OBSTRDCTION OF THE GALL-DUCT 
AND ITS BAD CONSEQUENCES, 
WITH 
REMEDIAL OPERATION SUGGESTED. 
By J. McF. GASTON, M.D., 
ATLANTA, GEORGIA. 
Any interruption in the discharge of biliary matters, whether the cause may 
be spasmodic, organic or mechanical, brings serious trouble in its train. The 
entrance of a calculus into the bile-duct is manifested by grave disturbance of 
the nervous system, and phenomena are soon developed which indicate the 
sympathy of the whole organism with the local difficulty. At the outset rigors 
alternate with flushes of heat, followed by cold sweats and the most intense 
suffering. 
The ordinary acute spasmodic paroxysms of pain in the right hypochondriac 
region, attended with the most distressing nausea and vomiting, are familiar to 
every practical observer of any experience. These results, from the passage of 
calculi of greater or less dimensions, are known as hepatic colic. If the transit 
of this mass of indurated bile along the common gall-duct from the gall-bladder 
into the duodenum is effected promptly, all the trouble passes without any serious 
consequences. Should, however, the resistance to the progress of the biliary 
calculus be great, and its delay in the canal be much protracted, constitutional 
disturbance is manifested, and local inflammation in the immediate proximity 
of the arrested body will be speedily developed. 
If curative measures are resorted to early after the interruption to the 
flow of bile, there is a good prospect of evacuating the gall-bladder. A 
dilatation of the ductus clioledochus may permit of the passage of gall-stones 
of the size of an ordinary plum-seed, and the results which have been 
reported recently under the olive oil treatment commend themselves to the 
favorable view of the profession at large. The tendency to form biliary con- 
cretions being presented, if one calculus is discharged others are proven to take 
its place after a time, and the local and general embarrassments continue. An 
obstruction to the gall-duct may result from the actual presence of calculi in 2 
the canal, or may ensue from infiltration of its walls, causing occlusion of the 
passage. When the impediment is simply mechanical in the outset, this by con- 
tinuance becomes a source of irritation, and subsequently of inflammation in the 
tissues. Hence, there is never perhaps any protracted obstruction to the out- 
let of the bile without inducing some thickening of the walls of the duct, and, 
ultimately, agglutination of its adjacent surfaces. 
When the obstruction has gone to the point of agglutination by the 
effusion of coagulable lymph, it will be found impracticable to combat the 
adhesive inflammation of the tissues, and the canal remains impermeable. 
When the ordinary channel becomes thus closed, it may occur that an arti- 
ficial opening will be effected by an ulcerative process between the gall-bladder 
and the duodenum or the adjacent portion of the small intestine, thus remedying 
the difficulty temporarily, if not permanently. An outlet is afforded in this way 
to the biliary concretion or collections of fluid bile, and even sero-purulent 
discharges have taken place through such an ulcerated communication between 
these parts. 
It has been ascertained that the closure of the material route of exit for the 
bile is followed by an inspissation or thickening of this fluid, and that eventually 
masses of bilious formation exist in the sac without assuming the character of a 
well-defined solid. Again, in the event of disorganization taking place there may 
be an exudation of a vitiated and decomposed fluid from the internal surface, or 
there may be a purulent accumulation within its cavity. Such collections lead 
to the destruction of its walls, and ultimately to their dilatation and extension 
below the margin of the liver, and, after the lapse of time, to the protrusion of 
the gall-bladder downwards into the lumbar region of the anterior portion of the 
right side of the abdomen. It presents under these circumstances an oblong, 
fluctuating tumor, extending down to the level of the umbilicus, or even into 
the right iliac region, with a breadth of from four to six inches, or even larger, 
according to the quantity of the fluid contained in the sac. 
The retention of the bile for any considerable time without undergoing 
decomposition leads to its absorption into the circulation, and its diffusion 
generally through the system, so that jaundice is one of the ordinary accom- 
paniments of biliary obstruction, but not a necessary or regular sequel of occlu- 
sion of the bile- duct. Should there be present in the cavity of the sac, in place of 
bile, some decomposed fluid or regularly formed pus, it is evident that no bile 
can be taken up by the absorbents, and as a natural consequence there would 
not be jaundice. 
Should any one suppose that the analogy of bilious diffusion ought to lead to 
the dissemination of pus or other exudations, I would call their attention to the 
general law that holds in all suppurating cavities presenting a barrier in the 
peculiar modification of their internal surfaces against the absorption of their 
contents. Were not this pathological principle in force during the progress of 
suppuration in all parts of the body, there could not occur an abscess without 
purulent absorption, and, as a consequence, septicaemia. If decomposed fluids 
or pus are brought directly in contact with the areolar or cellular tissue, trouble 
ensues; but if retained within the cavities when formed, there is no contamina- 3 
tion of the tissues. It has been noted as one of the almost invariable elements 
of bilious diffusion in the system, that itching over the surface develops with 
the obstruction, and is relieved with its disappearance. They may, perhaps, be 
considered as pathognomonic of the disorders. As a consequence of occlusion of 
the gall-duct, there is a want of bile in the intestinal canal, and the fecal evacu- 
aitons are lighter-colored than natural, and owing to the absence of this stimulus 
to the peristaltic action of the bowels there is a torpid state of the alimentary canal. 
