CHOLECTSTOTOMY. 
BY 
EDWIN RICKETTS, M.D., 
CINCINNATI. 
READ BEFORE 
THE SOUTHERN SURGICAL AND GYNECOLOGICAL ASSOCIATION, 
1892. CHOLECYSTOTOMY. 
By Edwin Ricketts, M.D., 
Cincinnati. 
Cholecystotomy is an operation for a diseased condition. 
I wish to report the following case : 
Mrs. S., a German, aged thirty-four years, married for five 
years, no children; consulted me in June, 1892. She said that 
her trouble made its appearance about eighteen months previous, 
when she suffered from jaundice, tenderness over the region of the 
liver, loss of flesh, and had ciay-colored stools; she then weighed 
one hundred and eighty pounds; the attacks of pain in the 
region of the liver were not severe in character, nor was jaundice 
marked; however, she did have attacks of vomiting. 
Her physician made a diagnosis of gall-stones, put her on a 
restricted diet, and gave her phosphate of soda internally. 
There was, for awhile, temporary relief, but never in the whole 
eighteen months did the patient cease to lose flesh, and when I 
saw her for the first time she had lost thirty-five pounds in 
weight. Upon examination there was tenderness over the liver, 
but no marked distention ; upon deep pressure over the region 
of the gall-bladder through the very thick abdominal wall, no 
distention of that organ could be felt, but pain was more severe 
at this point than over the liver proper; I advised an explora- 
tory incision to be made over the gall-bladder as an aid to diag- 
nosis; the same was done, and on exposing the gall-bladder it 
was found to be very tightly distended and filled with fluid; no 
nodules of the anterior or posterior surface of the liver could be 
detected. 
Upon placing my index-finger against the duct it could be 
easily mapped out, owing to its distended condition, and a stone 
was felt down in the common duct. 2 
CHOLECYSTO TOMY. 
Massage was resorted to, hoping that in this way we might be 
able to force the contents of the gall-bladder through into the 
duodenum, as I had done in two previous cases. Here, however, 
I was unsuccessful, wholly so, in fact; and then I resorted to pack- 
ing the surrounding field of operation with flat sponges wrung 
out of hot water; after this was done as well and carefully as 
possible I proceeded to puncture the gall-bladder with a small 
scalpel; immediately a considerable quantity of clear fluid 
spurted out, in which there was no trace of bile apparently ; the 
force of the fluid demonstrated the great distention present. 
After thoroughly sponging away the fluid I introduced one 
end of my ten-inch silver coin olive-pointed probe down into the 
common duct with little difficulty, and succeeded in striking the 
stone at once; I now carried my left index-finger into the ab- 
dominal cavity, placed the palmar surface of it against the 
common duct at the point through which the stone could be felt; 
by this I was able to employ bi-manual pressure, and could thus 
help matters very materially. 
After passing the probe at some distance beyond the stone, 
keeping alongside of the duct wall, I withdrew it (the stone, 
weighing twenty-three grains) with a pair of Tait alligator 
forceps, which are ten inches in length; I hoped thus to be able 
to dislodge the stone, and was finally successful. 
Fearing that I might have a stone to contend with in the hepatic 
duct, and that it might fall into the common duct after the com- 
pletion of the operation, I passed the probe, already curved, as 
far into the duct as possible, and satisfied myself that the hepatic 
duct was free; after this the straightened probe was passed into 
the common duct to the duodenum, and I was then satisfied that 
the biliary ducts were all free. 
I now stitched the edges of the incised gall-bladder to the edges 
of the incised peritoneum ; transverse stitches of silkworm-gut 
were put in through all parts, and a long glass drainage- 
tube of the Price pattern was inserted, the perforated end of 
which was pushed low down into the common duct, and the 
wound was stitched up ; through this glass tube warm water 
was forced by means of a syringe; this was done while the 
patient was turned on her side. Some debris was washed out 
at the end of the second day ; the bowels were moved by means 
of saline cathartics. Bile began to make its appearance on the EDWIN RICKETTS. 
