Retention from Displacement, Bending and Valve 
Formation (Oblique Insertion) in the 
Biliary Tract. 
BY 
CHRISTIAN FENCER, M. D., 
CHICAGO. 
REPRINTED FROM 
THE MEDICAL STANDARD, CHICAGO, 
NOVEMBER AND DECEMBER, 1896, 
AND JANUARY, 1897. Reprinted from the Medical Standard, Chicago, November, December, 1896, January, 1897. 
RETENTION FROM DISPLACEMENT, BENDING AND VALVE-FORMATION 
(OBLIQUE INSERTION) IN THE BILIARY TRACT * j 
CHRISTIAN FENCER, M. D.. CHICAGO. 
In tHe following paper I wish to call atten- 
tion to a form of obstruction of the biliary pas- 
sages which has as yet received comparatively 
little attention, partly because it is not very 
common, and partly because a minute study 
of the anatomical conditions is required to 
make us see the real character of the obstruc- 
tion—namely, bending and valve-formation in 
the biliary passages. 
surface down to the cavity of the duodenum. 
Jts relations to the head of the pancreas are as 
follows: (a). It is located in a groove on the 
posterior surface of the head of the pancreas in 
fifteen out of twenty-two bodies (O. Wyss.) ; or, 
(b) it perforates the head of the pancreas; that 
is, it is surrounded by the tissue of the pan- 
creas on all sides in seven out of twenty-two 
cases. This anatomical condition is important 
inasmuch as a swelling of the pancreas will in 
the first case push the common duct out of the 
way without compressing it, and only very 
considerable enlargement of the pancreas can 
cause stenosis by pushing or bending of the 
duct; while in the second case, compression 
leading to occlusion may easily take place 
where the duct passes through the head of the 
pancreas. 
Schueppel, in his encyclopedic article on the 
“Extra-Hepatic Bile-Ducts,” states that the 
hepatic duct originates from a right and left 
main branch 5 mm. in diameter, which take up 
three or four smaller branches coming in from 
the longitudinal grooves in the hilus of the 
liver. The hepatic duct is 3 cm. long and 6to 7 
mm. in diameter. 
The gall-bladder contains on an average 50 
cc. of bile; its fundus is in a line with the an- 
terior border and in contact with the hypo- 
chondrium corresponding with the cartilage of 
the eighth rib, at the place where the right para- 
sternal line crosses the arch of the ribs. 
The intestinal portion of the common duct is 
3.4 cm. long, 3 mm. in diameter, perforates the 
wall of the duodenum obliquely, first passing 
through the muscularis, then running for a while 
in the sub-mucosa before it passes through the 
mucous membrane, which here forms the so- 
called caruncula duodenalis major, through 
which it enters the duodenum. While running in 
the sub-mucosa of the duodenum, it takes up the 
pancreatic duct at an acute angle, 8 or 10 mm., 
before it enters the duodenal caruncle. The 
opening or canal through the latter is called 
the porus biliarius. This main trunk, 8 to 10 
mm. in length, is the so-called Vater’s diverti- 
culum. 
The cystic duct is 4.8 cm. long, 4.5 mm. in 
diameter. At its place of origin, from the 
neck of the gall-bladder, it makes a consider- 
able—almost an abrupt—bend. The shape of 
its lumen is peculiar and distinct from that of 
the other biliary passages in that when it is dis- 
tended with fluid, the duct does not present a 
uniform smooth tube, but globular protuber- 
ances with furrows between, having a shape 
similar to a miniature colon; corresponding to 
the furrows there are found on the inner side 
of the wall semi-lunar valves, folds of the mu- 
cous membrane, the so-called Keister’s valves, 
alternating on one and then on the other side 
of the canal at variable distances. 
When we examine into the mechanism of occlu- 
sion of the bile passages as given by Schueppel, 
we find it arranged as follows: 
1. Obstruction from within, (a) Bodies that 
fill the lumen, gall-stones, parasites, echinococ- 
cus, ascaris, dystomum hepaticum. (b) Cicatri- 
cial strictures following local inflammations of 
the mucosa, causing or leading to either com- 
plete occlusion, that is, obliteration, or stricture 
formation, (c) Tumors within the bile ducts— 
benignant or malignant. 
The axis of the canal of the cystic duct will 
thus be a rather curved or wavy line. It is 
evident that this condition will not only predis- 
pose to the arrest of gall-stones on their 
passage through the duct, but is also apt to 
favor occlusion by bending and valve-forma- 
tion, as this condition is here so to speak, pre- 
existing. 
3. Obstruction from without. Compression 
from masses of cicatricial tissue or adhesions, 
the result of chronic inflammation, peritonitis 
or perihepatitis. 
The common duct is 7 cm. long, 6 or 7 mm. 
in diameter. In the hepatico-duodenal liga- 
ment, it has the hepatic artery on its right, 
and the vena porta on its inferior and posterior 
3. Finally, as has been especially stated by 
Niemeyer, deviations of the bile-ducts in the 
* Read before the American Surgical Association, 1896. FENGER: BENDING OF THE BILE DUCTS 
hilus from displacement caused by peritonitic 
adhesions between the hilus of the liver and the 
neighboring organs, colon, omentum, duode- 
num, stomach, abdominal wall. Virchow has 
pointed to similar conditions due to pregnancy 
and other causes. 
attacks of the symptoms. The obstruction 
will be followed by retention and increased pres- 
sure above resulting in dilatation or hypertrophy 
Hypertrophy without dilatation I have seen in 
the gall-bladder; dilatation sometimes with and 
sometimes without hypertrophy, in the ducts. 
I shall call attention at this time only to the 
last group. Virchow was probably the first to 
definitely call attention to retention from bend- 
ing of the bile-ducts. He states that in women 
with corset-liver-lobe and with considerable 
atrophy of the liver tissue in a line with the pres- 
sure from the ribs, he has seen, during preg- 
nancy, that the lobe has been folded over against 
the right lobe of the liver, and when the line of 
atrophy is located high up near the hilus, the 
gall-bladder has followed it, and this bending of 
the gall-bladder has caused traction on the bile- 
ducts, displacement of their shape and icterus. 
Obstruction caused by valve formation will 
give rise to the same symptoms as obstruc- 
tions from other causes, namely, recurrent 
attacks of biliary colic, without icterus, if the 
obstruction is above the common duct; with 
icterus if the passage of the bile into the intes- 
tine is prevented. 
Synopsis. Recurrent attacks of pain in region 
of gall-bladder for twenty years—no icterus. 
Tumor to be felt in region of gall-bladder. 
Cholecystectomy. Hypertrophied gall-bladder 
occluded by bend of cystic duct at its origin. 
Cystic duct otherwise normal. Extensive and 
firm adhesions between the entire biliary tract 
and surrounding organs. Recovery from opera- 
tion. Four months later, relapse of attacks of 
pain. 
Mrs. M. L., thirty-eight years of age, was 
admitted to Mercy hospital in my service Jan- 
uary 8, 1896. The patient’s family history was 
good. She had had the ordinary diseases of 
childhood. She is married and has two children, 
aged respectively fifteen and thirteen. Twenty 
years ago the patient began to complain of severe 
pain in the umbilical region, occurring in attacks 
at intervals of one or two months, and the 
attacks lasting four or five days. Occasionally 
the attacks terminated with vomiting. The 
patient was never jaundiced and never to her 
knowledge had claj'-colored stools. Early in 
November, 1895, the attacks became more se- 
vere and without free intervals between the 
attacks, constant soreness being present. The 
appetite failed and the patient lost ten pounds 
in weight. About this time she noticed a 
tumor in the abdomen just above and to the 
right of the umbilicus. The tumor moved with 
respiratory movements, and after palpation 
it almost disappeared. The urine was normal, 
but there was impaction of feces. 