Even in an acute paroxysm of hepatic colic, when the interruption to the flow of 
the bile is only temporary, there is observed to exist a marked torpidity of the 
intestines, so that it is difficult to obtain the purgative effect of medicines when 
administered by the mouth. The use of enemata is more successful generally 
in such cases in evacuating the bowels, as their cathartic influence is brought to 
bear immediately upon their mucous surface. 
The appropriate sphere of the bilious secretion is brought into operation after 
the gastric digestiou is completed. The bile only becomes a proper admixture 
for the alimentary mass after it passes out of the stomach, and if from any 
cause there should occur even a very limited regurgitation of bile into that 
organ, it gives rise to disorder in the performance of its office for digestion. 
The bilious matter, combined with the pancreatic juices in the duodenum, 
co-operates with it in modifying the diversified ingredients which enter into the 
homogeneous mass of the chyme, so as to fit it for restoring the waste elements 
of the decomposition in the materials subjected to the process of assimilation. 
After having effected the requisite changes in the alimentary mass, the presence 
of the refuse bile serves to promote the fecal discharges, by exciting the peri- 
staltic movement of the bowels, and thus obviates the evils of constipation. 
The lack of susceptibility of the upper portion of the canal to the action of 
purgatives is owing doubtless to the limited supply of bile to the duodenum, 
while the bilious discharge may be regarded in some sense as an excretion by 
its admixture with the fecal evacuations ; yet it is more properly held to be a 
secretion in its quality of combining with the alimentary mass and so modify- 
ing the ingesta as to fit the materials for nourishing the body. There is no 
doubt on the part of physiologists of its containing elements that are requisite 
for completing the digestion and assimilation processes. 
The analysis of human bile affords the following results : Specific gravity, 
1,022.14. Its ingredients are : Water, 86.42 ; solids, 17.38 ; inorganic, 1.388; or- 
ganic, 9.902 ; bilirubin, 1.49 ; cholic acid, 1.819 ; glycocholate of soda, 2.329. 
Upon comparing this with the constituents of dog’s bile it is found that the 
organic matter in the hitter is about double that of a human subject, and that 
the quantity of cholic acid is ten times greater than in the bile of man. We 
may infer that this marked difference results from the more decided carnivorous 
habits of the canine species, and the greater proportion of inorganic elements in 
the human bile probably imparts to it a much greater tendency to the forma- 
tion of concretions. 
The knowledge obtained by observ ation and experiment in regard to the 
properties of the bile in promoting the proper nutrition of the organism, and in 
stimulating the peristaltic movements of the intestines, goes to corroborate the 4 
results of clinical experience as to its effects. Any material diminution of the 
quantity, or any considerable change in its quality from the normal standard, 
tends to produce derangement and depreciation of the assimilation process, so 
as to impair the alimentation of the entire organization. 
The interruption of the nomal supply of bile may result from a deficient secre- 
tion or from arrest of the discharge in any part of its course. It may occur even 
in the small tubes which convey the bile from the various glandular ramifications 
of the liver. 
We learn from the Gaz. des Hop. that M. Laborde sums up the results which 
have been obtained from physiological experiments in regard to hepatic colic as 
follows : 
“ First.—The excretory bile canals are endowed with a power of contraction; 
they are consequently able to contract spasmodically on the application of a 
stimulus, whether this be applied directly or indirectly. The contractility 
resembles that of unstriped muscular fibre, and the existence of such fibres in 
the walls of the canals is clearly shown by histology, and is in perfect harmony 
with the results obtained from experiment. 
“ Second.—The mucous membrane of these channels is exceedingly sensitive, 
and this occasionally manifests itself under the influence of more or less intense 
stimuli by painful symptoms, and by reflex phenomena, shown directly by 
spasms of the channels themselves. 
“ Third.—The phenomena are particularly induced by the presence and 
contact of foreign bodies, such as biliary calculi, whose spontaneous migration 
is thus rendered more difficult. These changes of place, when they occur, are 
only accomplished after a longer or shorter period, and they possess the 
peculiarity that the foreign bodies are always carried toward, and finally into the 
gall-bladder. 
“ Fourth.—Anaesthetic and anti-spasmodic medicines are best adapted for the 
treatment of this morbid state, of which the mechanical conditions can readily 
be realized by experiment. 
“ Fifth.—These remedies, more especially morphia, chloroform and hydrate 
of chloral, act by exercising at one and the same time an anaesthetic and para- 
lyzing influence, which produces a relaxation of the spasmodic contraction, a 
destruction of the spasmodic canals, and an accumulation of the bile, which acts 
upon the foreign body by means of a vis a tergo, and forces it onwards toward 
the intestines. 