3 
third day, and the tube was removed ; the patient made a satis- 
factory recovery, with the exception of a stitch abscess of the 
thick abdominal wall; this was treated with injections of per- 
oxide of hydrogen at frequent intervals. The patient has re- 
gained her former health and flesh, and attends to her household 
duties. 
I reported this case for the reason that there was no history 
of marked jaundice or of severe attacks of pain (hepatic colic), 
so usual in these cases. The main symptoms that prompted 
me to resort to an exploratory incision as an aid to diagnosis 
were : 
1. The presence of clay-colored stools. 
2. Loss of considerable flesh. 
3. Tenderness over the liver, most marked over the region 
of the gall-bladder. 
As I said in the beginning, cholecystotomy is an operation 
for a diseased condition, and I fully agree with Dr. Hal C. 
Wyman, who, in a recent paper before the Mississippi Valley 
Medical Association, took the ground that this operation 
promises much in the relief of certain engorged conditions of 
the liver by affording free drainage. We cannot compare the 
experimental work upon the bile-ducts of the lower animals 
with the operations upon the diseased gall-bladder in the 
human being. 
The advantages of cholecystotomy over cholecystectomy, or 
any operations upon the gall-bladder, are to me apparent; I 
mean over those operations where the gall-bladder is lifted up 
and dropped back into the abdominal cavity; much debris 
can be drained from the bladder after the finished operation by 
syringing through the drainage-tube, and even some stones 
can be removed through this tube that may have been over- 
looked and finally have dropped down from the hepatic duct. 
Or, if the stone is too large for this, the tube can be withdrawn 
carefully, and then the stone be removed whole or after it has 
been crushed with forceps. As to the positive relationship of 
gall-stones to cancer of the liver, beginning in the bile-ducts, CIIOLECYSTO TOMY. 
4 
I am quite satisfied that such is true; in two cases which I 
opened the abdomen for obstructed gall-duct I found in one 
ease a large stone, in the other five; cancer was present in both 
of these. As cancer of the liver usually runs its course within 
two years, I am satisfied that the presence of the stones ante- 
dated the cancerous conditions; I do not mean to say that all 
cases of gall-stones must necessarily have cancer to follow; 
but undoubtedly in many cases, especially in those above fifty 
years of age, the presence of gall-stones in the common duct 
undoubtedly plays an important role in the excitation of 
cancer. 
DISCUSSION. 
Dr. Joseph Eastman, of Indianapolis.—I have been inter- 
ested in the paper of Dr. Ricketts. I have opened the abdominal 
cavity for gall-stones nineteen times ; I have sixteen of the speci- 
mens with me (here the speaker showed specimens of sixteen cases). 
The other stones were impacted, and so crushed in their removal 
that they were hardly worth preserving.- 
There are one or two points in connection with the surgery of 
the gall-bladder that I feel constrained to call attention to. 
I differ with much of the teaching of to-day. I see it constantly 
reported that surgeons find stones in the common duct. I taught 
anatomy for seven years, and, I might say, in my anatomical 
demonstrations I believe I learned to determine where the com- 
mon, cystic or hepatic duct was, fairly well. I have opened the 
abdomen 400 times, and why it is I have never found gall-stones 
in the common duct I cannot say. I have found patients with 
clay-colored stools, and after removing stones from cystic duct 
the stools contained gall. I have found that compression of the 
common duct wras due to distention by the pressure from accu- 
mulations of gall-stones in the gall-bladder and in the cystic 
duct. I am not saying that Dr. Ricketts was mistaken in his 
case. I am ready to concede that in his case there was a stone in 
the common duct; but I am at a loss to know why he and others 
should find something that I have been unable to find. 
Within the last few years the operation of cholecystotomy has 
been made so often that it is quite probable, in my mind, that DISCUSSION. 
5 
much of the literature we have on the subject had better be 
rewritten, as it has been written from books that were gotten up 
by the theorist of the closet, or from the book-worm of the library. 