The diagnosis lay between carcinoma of the 
ventricle or transverse colon, inflammation m 
and around the gall-bladder, peritoneal tuber- 
culosis and fecal accumulation. Dr. Billings 
made the diagnosis of right movable kidney and 
in addition a tumor, probably of the gall-blad- 
der. 
Operation.—On January 17, 1896, I operated 
in the following manner: The patient was 
anaesthetized with ether. An incision was made 
along the outer border of the right rectus 
muscle. The gall-bladder presented in the 
wound one inch below the border of the liver. 
It was hard on the sides, but there was fluctua- 
tion over the fundus. It was adherent to the 
transverse colon and pylorus, and the lesser 
curvature and anterior wall of the stomach. 
The adhesions were so firm that it was 
necessary to peel off a layer of the wall 
of the gall-bladder m order to loosen the 
organ. From the feeling of the gall-bladder I 
suspected carcinoma, but no carcinomatous 
nodules could be found anywhere in the sur- 
rounding organs. The introduction of a hypo- 
dermic needle brought out no fluid because the 
Case 1. Bending of the Cystic Duct. 
Virchow saw a fatal case of severe icterus 
where the corset-liver-lobe was turned upward 
in a patient who was not pregnant, but because 
of adhesions between the gall-bladder and the 
colon which came up on the anterior surface of 
the liver, pulling the bile-ducts with it. 
Courvoisier mentions bending of the cystic 
duct at its origin as a cause of obstruction of 
the gall-bladder. He further mentions that 
the permanency of a biliary fistula following 
chlolecystostomy with normal bile-ducts may 
be due to traction on the gall-bladder and 
cystic duct in an abnormal direction (for in- 
stance, downward), causing a bend at the upper 
end of the ductus choledochus, so that the 
hepatic duct is in line with the cystic duct, 
resulting in all or most of the bile passing out 
through the fistula and little or none through 
the common duct. 
Bending of the duodenal portion of the com- 
mon duct followed by unilateral dilatation above 
and valve-formation, the same as in the urinary 
passages, has been observed and rightly inter- 
preted by Konitzky. Seyffert, in a similar case 
of dilated common duct, speaks briefly of “ Ven- 
tilartige Verschluss,” valve-hke occlusion, but 
does not enter into any detailed consideration 
of the subject. 
My views on the question, from what I have 
seen in the cases to be mentioned below, are 
the following: 
Bending is most likely to take place at the 
beginning of the cystic duct and at the begin- 
ning of the duodenal portion of the common 
duct, because these are the places where there 
is a sudden change in the diameter of the pas- 
sages. The bending may be caused either by 
elongation of the ducts or by traction from 
adhesions. The obstruction caused by the 
bending is here, as in the urinary passages, at 
the beginning incomplete, resulting m intermit- 
tent retention and consequently in intermittent FENCER; BENDING OF THE BILE DUCTS: 
3 
gall-bladder was afterwards found to contain 
only a little bloody gelatinous mucus, and a 
number of small, irregular pigment concretions. 
I could detect no grating of the needle on 
si one, but Dr. Morgan noticed a grating which 
was probably produced by contact of the needle 
with one of the pigment concretions. 
On May 16 I recefved a letter from the patient 
in which she said she had been gaming steadily 
until a week previous, when she began to feel 
very much as she did before the operation. It 
therefore seems prooable that a second opera- 
tion will be necessarv in this case. 
The gall-bladder was loosened, peeled off 
from the liver, the haemorrhage stopped by the 
Paquelin cautery. The cystic duct was then iso- 
lated, ligated, disinfected with crude carbolic 
acid and cut off. The wound was packed with 
sterile gauze, which was brought out of the 
wound. The patient made a good recovery and 
was discharged from the hospital on Febrl7. 
On the fifth day after the operation the packing 
■was removed from the 
Remarks.—The choice of operation in this 
case between leaving and removing the gall- 
bladder was easy, as the gall-bladder was evi- 
dently useless and was the seat of inflammation 
of long standing. The density of the adhesions 
of the surrounding organs to the whole tract 
of bile-ducts made any further loosening of the 
adhesions inexpedient ■ so much the more as I 
thought I had the right 
to expect that the symp- 
toms would be relieved 
by division at this point 
as the cystic duct was 
normal. The return of 
symptoms as shown by 
the letter from the pa- 
tient, seems to prove 
that it belongs to the 
same class as the eigh- 
teen cases operated upon 
by Riedel, where the pain 
was Caused by adhesions 
between otherwise nor- 
mal bile passages and 
the surrounding organs, 
and in this case it 
would seem as if sep- 
aration of the adhesions 
from the remainder of 
the bile-ducts would be 
necessary in order to 
cause permanent cessa- 
tion of the symp- 
toms. 
Riedel remarks; 
‘‘But even when the 
stones have been passed 
by the bowel, the pa- 
tient is not even then 
sure to be free from 
attacks of pain and 
digestive disturbance, as 
wound and the edges of 
the wound approxi- 
mated. 
As shown by the fig- 
ure (Figure 1), there is a 
very considerable hy- 
pertrophy of the non- 
dil ated gall-bladder and 
the cavity is smaller than 
usual, and is partitioned 
off m three wide spaces 
with narrow necks be- 
tween. It contained 
about a teaspoonful of 
reddish gelatinous mu- 
cus, not bile-colored, in 
which was found a few 
irregular concretions of 
inspissated bile pigment 
masses, not gall stones 
Microscopic examina- 
tion of the wall shows no 
distinct hypertrophy of 
the muscularis, but the 
wall consists of a mass 
of wavy connective tis- 
sue, sparsely provided 
with vessels. In the 
para-vascular spaces 
and lymph spaces are 
granulation tissue cells, 
here and there in 
larger groups, showing a 
chronic lymphangitis 
and periphlebitis, simi- 
lar to the condition I 
have so often found in 
the chronic inflamma- 
tions of the appendix, 
giving rise to attacks of 
remittent appendicitis. 
Near the surface of the 
Figure I.—Gall-Bladder, 
1. Fundus. 8. Corpus. 3. Cystic Duct. 4. Lymph-Gland. 
5. Mucosa, thickened and velvety, 1 to 8 mm. thick. 
6. Sub-Mucosa, 3, 5, 7 mm. thick. 7. Muscularis, 3to 5 
mm. thick 8. Small Cavity in Fundus. 15 mm. wide, 
5 mm. high, caused by constriction, separated from 
9, Large Cavity in Corpus, 85 mm.wide, 33 mm. long, 
separated by a stricture 15 mm. long from 10. Cavity 
15 mm. long, 15 mm. wide, Entrance io Cystic Duct, 
whose opening is 1.5 mm. wide. 11 .Hard, irregular 
bile pigment concretions. 
gall-bladder in the place of the serosa, the these symptoms can be caused by adhesions 
accumulation of leucocytes is more dense. between neighboring organs and the gall-blad- 
-Ihe inner wall is covered with a layer of mucous ® . ... . . * 
membrane, in which are a number of tubular W^ maY contain bile, but is oftentimes 
glands, on the surface of which is cuboid and pulled into manifold shapes.” He also states 
cylindrical epithelium. that in addition to one hundred and twenty cases 
On the outer wall of the gall-bladder near the 0f gall-stones operated upon in his surgical 
cystic duct, is a swollen lymph-gland the size of r ■ , 45 
a hazel-nut. The cystic duct goes off at a climc> there were eiShteen patients who were 
right, or rather at an acute angle; its wall is operated upon on account of attacks of pain 
normal, not thickened. Its lumen is 15 mm. caused by adhesions alone. As long as these 
wide and is consequently, if anything smaller adhesions do not cause retention, as in the 
than normal. A probe passes from the cystic .; _ ' . , 1 
duct easily into the gall-bladder and at the en- eighteen cases mentioned, the patients retain 
trance, at the angle of the bend, the wall forms their weight and strength, because there is no 
a valve which has caused the occlusion. cholaemia and no sepsis. If infection from reten- 4 
FENGER: BENDING OF THE BILE DUCTS. 
tion in the gall-bladder has been the cause of 
the pericystitis, we may expect to find the re- 
maining adhesions less dense and easier to sep- 
arate. 
irregular intervals, which diminished gradually 
from three months until now they recur every 
two to four days. 