“ Sixth.—The combination of morphia with hydrate of chloral or with chloro- 
form, i. e., the simultaneous administration of those remedies, is the most 
effectual way of obtaining the required results, which are the insensibility of 
the biliary canals, the prevention of pain, and the favorable influence upon the 
migration and rapid extrusion of the extraneous substances.” 
The secretory function of the liver becomes interrupted in the course of chronic 
obstruction to the discharge of the bile by a sort of reactionary influence, which 
arrests more or less the production of this fluid. 
It is observed, under such circumstances, that no fresh supply of bile is mixed 
with the long-standing accumulation of bilious matter in the gall-bladder. 5 
There is, if we may so express it, a suspension of vitality in the hepatic organ- 
ism, and a torpor of its delicate mechanism, so that it remains, as it were, a 
quiet looker-on at the troubles which ensue to other parts of its functions. 
Under such conditions the liver ceases to generate bile, and there is no pain, 
swelling or indication of the organ which could indicate an inflammatory state. 
Yet it is not alone this torpor which occurs in connection with retention of the 
bile, as other and graver complications are frequently present with it. The 
intimate structure of the entire organ undergoes a very marked change, and yet 
the size and general configuration of the liver does not always differ materially 
from what is observed ordinarily in health. 
i’he present inquiry being confined to the atonic condition which results from 
inaction, and which occurs independent of any idiopathic derangement of the 
secretory functions, I may ask attention to the analogy afforded by the suspen- 
sion of action in other organs, and the consequent loss of capacity for the 
performance of their respective parts in the roles of the animal economy. 
Numerous instances of physiological disability will be recalled by those who are 
familiar with the history of suspended activity, and they serve to illustrate the 
effect of obstruction of the gall-duct in the case under consideration. The pro- 
duct of hepatic action is not utilized, and the organ ceases to perform its office 
in secretion of the bile. 
This is not the place to enter upon the details of hepatic torpor. My task at 
present is confined to some points connected with the special train of troubles 
growing out of temporary or permanent occlusions of the gall-bladder. 
I have had occasion to make latterly two post-mortem examinations in cases of 
complete occlusion of the bile duct, the full records of which cannot be now re- 
produced. 
In general terms, it may be stated that one of the patients was a middle-aged 
man, of most active habits, who had come from the United States to Brazil some 
ten years previously. He had occasionally been troubled with hepatic derange- 
ment prior to his fatal sickness, but there was no serious disorder on these 
occasions. Being under the care of another physician in the early period of 
this illness, I found him suffering severely with all the concomitants of biliary 
obstruction, including absence of bile in the evacuations, with jaundice, itching 
over the surface, and tenderness over a fixed point a little to the right and 
below the ensiform cartilage. There was also a peculiar and very persistent 
pain in his right arm. After being under a course of treatment for some time 
with little effect, there was a somewhat sudden improvement in all the symp- 
toms, with a change in the character of the evacuations, accompanied with a 
number of gall-stones. Some of these were of a size that caused me to suspect 
an ulcerated communication of the gall-bladder with the upper portion of the 
alimentary canal. There was immediate relief to all of his sufferings, with 
gradual restoration of the natural bilious aspect of the fecal evacuations, and the 
slow decline of the icteric hue from the eyes and the general surface. Being 
comparatively free from trouble, and having gained some strength with the 
return of appetite, he went back to the country and took charge of the planta- 
tion of which he was the superintendent. But he came to me again some weeks 6 
afterwards with aggravations of a most serious nature, and died in a few days. 
The autopsy revealed ulcerations connecting the gall-bladder with that part of 
the intestines adjacent to the duodenum, and an opening through the diaphragm 
into the lungs, with which firm adhesions existed. The ductus choledochus was 
completely closed, and its walls engrossed and hardened. The collection of 
disorganized bile and serous exudations, which was doubtless originally confined 
in the dilated sac of the gall-bladder, had made its way into a cavity formed 
between the upper surface of the liver and the lower surface of the diaphragm, 
and extended through the aperture into the pulmonary structure. The patient 
had expectorated this offensive matter in great abundance, and its flow into the 
bronchial tubes seemed to be the immediate cause of death. 
The other post-mortem examination was in the person of a middle-aged 
Swedish woman, to whom I had been called on the day previous to the fatal 
result of her disease. A tumor extending below the line of the umbilicus from 
beneath the ribs on the right side, and the breadth of my hand, gave indications 
of fluctuation, and I took a colleague to assist me in determining upon the 
feasibility of the removal of the fluid by aspiration. But her forces were so 
much exhausted that we concluded not to precipitate the inevitably fatal result, 
and she died next morning. The patient had been confined to bed for three 
months with jaundice, and the surface was still of a dingy yellow or brownish 
hue. It was found upon the autopsic investigation that the sac forming the tumor 
was the relaxed and distended gall-bladder, which was filled with a semi-fluid 
dark brown collection of inspissated bile, in which there existed several concre- 
tions of different sizes and offering but little resistance to compression. The 
entire tract of the ductus choledochus was obliterated with thickening and 
hardening of the tissues. At what had been the cystic orifice of the canal there 
was a very considerable dilatation, containing a biliary concretion which was 
closed in on all sides by a membranous formation, into which an incision was 
made for its removal. 