In other departments of abdominal surgery text-hooks will have 
to be rewritten. With reference to detaching stones from the 
cystic or common duct, it has been suggested, in an article in the 
Virginia Medical Monthly, to cut open the duct to remove the 
stone. With what little experience I have had, I should say that 
that is not good practice. I believe it is better to introduce a 
drainage-tube in the gall-bladder, with the hope of the stone 
becoming disengaged, and either absorbed or discharged in some 
way, than to open the duct. I doubt the possibility of a suture 
that would close the duct nicely, without impairing its function, 
so that there would be a discharge of gall in the bottom of the 
cavity. When gall has been in the gall-sac for a considerable 
length of time, and there has been more or less peritoneal inflam- 
mation or cholecystitis, as we find in many of these cases, I doubt 
whether that gall would be as harmless in the peritoneal cavity 
as pure gall. I have on two occasions ( both patients recovering) 
crushed a stone in the cystic duct as large as the end of my 
finger. I have been able to crush with forceps by slipping a 
piece of rubber tube as large as my finger on the point of for- 
ceps. I have on several occasions found fragments of stone that 
were washed out of the tube in gall-bladder. 
When the patient strains, vomits, or retches, there is force 
enough to send it out through the drainage-tube. A drainage 
tube inserted into the gall-bladder will relieve a great many 
chronic conditions of the liver. I have found gall-stones in con- 
nection with cancerous diseases of the liver, and have been teach- 
ing that obstructed gall-ducts stand in a causative relation to that 
disease. 
Dr. Arch. Dixon, of Henderson, Ky.—I have seen cases of 
impaction of the common duct with gall-stones. A number of 
years ago a man fell from an elevator in our town and ruptured 
the gall-bladder. I did a cholecystectomy on him, and the case 
was reported in the Annals of Surgery. The man did well for a 
time, but subsequently died of a cholic diarrhoea. Autopsy 
revealed an impacted gall-stone in the common duct, which 
precluded the possibility of the passage of bile into the intestines. 
Dr. J. McFadden Gaston, of Atlanta.—I have not had an 6 
CHOLECYSTO TOMY. 
extensive experience in connection with operations of the gall - 
bladder for a diseased condition, but I have investigated the 
subject very thoroughly, and I will endeavor to enlighten my 
brethren on obstructions of the gall-bladder by stating that the 
common duct is not only obstructed in some cases by gall-stones, 
but that gall-stones have been extracted a number of times from 
the common duct by incision. Two of these operations have been 
done in this country, one by Dr. Marcy, and the other by Dr. 
Yander Veer. There is no question about the matter of gall- 
stones forming in the common duct and obstructing it. 
In regard to catheterization of these ducts from the gall- 
bladder, through the cystic duct and into the common duct, I 
will say that if Dr. Ricketts has succeeded in doing what he 
describes, he has done what has never been done before. If he 
has passed a forceps from the gall-bladder through the cystic 
duct into the common duct, and extracted a stone from the lower 
part of that duct, he is entitled to priority in that line of opera- 
tion. It has not been done in the history of gall-bladder surgery 
prior to this time. Catheterization of these ducts is regarded as one 
of the most difficult things in connection with gall-bladder sur- 
gery. The passage of a curved sound from the gall-bladder 
through the cystic duct into the common duct, which we know is 
almost an acute angle, is attended with a great deal of difficulty. 
Dr. Ricketts’ statement, that he has succeeded in passing a glass 
drainage-tube from the gall-bladder through the cystic duct into 
the common duct, is remarkable. I do not intend to throw any 
discredit upon what he has said, but there must have been some 
remarkable anatomical or pathological condition for him to have 
been able to accomplish this result. The practicability of cathe- 
terization of the common duct through the cystic duct is one of 
the problems to be solved. 
The operation of cholecystotomy is one that has been very fre- 
quently performed. We are aware that this is Mr. Tait’s famous 
mode of relieving all obstructions connected with the gall-bladder. 