The reason why, in this case, the symptoms 
should persist, while the remaining adhesions 
after the apparent removal of the cause should 
yet cause recurrent attacks of pain, is as yet 
Although the patient had carefully examined 
the stools for several years, she found a gall- 
stone for the first time in December or January 
last. She has lost rapidly in weight anci 
strength since the attacks have recurred so fre- 
quently. Her appetite is good; the bowels are 
obstinately constipated, but the 
bowel-movements are normal in ap- 
pearance and color. During the 
attacks the patient gets relief only 
. , ——- by assuming the knee-chest posi- 
tion. 
Examination.— The patient’s 
skin was slightly icteric, the con- 
junctival very slightly if at all 
abnormal; the abdomen was lax, 
as the patient had borne children; 
the border of the liver could be 
felt in normal position right below 
the costal arch at the outer border 
of the rectus. An indistinct hard- 
ness could be felt at the border of 
the liver. There was slight ten- 
derness over the gall-bladder and 
over the entire right half of the 
epigastric region. 
Diagnosis.-Choledochus obstruc- 
tion from stones in the duct, one having passed 
four months ago. The symptoms were apparently 
typical; many slight attacks, two or three per 
week, the stone passed four months ago which 
presented round surfaces and no facets, and 
the inflammation of the gall-bladder, which was 
retracted but thickened with adhesions. 
I advised choledocholithotomy and on April 
24, after the usual preparations, I operated in the 
following manner: The patient was prepared 
as usual. Dr. Letourneau administered the 
ether and Drs. Morgan and Rankin assisted. 
unknown to us. As Riedel remarks; “ Why is 
it that thousands of patients walk around with 
their adhesions without ever dreaming of their 
existence, and a few only have to suffer all the 
time from identical adhesions?” 
Figure 11. 
Case 11. Bending of the Duodenal Portion of 
the Comifion Duct Without. 
Dilatation Above. 
Synopsis. Intermittent attacks of pain in 
right hypochondriac region with vomiting and 
jaundice for eight years. Three or 
four months previous to the opera- 
tion a gall-stone passed by the 
bowels. Since that time, increasing 
frequency of attacks. Operation 
between attacks. Icterus present. 
No gall-stones in biliary passages. 
Gall-bladder slightly thickened but 
otherwise normal. Dilatation of 
cystic duct. Common duct not di- 
lated. Extensive adhesions be- 
tween duodenum and common duct 
and between descending and 
ascending portions of duodenum. 
Loosening of all adhesions. Cho- 
lecystostomy. Free passage of a 
flexible sound from gall-bladder 
down into duodenum. Recovery. 
Mrs. A., 38 years of age, was 
admitted into Mercy Hospital in 
mv service, April 30, 1896. The 
Figure 111. 
patient’s family history was good, she had 
had the ordinary diseases of childhood, but 
until 1888 was very healthy. At this time, 
however, she began to have severe paroxysms 
of pain in the right hypochondriac region radiat- 
ing toward the right scapula, accompanied by 
nausea and vomiting and followed by jaundice, 
which would last for about a week. The stools 
were clay-colored, and there was great tender- 
ness at the right costal arch. The first attack 
lasted for a few hours only and she felt well 
until three months later, when she had a similar 
attack. These attacks have since recurred at 
A lateral longitudinal incision was made 
from the ribs to the umbilicus, the peritoneum 
stitched to the skin, and eighteen fiat gauze 
sponges inserted. Upon palpation the fundus of 
the gall-bladder was found free on line with 
the border of the liver. The transverse colon 
was adherent to the body of the gall-bladder 
close to the fundus (Figure II). The pyloric 
portion of the duodenum was adherent to the 
gall-bladder and the transverse colon. The 
adhesions were loosened partly by cutting be- 
tween the ligatures and partly'by blunt dissec- 
tion with the end of the finger and Kocher’s FENGER; BENDING OF THE BILE DUCTS. 
■sound, and the gall-bladder freed up to the neck. 
Below the neck could be seen a transverse swell- 
ing, the upper half of the cystic duct, which 
went off at a right angle, was one cm. broad 
and two to three cm. long, and on palpation 
was found to be empty—that is, it contained no 
stones. (See Figure III.) 
duodenal portion in the endeavor to discover a 
stone in Vater’s diverticulum. The fine needle 
could do no harm even if it went through the 
duodenum. However, after pushing the needle 
in different directions from a single point of in- 
sertion, I could not detect any stone. 
The gall-bladder was empty, the wall slightly 
thickened. The duodenum was found to be 
pushed over so as to cover the hepatico-duo- 
denal ligament, and was loosened by blunt dis- 
section and pushing with the ends of the fin- 
gers so as to expose the territory of the com- 
mon duct. When this had been laid bare for 
an inch and a half or two inches, the finger 
passed up through the foramen of Winslow 
could feel no stone, but the pancreas was so 
swollen and nodular that I suspected cancer. 
I concluded that no stone could be present 
except perhaps a small one in Vater’s diverti- 
culum, and that there was no carcinoma. The 
question as to the cause of the icterus and the 
measures to be taken to relieve the condition 
then arose. 
1 did not want to open either the duodenum 
or the common duct simply for exploration; I 
therefore resolved to open "the gall-bladder, to 
attempt to explore the common duct from this 
point, and to relieve the icterus and cholaemia 
for the time being by the establishment of a bil- 
iary fistula. 
Sponges were packed entirely around the 
hilus of the liver and two loops of heavy silk, 
half an inch apart, were inserted in the gall- 
bladder. The wall of the latter was thickened. 
The gall-bladder was now incised between the 
loops. Upon incision, neither bile, pus nor 
other fluid escaped, but after a few minutes 
a little blood came out, from which cultures 
were taken with negative results. Upon ex- 
ploration with the little finger no stones were 
found in the gall-bladder, whose walls were 
smooth and velvety. 
The common duct was now explored through 
the gall-bladder. A flexible, olive-pointed 
bougie was inserted in the wound in the gall- 
bladder, but was stopped at the bend in the 
cystic duct, which it could not pass. By lifting 
the liver and making traction upon tne gall- 
bladder, the bent upper half of the cystic duct 
could be straightened, and by manipulating the 
cystic duct with the index finger (exactly as a 
finger in the rectum on the prostate gland can 
guide a catheter into the bladder) the end of the 
bougie was passed through the cystic into the 
common duct, and, by manipulating the duo- 
denum and head of the pancreas, was finally 
passed down into the duodenum. 
