as is common to the ducts, the ureters, and the small intestine. Their contraction readily overcomes this muscularly closed outlet, and the peculiar manner in which nature delivers a duct into a viscus by passing it partly through the wall, then continuing between the outer wall and the mucous membrane, so that internal pressure closes by compression from within but does not interfere with peristaltic delivery through the duct, is true of the common duct; under normal conditions it prevents back flow. This also is true of the little ducts delivering from the lobules of the pancreas into the main pancreatic ducts, not directly at right angles, but on a slant so that internal pressure tends to close them, undoubtedly a provision of nature to prevent the possible irritative effects of chemically changed bile in obstruction from entering the small pancreatic ducts.

Rosenow's investigations were based on the theory that the infection is carried through the blood stream, even in the tissues closely associated in function or connected by ducts, in other words, the specificity of localization of bacteria, which is now commonly accepted. It is probable that the chemical effects of bacteria and stasis of the gallbladder cause the development of stones, the materials for which are taken from the blood stream, although it must be admitted that the same materials are also present in bile.

10

Specific destruction of tissues by toxic agents has long been known; recent experiments of Mann are most illuminating in showing the chemical effects of nontoxic drugs acting through the blood stream, being wholly selective in their effects on the gallbladder. Mann has shown that Carrel-Dakin solution injected intravenously into dogs in amounts from 5 c.c. to 10 c.c. to each kilogram, produces selective changes in the circulation of the gallbladder and destruction of that viscus, varying according to the quantity of solution used.

The increased cholesterol content of blood during pregnancy undoubtedly contributes to the higher percentage of women affected by cholecystitis with stones; the ratio is about 77 per cent in females to 23 per cent in males. Approximately 90 per cent of the women have borne children and have had the first attack

in close relation to a pregnancy. It is of interest to note that cholecystitis without stones occurs in women twice as often as in men.

Is it probable that cholecystitis can be cured by temporary drainage? Years ago before we began freely to employ cholecystectomy as a definite surgical procedure we found that it was not generally possible to cure cases of cholecystitis without stones, although we then were draining gallbladders without marked evidence of cholecystitis after the removal of stones. The removal of stones removed the cause of acute colics but the patients were frequently left with the reflex gastric symptoms evident before operation, which were attributed to dyspepsia, but which we now recognize as being caused by cholecystitis. We further found that drainage, which gives only temporary relief, left the fundus of the gallbladder fixed to the abdominal wall and frequently added to the impairment of function and often still further increased the suffering of the patients for varying periods. I believe, however, that it is a debatable question whether some of the milder cases of cholecystitis should not be considered medical instead of surgical. A general knowledge of the pancreas and its diseases is very essential in the diagnosis of the diseases of the upper abdomen. In the majority of instances the condition of the pancreas, even in tumor formation, is overlooked unless the changes are gross, and mild derangements of function are often attributed to obstruction or disease of the liver. To be sure the condition of the pancreas is usually secondary to an infection involving the structure of the gallbladder, and although the infection may be brought through the continuity of tissues involved, through the duct itself, or through the lymphatics surrounding it, experimental evidence indicates that the pancreas too is probably more commonly affected through the blood stream. Of the 1254 patients seen at the Clinic with gallstones and cholecystitis during the last year 339 showed changes in the pancreas so marked as to be recognized clinically.

A consideration of the grosser pancreatic changes, with jaundice due to duct obstruction, increases the interest of a discussion as to whether the treatment in some cases of usually

distended gallbladder shall be removal, drainage, cholecystectomy, or choleeystostomy. In certain cases in which there is marked cholecystitis with or without stones cholecystostomy with drainage for many weeks or several months may be indicated to relieve the patient of a pancreatitis. If the gall-E bladder is preserved a re-ins lapse may be relieved by

cholecystenterostomy

or

performed in cancer of the pancreas accompanied by jaundice. In such cases the distended gallbladder does not show disease. Since the common duct often takes up its work intermittently, however, the fistula tends to close; to prevent this, the common duet should be closed,

thus insuring permanency of the fistula.