A third fatal case of biliary obstruction has been recently under observation. 
Being called in consultation by a medical friend, in whose care the patient had 
been under treatment for some weeks, he gave me the well-defined history of 
occlusion of the bile-duct. There was present still a characteristic icteric 
discoloration of the entire surface, with the yellow tinge of the conjunctiva, and 
a tremor imparting a sense of fluctuation extended below the ribs in the right 
hypochondriac and epigastric regions. Unfortunately, no opportunity was afforded 
for making a post-mortem examination, yet there could be no doubt in regard to 
the complete occlusion of the gall-duct being the source of trouble in the case, 
and the cause of death. There occurred during the few last days of my atten- 
dance irregular paroxysms resembling those of a malignant fever, doubtless from 
blood poisoning. 
A case of occlusion of the bile-duct, having many points of interest, has been 
under treatment for several months, and remains in my charge at present. The 
patient is an American woman, seventy-four years old, who led an active life 
until within the last twelve months, and had enjoyed a fair measure of health 
and strength. 7 
When my attention was first called to this case there was general debility, 
accompanied with icteric discoloration of the surface and eyes, as likewise 
torpor of the bowels, and deficient coloring matter in the evacuations. 
Considering it, then, as a case of jaundice, dependent upon a temporary 
interruption of the biliary secretion, the following prescription was made: Com- 
pound extract of colocynth and blue mass, each \ drachm ; podopliyllin, 3 
grains; made into twelve pills, of which two were taken night and morning. 
They acted moderately as a purgative, and were continued for a week without 
notable sign of change in the discoloration. This was followed by an infusion 
of gentian with bicarbonate of soda, which was used for two weeks, and yet no 
material alteration. Finding the strength of my patient less than at the outset, 
and that a tonic was indicated, I prescribed the following : Mandated tincture of 
iron, £ ounce ; spirits of turpentine, 2 drachms ; tincture of nux vomica, 1 
drachm ; simple syrup, 2 ounces; of which a teaspoonful was taken every tlnee 
hours during the day, and it was kept up for some ten days. 
At the expiration of this period, observing that there was no improvement in 
the jaundice, and that the intestinal torpidity continued, she was ordered the 
following pills: Calomel, aloes, jalap and extract of rhubarb, each 1 grain ; 
podopliyllin, £ grain ; of which three were taken every morning. They acted as 
a cathartic, and after a few days were only given occasionally to secure proper 
evacuations of the intestinal canal. 
At this time it was stated, for the first time, that there was general itching 
over the surface, though it had been present previously without becoming 
noticeable. My attention being again directed to the patient, a hard mass about 
the size of a kidney was discovered in the anterior right lumbar region, and it 
might have been mistaken for a floating kidney if further examination had not 
revealed that it was within a sac of an oblong shape, that extended up under the 
ribs. There was a well-defined unoccupied space between the upper border of 
this indurated mass and the lower margin of the ribs, and by thrusting the 
fingers below and drawing upwards, this body could be carried up to the line of 
the ribs, moving readily within the sac. That portion of the tumor not occupied 
by this body gave the sensation of a semi-fluid collection, and though the evi- 
dence of fluctuation was not very distinct, I was convinced that it was inspis- 
sated bile, while the kidney-shaped mass was a concretion from the same. My 
diagnosis was, therefore, obstruction of the bile-duct, with dilatation of the gall- 
bladder, containing a considerable quantity of semi-fluid bile and this larger 
biliary concretion. 
Ileiterated and careful manipulations confirmed this view of the case, and 
from the entire absence of the coloring matter of the bile in the fecal evacuations, 
with the torpidity of the intestinal canal, it was inferred that the occlusion was 
complete, and that no operative procedure could accomplish a satisfactory result, 
though the subject manifested a willingness to have the tumor opened and the 
foreign body removed. Her age likewise militated against the operation, and 
my measures were addressed to a palliation of the constant acidity and atony of 
the stomach, with a tonic course to relieve the general debility, which was now a 
prominent feature of the case. 8 
She was directed to use constantly the mixture of infusion of gentian, 10 
ounces ; aqueous tincture of rhubarb, 2 ounces ; tincture of nux vomica, 1 drachm, 
and bicarbonate of soda, 1 drachm; the dose being half a wineglass every 
three hours. After continuing this for some weeks it failed to act as a laxative, 
and the discomforts of every kind being increased, with a very marked febrile 
excitement, and acute sensitiveness over the epigastric region, it became neces- 
sary to resort to some other means of giving at least temporary relief. 