Digital exploration along the bougie in the 
gall-bladder, the cystic duct, the common duct, 
and for three or four inches in the duodenum 
where it met the lower bend of the duodenum 
failed to detect any stone. 
I therefore concluded, that no stone was pres- 
ent, that the bile-passages and the common 
duct were patent and that the icterus had been 
due to bending or oblique insertion of the intes- 
tinal portion of the common duct, which was 
pulled to one side by the adhesions between the 
ascending and descending portions of the 
duodenum. 
The cholecystostomy was completed by unit- 
ing the gall-bladder to tne parietal peritoneum, 
but not to the skin, by eight sutures, and pack- 
ing the wound in the wall outside of the opening 
in the gall-bladder, in which a rubber drainage 
tube was inserted. A gauze drain was also 
passed down on the common duct and the duo- 
denum. The operation required about two 
hours. 
Upon palpation of the duodenal (anterior) 
surface of the pancreas through the duodenal 
wall, neither stone nor movable polypus could 
be felt, but only the enlarged hard lobes of the 
pancreas. Along the common duct, on its free 
border, were two lymph-glands the size of a half 
hazel-nut. 
By stretching the common duct I could see it 
shining through the anterior wall of the liga- 
ment as a whitish band, 7 to 10 mm. broad, 
little if any dilated. I could also see the lower 
half of the cystic duct shining through, begin- 
ning at the bent, dilated, horizontal, upper half 
of the duct and going down to the common 
duct at a right angle with the upper portion 
and in line with the common duct. 
So far, the examination gave no explanation 
of the symptoms. Stenosis from the bend in 
the dilated and thickened cystic duct might 
cause pain in the region of the gall-bladder by 
reason of retention, but would not cause icterus, 
and besides this the gall-bladder was empty. 
I thought of carcinoma in the head of the pan- 
creas, but the pancreas felt exactly as the in- 
flamed pancreas feels in cases of gall-stone. I 
sought for stone in Vater’s diverticulum, but 
could detect no hard, movable body through 
the duodenal wall. 
The pancreas was not freely palpable on both 
sides of the duodenum because the left side of 
the pancreas near the head was covered with a 
loop of the duodenum—that is, the ascending 
portion. 
The ascending portion of the duodenum was 
now loosened from the descending portion; the 
adhesions were soft and elastic, like spider’s 
web, and an inch or more below, the nodular 
left border of the head of the pancreas was 
encountered. 
I thought perhaps the traction on the duode- 
num from adhesions might cause pain and pos- 
sibly icterus and that by loosening the adhesions 
and freeing the ascending from the descending 
portion of the duodenum, the attacks of pain 
might cease. When this had been done I 
could grasp the head of the pancreas and the 
duodenum over it with the left index finger and 
thumb, the index finger being in the foramen of 
Winslow, and lift the head of the pancreas and 
the duodenum a little forward, and could pal- 
pate the entire duodenal surface of the head of 
the pancreas with the fingers of the right hand. 
I could detect no stone, but felt some harder, 
nodular portions, especially one shown in Figure 
111, between the two portions of the duodenum. 
I then passed a long fine sewing needle 
through the side of the pancreas and the hard 
nodule into the head of the pancreas and its 
The patient’s progress was uneventful; 
May 1, the dressings were soaked with bile. 
The packing below the gall-bladder was re- 
moved and the stitches tightened. The wound 
was clean. May 4, the stitches were removed, 
the wound had united perfectly. The dress- 
ings were saturated with bile. The packing 
around the tube was removed and new packing 6 
FENGER; BENDING OF THE BILE DUCTS. 
inserted. May 6, very little bile in the dress- 
ings. May 8, no bile in dressings, and icterus 
disappearing. May 11, tube removed. Dress- 
ings slightly stained with bile. Light packing 
inserted arid the stitch tightened. May 13, 
dressings stained with bile and wound closing. 
May 17, the patient has been out of bed for six 
days, has had no pain since operation, can walk 
around, is up all day and can eat anything. 
The stools are normal. The dressings are 
slightly tinged with bile and serum. The skin 
and sclerotics are normal in color. Two weeks 
later biliary fistula finally closed. 
Remarks.—Could the stone which had passed 
four months prior to the operation and had 
caused adhesions—that is, local plastic periton- 
itis on the surface of the biliary passages and 
the pancreas—have left adhesions uniting the 
ascending and descending portions of the duo- 
denum over the head of the pancreas, producing 
a displacement sufficient to cause pain ? This 
was possible. Could this condition also 
have caused recurrent retention of bile and 
icterus by deviation or displacement of the 
direction of the duodenal portion of the com- 
mon duct or the papilla, or must there of 
necessity be a small stone in Vater’s diver- 
ticulum to account for the icterus? 
testine that no permanent dilatation of this duct 
resulted. During its passage through the com- 
mon duct, the usual plastic peritonitis, which 
extended to the pancreas, caused the free sur- 
faces of the ascending and descending portions 
of the duodenum to become adherent to each 
other for one inch in the transverse diameter of 
the intestine. This adhesion in the exact line 
where the duodenal portion of the common duct 
is situated, caused displacement (Verlegung), 
and the consequent continuance of the attacks 
of pain and icterus after the disappearance of 
the stone or stones. 
Leichtenstern reports a similar case of fre- 
quently recurrent attacks of colic without pas- 
sage of stones by the bowels, with chronic 
icterus. At the operation the gall-bladder was 
found to be totally atrophied. It was univer- 
sally adherent to the surrounding organs and 
contained a thimbleful of mucus. No stones 
were found here or in the cystic or common 
duct, after thorough separation of the adhe- 
sions. The icterus disappeared immediately 
after the operation and perfect recovery fol- 
lowed. Leichtenstern remarks; “The pain 
TRUAX CRFENE 8r CO. 
Figure IV. Flexible Metallic Sound. 
The plastic peritonitis on the left half of the 
head of the pancreas caused the here otherwise 
movable descending portion of the duodenum 
to adhere to its surface and become still more 
firmly fixed by additional adhesions to the 
ascending portion of the duodenum. 
and periodic attacks of colic as well as the 
icterus must have been caused by pulling and 
constriction from the adhesions.” 
The anxiety I experienced in this case in order 
to make sure that no stone existed anywhere in 
the biliary tract, was not relieved by the passage 
of a flexible sound from the gall-bladder down 
into the duodenum, because a small stone, half 
hidden in a diverticulum, might escape notice, 
notwithstanding palpation along the sound. 
Could the immobilization of the duodenum 
have caused the difficult passage of ingesta and 
the duodenitis? Duodenitis would not give 
rise to such frequent attacks of pain. A me- 
chanical cause for the frequent attacks would be 
much more likely, but in a former observa- 
tion, (Case V, “Stones in the Common Duct,”) 
a small stone in Vater’s diverticulum did 
not cause obstruction, but did cause the frequent 
attacks of pain, not by inflammation of the wall 
of the duct but by some mechanical action. 