He claims to have secured very remarkable results, and no doubt 
has, where the common duct was obstructed, by removal of the 
gall-stones. Dr. Ricketts tells me that the gall-stone in his case 
was removed without crushing. Obstruction in the common 
duct is the great difficulty which Mr. Tait’s operation cannot 
relieve. The simple attachment of the gall-bladder to the DrSCUSSION. 
7 
external parietes is not likely to relieve a stone where you have 
agglutination of the walls of the common duct. I had the mis- 
fortune to operate on a case of this kind where the agglutination 
of the common duct was such that no relief was given. Bile 
poured out freely through the opening in the external wall. 
Another case of a similar character, under my observation, had the 
same termination. The obstruction continued, and the only relief 
given in these cases is to bring about direct communication of the 
gall-bladder with the intestinal canal, either with the duodenum 
or small intestine. 
Dr. W. E. B. Dayis, of Birmingham, Ala.—I regard the 
case reported by Dr. Ricketts as an extraordinary one. I can- 
not see how it is possible to introduce a tube as Dr. Ricketts has 
done, unless there are very marked pathological changes. The 
obstruction must have existed for a long time in order to produce 
such an extreme dilatation of the duct. 
As to the treatment of these cases, I think the crushing of these 
stones through the duct with a forceps is a risky procedure. In 
doing this you cause such injury to the duct that you are liable to 
have sloughing afterward, and escape of the contents of the duct 
into the abdominal cavity. The method of puncturing with 
needles is also a risky procedure. Unless the stone can be dis- 
lodged either into the intestine or back into the gall-bladder, to 
my mind it is much wiser to incise the duct and remove the 
stone. Of course, all operations for stones in the common or 
hepatic duct are serious. The patient is suffering from cholsemia, 
and is in an unfavorable condition for an operation. These opera- 
tions do not compare with those for stone in the gall-bladder. 
They are operations of much greater mortality. Returning to 
the operation, it seems to me that the better plan would be to 
incise the duct, and clean it out thoroughly, and if you cannot 
stitch it satisfactorily, to pack around it with iodoform gauze. 
I have conducted some experiments to test the value of gauze 
in draining bile from the gall-bladder and ducts. I have removed 
the gall-bladder without tying the duct, by packing with iodo- 
form gauze, which was removed on the third day; the animal 
got well without serious trouble. I have also incised the gall- 
bladder, packed gauze around the opening, no stitches being 
used, and the animal did well. Similar experiments have been 
conducted by others, and from them we learn that if an animal 8 
CHOLECYSTOTOMY. 
can get well by packing with gauze, without any stitches, it is safe 
to rely upon the gauze in opening the duct and removing the 
obstruction. A glass tube might be used with the gauze. 
Dr. Eastman.—In one case I crushed the stone with my 
fingers ; in another, with forceps, and recovery was everything 
that could be asked for. 
Dr. Ricketts.—I said in the beginning of my remarks that 
cholecystotomy was an operation for a diseased condition, and 
experiments upon dogs that have healthy gall-bladders, healthy 
common ducts, I do not think should be taken into consideration 
with an operation of this kind upon the human being. In the 
removal of small cystic ovaries, are they to be compared with 
an ovarian tumor weighing fifteen or twenty pounds ? An 
ovarian tumor weighing fifteen or twenty pounds goes on to 
greater distention than a cyst containing three or four ounces. 
That is just the condition found in the cases under consideration. 
When the ducts are distended they are put upon a stretch, and 
when you come to make a comparison of healthy common ducts 
with distended ducts, you fall short. We are operating for a 
diseased condition. 
As to inability to force stones through the common duct, I 
will say in one case, in which I removed twenty-eight stones, 
I found the same in the common duct. I forced six smaller 
stones down through the common duct into the duodenum, and 
got them afterward in the stools. 
As to the method of crushing stones in the cystic or common 
duct, I have never resorted to it, for the reason I have been able 
to remove the obstruction without it. 
I selected the case I have reported for the reason that it was 
unique. Symptoms of hepatic colic were not present; there was 
no marked condition of jaundice. For a long time, however, 
there were clay- or putty-colored stools, and with it a loss of flesh.