Having observed the reports in regard to the use of olive oil in cases of 
liepatic colic, with the result of dislodging gall-stones, it was thought that, if it 
■did no good, it could do her no harm to try the experiment of a full dose of the 
oil. I confess that nothing further was expected from it than its laxative effect 
in relieving the then existing constipation of the bowels. She took a teacupful 
of the sweet oil, such as is used for the table, at intervals of three hours, until 
three were taken, when her stomach refused to accept any more. In the course 
of the same night she had free evacuations of a dark gramous matter, which con- 
tinued for twenty-four hours with greater or less intervals. After the first 
discharges there was very little of the characteristic fecal odor with the evacua- 
tion, but a disagreeable smell (which was sui generis) accompanied the dejec- 
tion of the semi-fluid matter that passed, and which had been previously 
retained within. In the meantime the tumor extending below the ribs on the 
right side diminished, and the hard mass already described receded upwards to 
the margin of the ribs. The pain and sensitiveness in the epigastrium ceased, 
but in the course of a week the darkish discharges disappeared, and eventually 
there was no further action of the bowels. The patient again became uncom- 
fortable, and the olive oil was repeated with a good result in producing dis- 
charges resembling the former matter, but less in quantity, which recurred at 
intervals subsequently. 
Her appetite now returned so that she ate indiscriminately of such vegetables 
and other articles as she desired without any indications of indigestion, and 
■eventually there seemed to be a restoration of the proper bilious secretion to the 
evacuations. During this improvement in other respects the itching over the 
surface was not felt any longer, but there was a very slight diminution of the 
intensity in the yellowness of the skin and the eyes. 
There was no appearance of biliary calculi in the discharges from the bowels, 
cither under the direct influence of the olive oil or subsequently; but there 
were evidently present in the evacuations the retained secretions and the for- 
mer contents of the distended gall-bladder. 
The channel by which the inspissated bile found its way from its receptacle 
into the intestinal canal could not have been by any dilatation of the natural 
outlet, but must have been the result of ulceration, as the circuitous general 
symptoms indicate, which caused a communication of the gall-bladder with the 
upper part of the small intestine, adjacent doubtless to the duodenum. This 
opening, having closed after the first discharges, reopened with the repetition of 
the oil, and has continued as an outlet for the bile. 
The relief afforded in other respects has not been attended with a correspond- 
ing change in the icteric hue, and this may perhaps be explained by the fact 9 
that a large mass of biliary concretion remains in the sac, and that more or less 
accumulation of bile remains along with this body, thus affording the conditions 
of absorption which keep up the jaundice. 
The bile does not escape entirely by the artificial orifice, and, like the overplus 
of urine in a relaxed state of the bladder, there is perhaps some gradual accumu- 
lation in the paralyzed sac which was recently so much distended. I feel no 
assurance of the ultimate restoration of the normal function of the gall-bladder 
while so large a mass of biliary concretion remains in its cavity, and though the 
patient has gone to the country, hoping for a re-establishment of health, I think 
it most probable that she will fail to realize any permanent benefit. 
Still another case has been treated having all the indications of obstruction 
of the bile-duct with hepatic colic and jaundice. 
My attention was first called some two years ago to this gentleman, who is a 
German by birth, but spent his early manhood in the United States, and has 
resided in Brazil for the past twelve years. He was then suffering with 
derangement of the stomach, connected with biliary disorder, and habitually con- 
stipated, without proper color in his fecal evacuations. Jaundice was an accom- 
paniment of his other serious troubles, and energetic measures were required 
for his relief. Yet he subsequently seemed to be re-established in health, until 
the return of similar disturbance in his hepatic functions at the close of the first 
year. I was called anew to see him on December 17tli, 1880, and prescribed 
comp. ex. of colocyntli, blue mass and podopliyllin, in purgative doses daily for 
four days. But, noting that the torpidity of the liver continued, on the 22nd, 
I ordered the capsules of spirits of turpentine of Clertau, of which two were 
taken four times a day. On the 26th of the same month I was summoned to 
attend him with an aggravation of all the symptoms, and marked increase of 
the icteric hue of the skin and eyes. Calomel and quinine, each 18 grains, 
divided into three portions, were given every three hours, and followed by a 
purge of magnesia and rhubarb on the next day. On the 28tli, found my 
patient writhing with the pain of an hepatic colic, when I gave 12 grains of 
calomel every two hours until 36 grains were taken, and within two hours after 
the last he took four tablespoonfuls of castor oil with one of spirits of turpen- 
tine. This failing to act upon the bowels, he was given enemata of castor oil 
with lac assafoetida and warm water repeatedly, until evacuations of fecal matter 
were secured. In the meantime stupes of turpentine and camphor, with flannel 
wrung out of hot water, had been diligently applied over the abdomen. After 
the discharges began this was substituted with fomentation by belladonna oint- 
ment, and as soon as the biliary secretion made its appearance there was a 
mitigation of all his sufferings. On the 30th there was some febrile excite- 
ment, with considerable tympanic distention of the abdomen, and tenderness 
over the epigastric region. The Carlsbad salt was given in teaspoonful doses 
every three hours, and a liniment of spirits of turpentine and camphorated oil 
was kept constantly over the entire abdominal surface with a flannel roller, 
giving a moderate support around this part of the body. The acute symptoms 
being materially modified, on the 1st of January, 1881, he was ordered a mixture, 
which has proved useful in all relaxations of the alimentary canal in which a 10 
tonic effect generally is desired. This formula, already given for gentian, 
rhubarb, nux vomica and bicarbonate of soda, was kept up for more than two 
weeks, with relief to most of his troubles. In the meantime he, being a person 
of much energy, insisted on looking after his outdoor duties, and wras ordered 
the elegant preparation known as qumium Labarraque, to be taken four times a 
day in portions of half a wineglass, which was continued from the 16tli to the 
27th of January, 1881. This was then changed for a decoction of cinchona bark, 
with sulphuric acid and tincture of nux vomica, during the daytime. As he was 
restless at night, I prescribed the syrup of chloral of Follet to be taken in table- 
spoonful doses, with intervals of an hour until three should be taken, at night. 