As the rubber sound does not permit of feeling 
the click of a stone, I have had made a flexible 
metallic sound (see Figure IV). I first had 
made a flexible metallic sound 88 cm. long, olive 
pointed at both ends, and made of a steel 
spiral. In searching for stones in the cystic 
duct, through the gall-bladder, I found that the 
click of a gall-stone could be easily felt at any 
distance, but I also found that the flexibility of 
the sound would not allow it to pass the angles 
of a bent cystic duct. I therefore made the 
following modification: Through the hollow 
flexible metal sound I passed a soft metal (cop- 
per) stylet. This permits of giving the sound 
any shape or bend desired, which is retained 
as long as the stylet is in. lam thus enabled 
to pass the sound over the angle or bend, and 
by removal of the stylet the flexible sound can 
then be passed further on. I can thus feel 
the click of a stone low down in the com- 
The course of the disease in this case seems 
to be as follows: When the symptoms began 
eight years ago, with biliary colic and icterus, 
a stone or stones, perhaps the one passed four 
months previous to the operation, became im- 
pacted in the cystic duct, causing dilatation and 
bending as found during the operation and 
shown in Figure 111. The inflammatory swell- 
ing around this dilated cystic duct caused com- 
pression of the hepatic duct or inflammation of 
the ducts sufficient to occasion icterus. The 
stone passed down into the common duct so 
short a time before its removal through the in- FENCER: BENDING OF THE BILE DUCTS. 
7 
mon duct or in Vater’s diverticulum, even 
*of a small stone that would escape notice upon 
palpation along the sound through the wall of 
the duodenum. 
autumn. The attacks would last for ten days 
with one exacerbation daily, which usually 
occurred one hour later each day. The attacks 
would be brought on by mental excitement, 
anger, or irregularities in diet, such as too heavy 
a meal, or too much wine or coffee. As she 
was aware of this she put herself upon a well- 
regulated diet, and lived a quiet life,, but still 
had difficulty in filling her position as a teacher. 
Menstruation commenced at the age of 13. 
It was always painless and lasted three days. 
She had no leucorrhoea. She was habitually 
constipated, and sometimes her bowels would 
not move for several days. She used rhubarb 
as a laxative, and after it operated the move- 
ments were apparently normal. Occasionally 
the stools were clay-colored. The urine was 
often dark after the attacks, was passed slowly 
and in small quantities. She was subject to 
severe headache, and became very nervous 
after work or when exhausted. 
I have recently had an opportunity to dem- 
onstrate the usefulness of this sound at a post- 
mortem examination on a patient upon whom I 
had made an exploratory laparotomy which had 
failed to detect any gall-stones, and who died a 
month later with symptoms of duodenal obstruc- 
tion. A biliary calculus the size of a cherry stone 
was found in the duodenal portion of the duct. 
The sound passed down from the gall-bladder, 
passed by the stone and entered the duodenum 
without difficulty. On moving the sound up 
and down I could easily feel the grating of the 
stone against the side of the spiral sound. 
The attacks often commenced with sudden 
and violent pain, which forced her to lie down, 
undress and apply hot compresses over the 
liver, and also required the hypodermic use of 
morphine. Icterus was sometimes present 
during the attacks, with yellowish-green skin 
and yellow conjunctive. 
Case 111. —Oblique Insertion of the Duodenal 
Portio)t of the Common Duct with 
Dilatation Above. 
Synopsis.—Recurrent attacks of pain of vary- 
ing intensity and at irregular intervals in the 
region of the liver for twenty-five years, some- 
times followed by icterus, most severe in the 
spring and autumn. Probable diagnosis, stones 
in the common duct with probable cholecystitis. 
Operation during severe attack in January, 1896. 
No stones found, but chronic cholecystitis 
and extensive adhesions between the cystic and 
common ducts and surrounding organs. Ex- 
treme dilatation of the common duct, which pre- 
sented a sac the size of a hen’s egg. Cho- 
lecystotomy, no stones in the gall-bladder. Duo- 
denum opened to explore diverticulum of 
Vater, no stones found, wound closed. Open- 
ing of common duct revealed no stones, but 
enormous cystic dilatation. Closure of wound 
in common duct. Opening in gall-bladder 
united to skin. Death after twentv-four hours. 
Autopsy: No bile in peritoneal cavity, no 
peritonitis. Duodenal portion of common 
duct of normal size and patent; at its upper 
portion bending and oblique insertion into the 
dilated common duct, dilatation of cystic and 
hepatic ducts. 
Miss X., a teacher, 33 years of age, was sent 
to me for operation by Dr. Windrow, Jan. 34, 
1896. She was never well as a child, but was 
always dull, hypochondriac and morbidly retir- 
ing. She had an extremely violent temper, which, 
as she came to adult life, she was careful to 
keep under control. She had the first attack 
of pain in the region of the liver at the age of 
7or 8. The attacks which were sometimes fol- 
lowed by icterus, recurred and she began early to 
use morphine to relieve the pain. During the more 
severe attacks she became intensely cold, and 
was obliged to use hot baths to overcome the 
cold and pain. She had consulted prominent 
medical men in Europe, but without relief. 
One physician diagnosed gall-stones, and ad- 
vised operation. During all this time she was 
treated with internal medicine, massage and 
electricity, but did not improve. 
Change of climate and work was advised for 
her, and she came to the United States in 1889. 
During her stay in the east she felt better at 
first, but, later on, the seacoast did not seem to 
agree with her, and so in 1893 she came to 
Chicago. She seemed on the whole better after 
this, but had severe attacks in the spring and 
During 1893 and 1898 she drank a good deal 
of Vichy water, and applied cold water com- 
presses over the liver at night, which seemed to 
help her for a time. During the summer of 
1895 she was ill most of the time and had very 
frequent attacks. With the advent of 1896 
she became worse. Her last attack occurred 
on January 18; it was attended with violent pain, 
which was not relieved by morphine; icterus, 
temperature 103 degrees, extreme tenderness 
over the liver and obstinate constipation. 
When the latter condition had been overcome 
by large doses of rhubarb, the stools were clay- 
colored. The patient was confined to her bed 
for two weeks, at the time of this last attack, in 
the hospital where I was called to see her. 
Upon examination, the patient was not ema- 
ciated, was deeply icteric, the skin was dark 
greenish-yellow and conjunctivse icteric; tem- 
perature 103 degrees; pulse 110. She had con- 
stant pain in the region of the gall-bladder, and 
the feces were clay-colored. Examination of 
the abdomen showed that the hot fomentations 
for the pain had so burned the skin of the right 
half of the abdomen that several granulating 
surfaces were present. The liver was some- 
what enlarged, extending one and one-half 
inches below the costal arch. There was indis- 
tinct resistance in the region of the gall-bladder 
and tenderness on pressure. 
The frequently recurrent attacks of pain and 
icterus, with comparatively short duration of 
the latter, made the diagnosis likely to be gall- 
stones in the common duct, together with proba- 
ble stones in the gall-bladder causing inflamma- 
tion of the same. The patient was removed to the 
Passavant Memorial Hospital for operation. 
Operation.—On January 86, I operated in the 
following manner: Ether, preceded by mor- 
phine, was administered by Dr. Waters. The 
abdomen was disinfected, the granulating skin 
surfaces scraped with a sharp spoon, and a 
piece of gauze sewed to the margin of the skin 
incision. 
I now made a lateral longitudinal incision 
from the ribs to below the umbilicus. Consid- 
erable haemorrhage ensued from the vessels in 
the abdominal wall. The fat was an inch in 8 
FENGER: BENDING OF THE BILE DUCTS, 
thickness and the posterior sheath of the rectus 
muscle terse. The peritoneum was sewed to 
the skin wound. The border of the liver and 
the gall-bladder presented in the wound. The 
gall-bladder was of the same color as the liver, 
and, on a plane with its free border, felt luce a 
mass of flesh or liver, had the shape of a bent 
finger, and no fluctuation could be detected. 
