him by
as the stone allows the bile to pass, and his different physicians.
the bladder eventually becomes thickened and Some people have luck--some people always
contracted. On the other hand, if the obstruc- will have—but ordinary mortals cannot depend
tion is fixed, as by a fixed stone, or an increas- on that; the stones, if left, have a fashion of
ing tumour, or inflammatory product, or a jumping the fence, or rather of not making
stricture, the result of an ulceration with con- themselves scarce by the orthodox exit, even
traction, then the gall bladder, finding it use- when supplied by oil. I remember being asked
less to fight against the obstruction, distends, to see in consultation, with a view to operation,
and is, as it were, thrown out of commission ; a lady who had suffered from gall stones for
and, if poisoned, fills with pus, or, if not, with many years. She had very violent pain, and

, bile, which becomes decolourised, and with evidently some peritonitis ; she had passed a mucus from the mucous lining of the walls. few small stones, so that we decided not to

Now, had this woman been examined under operate immediately, but to wait a little ; in an anæsthetic, we should have known (as we the meantime she vomited some large stones, did later) that she had a distended gall bladder, one very large one and a lot of others had with constant and increasing jaundice, and this passed by the rectum They had probably would, in itself, have rather pointed to the fact slowly ulcerated into the stomach and bethat the obstruction was constant, and so prob- come voided, but she was lucky; they might ably not caused by a stone, and as stones are just as easily have ulcerated through into the generally formed first in the gall bladder (on abdominal cavity and set up a fatal peritonitis. account of the conditions necessary for their Now this patient had lived for years on the formation being existent in the gall bladder brink of a precipice, suffered constantly recurmore so than in any other part of the bile tract), ring attacks, in the constant danger of death, there would have been painful attacks before or what was much worse- -the danger of cancer. the last sudden one in the passage of the stone She had the good luck to come out all right, but along the cystic duct; but we get no history of how many can depend on that, and if in the there having been any, and at the operation no end an operation had been necessary it would stone could be found.

have been . Hence it looks as though the cause of the Ye have operated upon a great many cases of obstruction was an adhesion or pressure of some gall stones, and I can say that the only case sort, malignant or inflammatory. The attack that was not cured was one of very long standcame on too suddenly for malignant disease, so ing-20 years--then on his last legs from pain, that it probably was inflammatory. Probably cholcemia, and exhaustion, with stones impacted the cause was interstitial pancreatitis, with in his common duct ; I removed seven as the cholangitis and empyæma. A cholangitis result of a long, tedious, and difficult operation, alone or desquamative angio-cholitis would but he died in a short time from the shock, hardly account for such fixed obstruction, added to his already cholæmic condition. This lasting after the gall bladder and ducts had was the only case I ever lost, showing what a been thoroughly drained for four months. safe operation the operation on the gall bladder

Now this and other cases which I have had is; and I don't think anyone should leave a have made me think a good deal about jaundice painful and distended gall bladder in the hopes and gall stones, and teach that one can have a that it may get well-for that is what it comes good deal of jaundice without any gall stones, to—and watch a stone, which is literally in his

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