But the usual soporfic influences of this soothing medicine was not satisfactorily 
manifested on this occasion, and after a few nights it was discontinued. The 
jaundice had disappeared ; but my patient was annoyed very much with indi- 
gestion and irregularity of the bowels, being at times inactive, and on other occa- 
sions passing off what seemed to be bilious matter, that assumed a periodic char- 
acter on every morning before daylight. Accordingly, on the 12th of February the 
following was prescribed: Sulphate of quinine, 36 grains; camphor, in powder, 12 
grains; extract of belladonna, 3 grains; con. of roses, q.s. to make 12 pills, of which 
two were taken every two hours. This appeared to be attended with some benefit, 
so that I was encouraged to persist in this course, and adopted one of my 
favorite tonics February 21st, 1881 : Sulphate of quinine, 36 grains ; sulphate 
of iron (pure) 1 drachm; sulphate of strychnine, 1 grain; sulphuric acid 
(conct.) 1 drachm ; distilled water, 1 pint. Mix and take a tablespoonful every 
three hours. Finding that a periodic febrile paroxysm appeared in the after- 
noon daily, Fowler’s solution of arsenic wras added to the above on the 2nd of 
March, and given constantly for some days. 
March 12th, 1881. The patient having little appetite, and the food taken be- 
coming uncomfortable, with acid eructations and occasional vomiting, I used 
the nitrate of silver with opium, each three grains made into 18 pills, giving 
one every three hours until six were taken daily. But observing little or no ad- 
vantage from this course, I resorted to subnitrate of bismuth, prepared chalk, 
cinnamon water, syrup of opium and mucilage of gum arabic, with better re- 
sults in allaying the disturbances of the alimentary canal. March 20th, it was 
perceived that there was a constant acceleration of the pulse, exceeding a hundred 
to the minute, with nervous irritability, and the infusion of digitalis with 
bromide of potash was taken for more than a week without relief. April 1st, 
1884, as a corroborant and alterative I had recourse to the nitro-muriatic 
acid, and while the general tone of the digestive apparatus was improved, there 
was no diminution of the frequency of the pulsation. This patient gave no 
signs of organic heart disease, and with the continued gastric and intestinal 
trouble, associated with more or less tenderness over the epigastrium, along 
with nervous excitability and acceleration of the pulse, dating from the period 
of the attack of hepatic colic, it is perhaps a legitimate inference that the 
structural changes initiated then had progressed with ulceration in such form 
as to account for the whole train of disorders. The rest and quiet of a sea 
voyage, for it wras known in advance that he did not suffer from sea-sickness, 11 
was advised by me as most conducive to a subsidence of any inflammatory pro- 
cess which had existed, and the result has confirmed my anticipations. If the 
jaundice had been present at the outset, and given way shortly after the return 
of the bilious matter to the evacuations, it might be supposed that there was an 
error in diagnosing obstruction of the gall-duct, with abnormal cysto-intestinal 
communication. It must be concluded by all who are aware of the necessity of 
bilious matter to the proper performance of the processes of chymification and 
chylefaction in the upper part of the alimentary canal, that a permanent oblit- 
eration of the communication of the gall-bladder with the small intestine is in- 
compatible with health, if not inconsistent with the continuance of life. The 
prime consideration for the pathologist is whether any considerable collection of 
fluid ever occurs in the gall-bladder without occlusion of the gall-duct, and the 
question of paramount importance for the surgeon is the practicability of re- 
storing the flow of bile into the duodenum or the adjacent portion of the intes- 
tinal canal by the natural or an artificial communication. A fistulous external 
discharge may have carried off the vitiated contents of the sac, and thus given 
temporary relief to the patient; or an operation may be undertaken for the 
removal of the offending matter, yet the study of this very grave complication 
is in its infancy, and the heroic measures which are requisite should be regu- 
lated with discretion. 