There were no adhesions at the top of the gall- 
bladder, but the corpus was adherent to the 
pylorus, duodenum and transverse colon. The 
adhesions between the gall-bladder and the 
pylorus, greater curvature of the stomach and 
duodenum, which was covered by the fundus 
of the stomach, were separated to a depth 
of two or three inches, partially by division 
between ligatures and partially by blunt 
dissection. The pylorus and duodenum were 
thus loosened from the body of the gall- 
bladder and the adhesions between the latter 
and the transverse colon separated by division 
between ligatures and blunt dissection. The 
duodenum could not be recognized until the 
the body of the gall-bladder. The walls were 
smooth and velvety and no stones could be felt. 
No sound or probe, either metal or elastic, 
could be passed down into the cystic duct. The 
introduction of Murphy’s button was impossible 
on account of the thickness of the wall, which 
was 1 cm. thick. Consequently cholecystenter- 
ostomy by this method was out of the question. 
In continuance of the search for stones in the 
duodenal portion of the duct, I now opened the 
duodenum over the diverticulum of Vater. An 
assistant made digital compression of the duo- 
denum above and below the point of incision. 
I made a longitudinal incision one-half an inch 
long in the duodenum over the head of the 
pancreas, which was followed by the escape of 
air bubbles, bile and mucus. Upon introduction 
of the finger in the incision, no stone could be 
felt nor could the opening of the bile duct be 
discovered. 
The next step in the operation was the open- 
ing and exploration of the common duct. With 
the finger in the foramen of Winslow an incision 
Figure V-b.—Showing Oblique Inser- 
tion of Common Duct. Duodenum 
Covering Common Duct has been 
Removed. 
Bile-Ducts filled with Paraffin. 1. Gall-Bladder. 2. Upper Half of Cystic Duct. 3. Lower Half of Cystic Duct. 
4. Hepatic Duct, somewhat dilated. 5. Common Duct dilated to a large sac extending downward and to 
the left behind the descending portion of the duodenum, and even a little behind the ascending portion of the 
duodenum. 6. Descending Portion of Duodenum. 7. Biliary Papilla. 8. Probe passed through Duodenal 
Portion of Common Duct. 9. Pancreas. 10. Suspensory Ligament of the Liver. 11. Stomach. 12. As- 
cending Portion of Duodenum. 13. Point at which Non-Dilated Portion of Common Duct Enters Dilated 
Portion of the Duct. 
Figure V. (One-third natural size.) 
ventriculum of the stomach had been separated 
from its anterior surface. Finally I found the 
foramen of Winslow and on introducing the 
finger into the lesser omental sac, I found an 
elastic tumor the size of the small intestine be- 
tween the duodenum and the hilus of the liver; 
this was the common duct dilated to a tumor 
two inches in diameter, with the duodenum 
adherent to and partially covering it. I could 
detect no stones; no enlargement of the pan- 
creas could be felt, nor could any tumor be felt 
through the duodenum. 
With a view to exploring the bile ducts for 
gall-stones from within, the gall-bladder was 
opened at the fundus by an incision three- 
fourths of an inch long. The wall was 1 cm. 
thick, soft and bleeding, and mucus escaped 
followed by bile. Upon digital exploration 
after incision, I found the supposed tumor to 
be a thick partition wall encroaching upon the 
lumen of the gall-bladder from the knee like 
bend (Fig. V-a, I),dividing off the smooth upper 
portion. The exploring finger entered the 
cavity in the fundus, below which was a nar- 
row isthmus and below this a larger cavity in 
three-fourths of an inch long was made in the 
common duct, through which bile escaped. 
Digital exploration revealed a cavity the size of 
a hen’s egg, with smooth walls, and which con- 
tained no stone. In the upper right portion of 
this cavity I could feel two openings, the an- 
terior being the entrance to the cystic duct and 
the posterior the entrance to the hepatic duct. 
I could feel the division or place where the 
hepatic and cystic ducts united to form the 
common duct. The openings were 1 cm. or more 
in diameter at the upper right end of the cavity 
of the dilated common duct. The wall of the 
duct was white and firm, 3 mm. in diameter, 
slightly thickened and the duct was considerably 
dilated. The probe or sound could not be 
passed down into the duodenum, nor could any 
stone be felt. The duodenum was so immova- 
ble that it was impossible to bring it into appo- 
sition with the common duct for choledochoduo- 
denostomy. I therefore closed the wound in the 
duodenum with Czerny-Lembert sutures. 
As the operation had already lasted a con- 
siderable time—about two hours and a half— 
and as the patient was becoming weak, it was FENGER: BENDING OF THE DUCTS. 
9 
not deemed advisable to unite the common duct 
to the small intestine, and I therefore con- 
cluded to close the wound in the common duct 
and make a gall-bladder fistula to the skin to 
relieve the icterus. The wound in the common 
duct was now closed with a double row of 
sutures, and the opening in the gall-bladder 
sutured to the skin. A drainage tube was in- 
serted in the gall-bladder, with gauze above and 
below the gall-bladder, down to the wound in 
the common duct. Another drainage tube was 
inserted down to the wound in the common 
duct, with gauze packing below it. The wound 
was then closed and dressed in the usual way. 
At the close of the operation the patient was 
weak; pulse 130. 
duct. Small quantities of water passed down 
along the probe into the duodenum. 
As no stone could be found in the common 
duct or gall-bladder it was evident that the ob- 
struction to the flow of liquid was caused by 
valve-formation or bending or oblique inser- 
tion, between the gall-bladder and the 
cystic duct and between the common duct and 
its duodenal portion. 
These obstructions were still further studied 
and illustrated by filling or injecting the biliary 
passages with paraffin, for the careful accom- 
plishment of which I am indebted to Dr. 
Haiselden, my house surgeon in the German 
Hospital of Chicago. 
She never recovered from the collapse; in the 
course of a few hours her temperature began 
to rise, the pulse grew weaker, and she died 
twenty-four hours after the operation. 
Remarks,—No stone was present, the gall- 
bladder was hypertrophied by reason of a valve 
in the cystic duct; the common duct was dilat- 
ed on account of valve-formation near the di- 
verticulum of Vater, The operative indications 
under these circumstances were to open the 
duodenum and make a communication-opening 
between the duodenum and the common duct. 
This can be done when the common duct is 
found to be dilated, by first opening the com- 
mon duct and making digital exploration, and 
then opening the duodenum, sewing the wall of 
the common duct to the wall of the duodenum, 
and closing the openings in the duodenum and 
common duct, In this case, as the patient had 
been two and a half or three hours under oper- 
ation. I was unable to carry the operation be- 
yond this point. If the duodenum is sufficient- 
ly movable to allow the openings to be brought 
together, choledochoduoden ostomy could be 
made by suture or by the Murphy button. 
Autopsy.—The condition of the peritoneum 
was normal, the intestines little, if any, dis- 
tended; |the ovaries, uterus, appendix, lungs, 
heart and liver normal. The incision wound 
of the duodenum was agglutinated, and the 
gauze packing adherent to it. The wound in 
the common duct was firmly agglutinated, the 
duct greatly distended and its walls very much 
thickened. The gall-bladder was enlarged and 
its walls thickened. The gauze was universally 
adherent to the field of operation. No stone could 
be found. The kidneys were not examined, 
but the pancreas, spleen, and stomach were 
normal; the latter was filled with a brownish 
fluid. 