From 1907 to 1920 we operated on 158 patients with cancer of the gallbladder. Previous to 1910 the ordinary operation was a cholecystostomy for cholecystitis with and without stones. During this time 350 cholecystectomies were performed, 3 per cent of which (0.82 per cent of the total number

Fig. 1.

of operations on the gallbladder and duct) were for cancer, cholecystectomy being performed only in cases of advanced disease. Increased ability to diagnose cholecystitis and gallstones has led to a greatly increased number of early operations. Eleven thousand, four hundred twenty-nine operations on the gallbladder were performed from January, 1907

to August, 1920; of these 7,688 were cholecystectomies, but since the percentage of early operations before gross disease develops has increased greatly since 1910 the per centage of cancer found has been greatly reduced.

Cholecystostomy is now reserved for the special case in which advanced age or complications make it desirable; 3346 cholecystostomies

rington of 2027 operations on the gallbladder and ducts perfomed at the Mayo Clinic in 1917 and 1918 it was shown that 219, nearly 11 per cent, were secondary. In 109 of these calculi were found in the gallbladder or ducts, or in both. The primary operation had been performed at the Mayo Clinic in but sixty-four of the 219 (2.09 per cent). Some secondary operations are unavoidable. For instance, in our experience fresh soft stones have reformed three times in the common duct of the same patient and in a small percentage of cases stones had formed primarily in the hepatic ducts. We believe this great reduction in secondary operations in the Clinic has come from the general practice of cholecystectomy. Deaver has stated that 65 per cent of the secondary operations are due to failure to remove the gallbladder, and in a recent paper Jacobson, reporting 397 cases of gallbladder disease, gives the percentage of secondary operations as 4.2 per cent. If no gallstones are felt the whitening and thickening of the gallbladder wall is of some value in detecting cholecystitis during exploration. The question of adhesions must be weighed carefully in order to decide whether they are produced by the inflamed wall of the gallbladder or by perforating ulcer of the stomach or duodenum; sometimes both conditions are present in the same person. The appearance of local cirrhosis of the liver, shown by White and contracted areas back of the attachment of the gallbladder, is of value as an indication of bacterial invasion, yet it must be admitted that the appearance of the gallbladder and liver may be perfectly normal in some

have been performed at the Clinic from January, 1907 to August, 1920. Cholecystectomy with local peritoneal drainage has been the rule, but it is now used for gross infections, without biliary drainage, although biliary drainage is stll provided for in most cases of common duct disease, closure being made in suitable cases without biliary drainage but with peritoneal drainage.

In an investigation by Dr. Judd and Dr. Har

The palpable evidence of enlargement of the glands on the ducts, of which there is normally one on each duct and often two, is of the greatest importance. The one on the common duct next to the pancreas is often swollen in connection with duodenal ulcer as well as with pancreatitis, yet pancreatitis most frequently accompanies cholecystitis. The surgeon always should take advantage of his opportunity, when the abdomen is open, to examine these glands with a finger through the foramen of Winslow and a thumb over the ducts. By palpating the glands he may learn their normal condition, and thus be conscious of any changes.

In cholecystectomy a right oblique incision is made. I prefer to slant gradually through the vertical lines of muscle fibers, so that a firmer union of continuously divided muscle may be secured than by a split muscle incision; however, there are many incisions which will serve. Occasionally a gallbladder is placed deep beneath the liver and under its costal margin. Then the liver may be forced toward the midline by packing a large gauze square over the top and to the right of the organ. This maneuver of Masson brings the gallbladder directly into the exposed field and greatly facilitates the operation. Large distended and necessarily obstructive gallbladders are at times emptied by a trocar, and in acute inflammations may then be split from top to bottom. The mucous membrane in such conditions readily peels from the connective tissue on the surface of the liver. Bleeding is usually very slight; if it is at all sharp the separation has gone unnecessarily deep beneath the connective tissue on to the liver; the bleeding may be controlled by a temporary hot pack. The anterior surface of the gallbladder is completely cut away and the duct closed by suture. As a rule gallbladders are removed intact without being opened. The cystic duct is isolated, clamped between two forceps and divided, the cut ends of the duct exposed being touched with tincture of iodin and double ligated (Fig. 1). The cystic artery is then caught and ligated (Fig. 2). The distal end of the cystic duct is drawn up and with blunt pointed dissecting scissors the

low upward. This procedure prevents, to a great extent, the possibility of injury of the common or hepatic duct. The greatest danger, however, is accidental division and loss of the cystic artery during operation. Variations in the ducts and in the origin of the cystic artery lead to such accidents. The papers of Brewer, Ruge, Gosset, and Eisendrath describing such variations are well worthy of perusal. The surface peritoneum of the gallbladder which is left at its attachment to the liver furnishes an easily sutured field. An interlocking catgut suture closes the raw surface down to the ligated cystic duct. The needle with suture is