With the lights before us it is clear that an effort should be made to over- 
come the serious difficulties in the way, and if the operation of cholecystotomy 
is ever to be crowned with a success it should be resorted to while the patient 
has sufficient strength to rally from the shock of such a procedure, and can out- 
live the depreciation of all the vital functions which results from the interruption 
of the supply of bile. That an operation for the removal of foreign bodies from 
the gall-bladder through an opening in the abdominal wall should have been 
suggested by Petit, Thudicum, Manndor and Huglilings Jackson amounts to 
nothing practically, as there is no evidence that any of them put it into 
execution. 
The idea of Handheld Jones, to push the gall-stone into the intestine by 
manipulation only and without opening the gall-bladder, reminds one of the 
famous receipt for dressing a hare—first catch the hare. And it would doubt- 
less become equally important in the above cases to discover the said canal, be- 
fore pushing the hardened mass into it, the duct being closed. In the notice 
we have of Bartholow’s aspiration of the gall-bladder and the subsequent death 
of the patient, there is no intimation of the state of the bile-duct. Although he 
has proposed the use of a probe for exploring this canal, and claims that this 
operation is practicable, no details are given as to the proceeding in any given case. 
Brown’s report of discovering gall-stones by the probe and after making an 
incision of two and a half inches without being able to reach the gall-bladder, 
and closing up the wound seems to be very ineffectual. Yet “ in the night 
bile began to be discharged, the tumor disappeared, and she recovered with- 
out a fistula.” All will be prompted to ask what became of the biliary calculi 
that remained behind?—Were they discharged through the duct into the 
duodenum, and did they make their exit per vias naturales ? 12 
In the case given recently by Bryant, it is evident that the large biliary cal- 
culus was the source of trouble and caused the suppuration. This being re- 
moved, and the discharge continuing for some months externally, while the bile 
duct still performed its office as an internal drainage tube, the external parts 
gradually healed, and the normal relations soon became established. 
Viewing cholecystotomy as an effort to establish a fistulous discharge exter- 
nally, by which the bile shall be directed from its appropriate channel, and thus 
prevented from filling the role which normally pertains to it, it becomes us to 
inquire whether there is any guarantee of final and complete recovery, with the 
interruption of a supply of the bilious secretion to the alimentary canal, as 
occurs in the proposed diversion. 
An interesting account of a case is given by Mr. Frank E. Artaud in the 
June number of the New Orleans Medical and Surgical Journal, 1881, entitled 
“ Acute hepatitis, resulting from the presence of biliary calculi found in the 
parenchymatous structure of the right lobe of the liver.” The author states 
that “ palpation enabled me to deduce conclusively that the right lobe of the 
liver was by far larger than normally.” 
Noting the fact that the liver ordinarily does not extend below the margin of 
the ribs in the right hypochondrium, we should not overlook that, “ further- 
more, anteriorly an elevation resembling the under surface of an ordinary saucer 
was present, exceedingly prominent and exceedingly circumscribed, measuring 
three inches in diameter; its position was as follows, viz.: the upper edge was 
two inches and a half below the costal cartilage of the seventh rib, whilst the 
lower bordered upon the right lumbar region.” The operator made an incision 
from left to right transversely, from two to three inches in length just half an 
inch above the one he had made with the lancet, and four inches from the linea 
alba; also two inches below the costal cartilage of the seventh rib. 
The apparent inconsistency of incising a tumor, whose upper border was two 
and a half inches below the margin of the ribs, within two inches of this line, 
may be explained by the supposition of a change in the location of the abscess -T 
yet, he had introduced previously an exploring needle in the centre of the ele- 
vation, from which was drawn some pus mixed with blood; and this point must 
have been, according to measurements given, at least four inches below the 
margin of the ribs. This discrepancy in the statements leads us to conclude 
that there is an element of doubt in the description of the operation, and that 
there may be misapprehension as to the nature of the tissues referred to in the 
following statements : “ Having divided the several structures, I found that an 
adhesion had taken place between the hepatic and parietal peritoneum ; I in- 
troduced my fingers, and following the path which my instrument had pursued, 
as a matter of course enlarging it, I at length felt a cluster of calculi firmly 
imbedded in these cavities, and the contiguous tissues strongly bound down 
upon them. By means of a probe-pointed bistoury and forceps, I succeeded 
in extracting fifteen of these calculi in the space of two hours. Their size 
varied from one-eiglith to one-quarter of an inch in diameter, polygonal in 
shape, of a brownish-yellow color, friable and floating in water.” 
This operation being on the 22d of December, 1880, he states that on “ De 13 
cember 24th I thought it prudent to search for more calculi, and shortly ex- 
tracted five more, the fifth having larger dimensions than those heretofore 
extracted. December 2Gth : Wound once more explored and seven more calculi 
extracted, alike in size to the others. December 27th : Wound again explored, 
and no calculi to be found. December 28th : Appetite good, assimilation of 
food apparently taking place, stool containing a normal quantity of bile.” It 
should have been noted that attention was drawn to the absence of the bilious 
secretion in the evacuations in the early history of the case. It is notable that 
during the whole period of observation, before and after the operation, there was 
not an elevation of a single degree of temperature, nor exceleration in the pulse, 
and the author calls attention to the fact that jaundice was not connected with 
the case. 