The body was markedly jaundiced and quite 
well nourished. The dressings and gauze 
were saturated with greenish - yellow bile. 
After removal of the gauze around the drain to 
the common duct, no bile, pus, or serous fluid 
could be found; the surfaces were perfectly 
dry; there was no fluid of any kind in the 
peritoneal cavity, and the parietal and visceral 
peritoneum was glistening, smooth and per- 
fectly normal. 
The following injection experiments were 
made to show the patency of the biliary tract: 
• 
Konitzky reports the case of a girl twenty-one 
years of age who was admitted to the Gynae- 
cological Clinic at Marburg, October 34, 1887. 
She was healthy as a child, menstruated at six- 
teen. Menstruation was regular for a year, 
then ceased for two years and was irregular 
thereafter. She last menstruated June, 1887. 
At the age of fifteen she had general weakness, 
nose-bleed and was ordinarily subject to head- 
aches. In July, 1887, the headache increased, 
with loss of appetite, gradually increasing 
icterus, increasing weakness and enlargement 
of the abdomen in the region of the liver. On 
examination, strongly marked icterus was 
observed and a tumor which included almost 
the entire right half of the abdomen and ex- 
tended 10 cm. over on the left side. The 
tumor extended from the liver to the ilium. It 
was fluctuating and had no connection with the 
pelvic organs; the stools were clay-colored and 
the urine contained bile. The diagnosis was 
made of echinococcus cyst of the liver, causing 
pressure on the bile ducts. He operated on 
November 6, 1887. A longitudinal lateral in- 
cision was made, whereupon the cyst presented 
in the opening. Before the cyst was opened it 
was sutured to the parietal peritoneum. Upon 
1. Water was injected into the gall-bladder 
through the opening in the apex by a four- 
ounce hard rubber syringe. The water filled 
the gall-bladder, but was stopped at the neck 
and did not enter the cystic duct. Fluid could 
pass up into the gall-bladder, but, by reason of 
the valve-like formation, nothing could pass 
down. 
3. The nozzle of the syringe was now inserted 
into the common duct through a small open- 
ing made on its anterior surface above the su- 
tured incision made during the operation. 
The common duct now became distended until 
it formed a large round tumor, the size of a 
hen’s egg, or larger, extending downward and 
to the left behind the duodenum and upward 
to the hilus of the liver. As this sac became 
more tense the water entered the gall-bladder 
.and flowed out through the opening in its apex, 
but even when this was held closed and more 
water was injected, not a drop passed from the 
■common duct into the duodenum, showing 
complete obstruction when the common duct 
was destendcd. 
After reopening the wound in the duodenum, 
the opening in the diverticulum of Vater could 
easily be "found, and the probe passed up 
through the duodenal portion into the common FENCER; BENDING OF THE BILE DUCTS 
incision the cyst wall was found to be 3 mm. 
thick. A large amount of thin, greenish fluid 
was evacuated. The inner wall of the cyst was 
dark green. After evacuation the cyst wall was 
united to the skin, and the usual dressings ap- 
plied. Microscopic examination of the cyst wall 
showed it to be connective tissue, and no traces 
of glands, epithelium or muscles could be 
found. The condition of the patient was satis- 
factory immediately after operation. On the 
third day cough set in with bloody sputum; on 
the sixth day she passed 510 grams of urine, 
and vomiting commenced. On the seventh day 
the pulse was 100 and weak with severe vomiting 
and beginning collapse, and she died on the 
eighth day. The autopsy showed no periton- 
itis. The gall-bladder was atrophic and the bile 
ducts in the liver dilated. After opening the 
duodenum, the duodenal papilla was found low 
down, and permitted the passage of a sound 
from the papilla into the cyst. ,The duodenal 
portion of the common duct was 2yz cm. long, 
not dilated, but rather narrower than normal, 
but perfectly patent; was located on and en- 
tered the cyst on its lower left aspect or wall. 
It passed through the wall obliquely from be- 
hind forward. At the upper end of the cyst, 
(the dilated common duct) was a dilated hepatic 
duct. The gall-bladder was contracted and 
narrow, the cystic duct,or at least its lower half, 
dilated and about 2 cm. in diameter, and entered 
the cyst about 5 cm. away from the hepatic 
duct. The cyst ■ then was a common duct 
dilated in its whole extent, down to the duo- 
denal portion. The pancreas was normal. 
The pancreatic duct did not unite with the duo- 
denal end of the common duct, but passed into 
the duodenum separately and opened into the 
latter 4 cm. above the papilla for the common 
duct. 
who had presented the symptoms ot icterus, 
fever and a painful tumor in the right hypo- 
chondrium: The common duct was dilated to 
a large sac containing half a gallon of fetid bile. 
The walls of the sac were thickened and the 
openings of the hepatic and cystic ducts dilated 
so as to permit the passage of a finger. The 
gall-bladder and the portion of the cystic duct 
nearest the gall-bladder were not dilated, but 
there was considerable dilatation of the hepatic 
and bile ducts. At the lower edge of the large 
sac, towards trie duodenum, there was a 
small opening leading into a normal, un- 
dilated duodenal portion of the common 
duct, at the upper ‘end of which a sort of valve 
was found. 
Seyffert reports the case of a woman, 38 
years of age, who had been married three years. 
One year later, after child-birth, icterus set in, 
which was permanent, with an interruption of 
three months. Six months later she had swell- 
ing of the abdomen and tenderness on pressure, 
and nine months later a sudden and violent at- 
tack of hepatic colic, which lasted a day and a 
half and was accompanied by htefnatemesis, 
vaginal haemorrhage, and some gastric disturb- 
ances; the urine was dark; she had pain in the 
lumbar and sacral regions, which was relieved 
by flexing the thighs upon the abdomen. • An 
ovarian tumor was suspected. Examination 
showed tenderness over the liver and in 
narcosis, a normal sized, somewhat hard- 
ened gall-bladder was found in the normal 
location. 
Below and close to the right lobe of the liver 
was a large round tumor the size of a child’s 
head, soft, fluctuating, and extending from the 
border of the liver to two inches above the 
symphysis pubis. The fluctuation was indistinct 
and there was clear percussion over the tumor. 
It was not connected with the genital organs. 
The urine contained a small amount of bile col- 
oring matter. 
The author thinks it possible that gall stones 
may have been the primary cause of the dilata- 
tion, but after their passage other causes must 
have come into play. As the au opsy showed 
a bend of the common duct at the point where 
it enters the wall of the intestine, he believes 
that this bend caused a valve-like occlusion, 
and calls attention to the analogous condition 
of valve-formation in the upper end of the 
ureter, where it originates from the pelvis of the 
kidney. As the valve-formation in the ureter is 
often incomplete at first,causing intermittent hy- 
dronephrosis and gradual dilatation commenc- 
ing at the place of obstruction, so he thinks 
that a gradually increasing dilatation of the 
comrpon duct above the duodenal portion 
took place in this case above the valve or 
bend. 
Diagnosis—Cyst of the pancreas. 
Operation.—On May 28, 1888 an incision 10 
cm. long was made in the linea alba above the 
umbilicus, and the peritoneum sutured to the 
skin. The cyst was punctured and a portion of 
its contents,which consisted of dark green, ropy 
bile, evacuated; a piece of the wall of the cyst 
which was about 5 mm. thick, was excised, and 
the cyst wall sutured to the skin with mattrass 
suture. The cyst was now emptied and showed 
a smooth inner surface with no gall-stones or 
concretions. A drainage tube was inserted and 
dry dressings applied. 