now passed alternately into the right border of the gastrocolic omentum and the right border of the gastrohepatic omentum with an occasional catch into the fatty round ligament to include it in the suture. This fatty apron shuts the stomach, pylorus, and duodenum off from possible fixation to the liver through adhesive attachment. If drainage is indicated it is between the liver and the fat and not between the liver and the pylorus. More and more I am closing the abdomen without drainage, in only a few instances satisfying my old inclination to drain by leaving the double strand of catgut attached to the liver, where the gallbladder fundus was separated from it, and continued in a suture down to the cystic duct (Fig. 3). This catgut is brought out of the abdomen, but the abdomen (peritoneum, muscle, fascia, and skin) is closed tightly around it. Should there be any indication within a few days of a retained secretion forceps may be passed along the strand of catgut into the abdomen, as any drainage would have followed the catgut suture line to the abdominal wall. If by the fourth day the catgut is not required it is placed under slight tension and cut beneath the skin. This method of cholecystectomy with complete closure of the abdomen has reduced very largely the danger of hernia which was not infrequent in the old days of drainage, whether of bile or peritoneal exudate.

Failure to cure may be due to age or to associated disease. Therefore a careful general examination is required before operation; and with the abdomen open exploration should be made to determine the presence of other disease. The appendix may be the original focus. A diseased pancreas may be the cause of future colic, even after the gallbladder is removed; consequently the condition of the pancreas should always be stated in the operative records.

The percentage of cures following operations on the gallbladder varies; some patients with colic from stone consider themselves cured if relieved of the colic. A definite cure occurs in approximately 60 per cent, great improvement in 30 per cent, and 10 per cent have less improvement because of the extent of the disease or complications.

In conclusion I would say that the diseased

gallbladder should be treated by cholecystectomy as a rule, its drainage being required under special conditions, that abdominal biliary drainage is not indicated except in complications, and that abdominal drainage is indicated only in conditions in which it would be used in the surgical treatment of other abdominal disease in which infection is present or has been present. BIBLIOGRAPHY

1. Brewer, G. E.: Some observations upon the surgical anatomy of the gall bladder and ducts. Contrib. Scientif. Med., Baltimore, 1900, 337-354. 2. Deaver, J. B.: Cholecystostomy vs. cholecystectomy. Surg., Gynec. and Obst., 1917, xxiv, 284286.

3. Eisendrath, D. N.: Anomalies of the bile ducts and blood-vessels as the cause of accidents in biliary surgery. Jour. Am. Med. Assn., 1918, lxxi, 864-866.

4. Eisendrath, D. N.: Operative injury of the common and hepatic bile-ducts. Surg., Gynec. and Obst., 1920, xxxi, 1-18.

5. Galippe, V.: Mode de formation du tartre et des calculs salivaires; considerations sur la productions des calculs en general; presence des microbes ou de leurs germes dans ces concretions. Compt. rend. Soc. de biol., 1886, iii, 116.

6. Gilbert, A.: Note pour servir a l'histoire de la theorie microbienne de la lithiase biliaire. Arch. gen. de med., 1898, ii, 257-282.

7. Gosset, A.: Travaux scientifiques. son, 1919, 156 pp.

Paris, Mas

8. Jacobson, C.: Gall bladder disease. A statistical study. Arch. Surg., 1920, i, 310-335.

9. Judd, E. S.: The recurrence of symptoms following operations of the biliary tract Ann. Surg., 1918, lxvii, 473-488.

10. Mann, F. C. and Crumley, W. G.: Neutral solution of chlorinated soda (Dakin's solution) in the normal peritoneal cavity. Jour. Am. Med. Assn., 1918, Ixx, 840-842.

11. Mann, F. C.: A study of the tonicity of the sphincter at the duodenal end of the common bile duct. Jour. Lab. and Clin. Med., 1919, v, 107-110

12. Masson, J. C.: Exposure in gallbladder surgery. Ann. Surg. 1919, lxix, 422-424. 13. Rosenow, E. C.:

The etiology of cholecystitis and gallstones and their production by the intravenous injection of bacteria. Jour. Inf. Dis., 1916, xix, 527-556.

14. Ruge, E.: Beitrage zur chirurgischen Anatomie der grossen Gallenwege. Arch. f. klin. Chir., 1908, lxxxvii, 47-78