For several days after the operation the 
dressings were soaked with bloody bile; the 
stools were yellowish-brown and covered with 
bile. The patient got on well until four weeks 
after the operation, when more blood appeared 
He cites a similar case reported by Doug- 
las in 1852, who found the following condition 
at autopsy of a girl, seventeen years old, FENCER; BENDING OF THE BILE DUCTS. 
in the dressings, mixed with bile, and suddenly 
obstinate vomiting with abdominal pain, dizzi- 
ness and increasing weakness set in, and she 
■died two days later, apparently without much 
pain, with symptoms of anaemia. 
a year and a half, was probably caused at first 
by catarrhal duodenitis. The attacks of pain, 
which lasted a day and a half, were thus proba- 
bly caused by incarcerated gall-stones. The feces 
were ordinarily not clay-colored, consequently 
the occlusion of the bile ducts was not complete; 
the history also stated that feces were mostly 
normal. Subsequent to the operation the feces 
were always bile-colored; there was conse- 
quently incomplete retention, as both urine 
and feces contained bile, and the author 
concludes that the valve-like occlusion of the 
common duct must have permitted the passage 
of some bile after the emptying of the cyst. (The 
valve mechanism is not described or further 
mentioned by the author.—F.) 
Post-Operative Diagnosis.—Cystic tumor in 
the right hypochondriac region containing 
bile. 
The autopsy revealed a small,retracted,empty 
gall bladder, which did not extend beyond the 
border of the right lobe of the liver; the liver 
was large, smooth, and grayish-green. The 
liver, stomach, pancreas and duodenum were 
taken out together; the biliary papilla in the 
■duodenum was found to be swollen and no bile 
passed on pressure. The probe could be 
passed in for o cm.. The duodenal portion of 
the common duct was cut open from the biliary 
papilla, and from this point up, the duodenal 
portion of the common duct was normal, patent 
and opened freely into the large cavity. A sound 
could be passed from the gall-bladder into the 
cystic duct which was somewhat dilated and 
cm. long, and from here into the cystic cavity. 
The hepatic duct also opened into the cystic 
cavity, consequently the latter was formed by 
the enormoqsly dilated common duct, the cystic 
and hepatic ducts partaking in the dilatation. 
The cyst, when opened, presented a cavity the 
size of the fist; up toward the liver the surface 
was of a grayish-red color, the inner surface 
showing even to the naked eye the appearance 
of a dilated bile duct. On microscopic exami- 
nation, the inner wall of the sac was found to 
be covered with typical cylindrical epithelium. 
In the neighborhood of the cystic duct, the sac 
was of a greenish color; the lower por- 
tion of the sac, near the duodenal third 
•of the common duct, was ulcerated, uneven, 
with necrotic strings and masses, and was 
covered with a soft, fresh coagulum the size of 
a walnut. 
Why did the patient die, as the bile passed 
down into the duodenum after the operation, 
and as at first all the other grave symptoms 
disappeared? This was due to the necrotic in- 
flammation of the sac and haemorrhage and 
subsequent fatty heart. 
From the above cases it will be seen that 
bending and valve-formation at the beginning 
of the duodenal portion of the common duct are 
followed by considerable, even enormous, dilata- 
tion of the latter. When the dilatation reaches 
an extreme degree, a cystic tumor is found 
below the liver. 
Diagnosis has never yet been made before 
the operation or before the autopsy. The 
prognosis is apparently grave, as all the 
patients operated upon have died. As to the 
plan of operation, we can conclude what to do 
only when it is possible to make a diagnosis 
during the operation. The choice of procedure 
will be between choledochoduodenostomy or 
choledochoenterostomy on the one hand, and 
choledocho-abdominal fistula on the other. If 
the common duct is dilated to a large cavity, 
which presents like a cyst against the abdo- 
minal wall, choledochostomy might be pre- 
ferred for temporary relief, and possible spon- 
taneous disappearance of the pain when the 
sac is retracted. If the passage of bile into the 
intestines is not re-established spontaneously, 
choledochoenterostomy might be attempted 
later on. In lesser degrees of dilatation of the 
common duct, primary choledochoenterostomy 
might be made, preferably into the duo- 
denum. , 
Post-Mortem Diagnosis.—Large cyst of the 
common duct; laparotomy; ulcerative destruc- 
tion of the inner wall of the cyst with haemor- 
rhage; universal anaemia. 
Remarks.—The autopsy showed neither 
stones, strictures, valves nor tumors in or out- 
side the common duct. The ulcerated territory 
was probably caused by gall-stones that had 
disappeared, but no gall-stone could be found 
in the body or the feces. The lumen of the 
duodenal portion of the common duct was 
normal, patent, and passage was impeded only 
by swelling of the mucous membrane. The 
violent attacks of gall-stone colic, as given in 
the history, would speak for a pre-existing stone, 
but the anamnesis is imperfect, as the patient 
was in the clinic only two days before the oper- 
ation and the diagnosis of pancreatic cyst was 
made. The icterus, having persisted for almost 
In all cases of this kind it is impossible to 
make an exact diagnosis beforehand. There is 
no difference in the symptoms between obstruc- 
tion from stone and obstruction from other 
causes, with the exception of malignant tumors. 
As calculous obstructions are by far the most 
commonly encountered, we naturally at first 
expect to find a stone, and it is not until during 
the operation that we are disappointed in this 
respect, and find that we have to look out for 12 
FENGER: BENDING OF THE BILE DUCTS. 
other conditions. It is natural, therefore, that 
this is the class of cases which causes the opera- 
tor a great deal of mental anxiety during the 
operation in regard to making the choice of the 
different procedures at his disposal. How to 
relieve the patient from the symptoms must be 
decided then and there. 
weisen. Handbuch der speciellen Therapie 
innerer Krankheiten. Band 4, Abth. 6, b. 
Niemeyer, F. Lehrbuch der speciellen Path- 
ologic und Therapie. Berlin, 1868. Band 1, 
page 671. 
Riedel, B. Chirurgische Behandlung der 
Gallensteinkrankheit. Band 4, Abth. 6. b, 
page 80. 
269 La Salle Avenue. 
Schueppel, O. Die Krankheiten der Gallen- 
wege und Pfortader. V. Ziemssen’s Handbuch 
der speciellen Pathologic und Therapie. Lief. 
22, page 4. 
BIBLIOGRAPHY. 
Courvoisier, L. G. Casuistisch-statistische 
Beitraege zur Pathologie und Chirurgie der 
Gallenwege. Leipzig, 1890. 
Douglas. Cited from Konitzky. 
Seyffert, R. Zur Pathologie der Gallen- 
gaenge. Cyste der Ductus Choledochus opera- 
tiv-behandelt. Inaugural dissertation. Greifs- 
wald, 1888. 
Fenger. Stones in the Common Duct and 
Their Surgical Treatment. American Journal 
of the Medical Sciences. February and March, 
1896. 
Virchow, R. Die Krankhaften Geschwuel- 
ste. Band 1, page 276. 
Konitzky, G. Ein Fall von hochgradiger 
cysticher Erweiterung des Ductus Chole- 
dochus. Inaugural Dissertation, Marburg, 1888. 
Virchow R. Gesammelte Abhandlungem 
Page 756. 
Idem, page 777. 
Leichtenstern, O. Behandlung der Erkran- 
kungen der Gallenwege innere Behandlungs- 
Wyss, O. Zur Aetiologie des Stauungs- 
Icterus. Virchow’s Archiv. Band 86, page 454.