I have no disposition to forstall the judgment of the medical profession in 
regard to the nature of this case, and the author must allow that a correct 
impression of his instructive narrative is herein presented. Yet I beg leave to 
differ with him when he says : “ But taking into consideration the symptoms 
and course of the case, which I have had in close observation, I can safely 
assume that there was no analogy to those cases in which the gall-bladder has 
been the seat of disease.” Those who have had most experience in the dilata- 
tion of the gall-bladder from the contained purulent collection, and have 
observed the descent of the tumors formed by the distended sac, will detect 
in the description of the saucer-shaped projection below the ribs on the right 
side the well-defined characters of such a tumor. I am fully satisfied, like- 
wise, that such extensive suppuration, implicating the glandular structure of 
the fiver, could not be so entirely free from constitutional excitement as was 
reported in this case. 
Surgeons and pathologists, whose attention may be attracted to this case, 
should note carefully the position of the tumors and the proceedings instituted, 
s"> as to form an opinion upon the merits of the diagnosis made. There is a 
strange omission of any authorized judgment by a competent surgeon in regard 
to its nature, and with the able staff of medical officers connected with the 
University of Louisiana and the Charity Hospital, it seems most remarkable 
that no intimation should be given of the views taken by some one of them. 
We are only informed that in February, after the patient was relieved of all 
trouble, ‘ * with Prof. Bemiss’ consent, the patient was brought before the 
medical class and lectured upon in the amphitheatre of the Charity Hospital by 
the above-named gentleman.” 
The case is in many respects a remarkable one, and not the least so in the 
subjective phenomena, as absence of the bile in the intestinal discharges and want 
of the icteric hue of the surface, along with the speedy restoration of bilious 
matter to the fecal evacuations after the operations had produced their legitimate 
good effects. 
The adhesions between the sinous tissues reported seem to suggest that in 
cases which are connected with the distension of the gall-bladder, when the 
tumor is prominent below the border of the ribs on the right side, the operator 
should first seek to bring about an artificial union of the fining membranes at 14 
the space where the incision is indicated. Thudicum has inculcated the opening 
of the abdominal wall and securing the sac to the margins of the opening to 
effect their adhesion, but perhaps the two serous membranes could be stitched 
together without this opening. 
In the July number of the American Journal of Medical Sciences for 1881 
appears the record of a case having some points of correspondence with that 
which has just passed under review ; yet it differs materially in the concomi- 
tants developed as to general symptoms, and in the absence of biliary calculi. 
It is reported by Walter Mendelsen, M.D., house physician to the New York 
Hospital, as “ a case of abscess of the liver complicated with empyema.” 
Preliminary to any comment upon the nature and origin of the trouble, 
attention is asked to the following summary of the points presented : When the 
woman entered the hospital on October 9th there was enlargement of the liver, 
and on the 10th it was supposed that pus was taken from the right pleural cavity. 
But I would note a statement that “ the upper border of the liver was at the 
sixth intercostal space,” and that “ the largest needle, No. 4 of Dieulefoy’s 
aspirator, was inserted twice ; first in the eighth and then in the ninth intercostal 
space,” and “ each time only a drachm of very thick pus was drawn.” I leave the 
intelligent reader to determine its source. 
On October 16th a slight swelling in the light hypochondrium, just above and 
to the right of the umbilicus, was perceived for the first time, which by the 19th 
was as large as a goose’s egg. On November 2nd the patient expectorated 
large quantities of purulent material, and on the 5th the tumor in the epigas- 
trium was nearly imperceptible and quite soft to the touch. On the 18th the 
tumor was noticed to have reappeared, and fluctuation was very evident. At 
this time “ the expectorations had an orange-yellow color, as if tinged with 
bile,” so that it was inferred that the pus in the thoracic cavity communicated 
with the liver, and the reporter says that “ it would be hard to explain the 
subsidence of the tumor, except by supposing that it had discharged into the 
pleural cavity.” 
On November 22d the tumor had increased considerably in size, its growth 
having taken place mainly to the left of the umbilicus. The patient’s breath 
was horribly offensive, having the same odor as her expectoration. As the ab- 
scess showed decided signs of pointing, it was determined to operate. At 9 a.m. 
the pulse was 112, respiration 36, and temperature 101.8°. The patient being 
etherized, at 11 a.m. an incision one and a quarter inches in length was made 
just above, and one inch to the right of the umbilicus, in the softest part of the 
tumor. After a rather superficial cut the pus was reached and poured out in 
great quantities, about a pint or more discharging in a few minutes. The pus 
was thick, viscid, sanious and clotted. It was mixed with portions of bright 
yellow pus and shreds of broken-down tissue. It was entirely free from odor. 
“ The cavity was washed out with a solution of carbolic acid (1 to 40 of 
water), and on introducing a finger through the wound, the abscess was found 
to consist of two portions : one the main cavity, lying to the right of the median 
line, and having the size of a very large orange ; the other a smaller one about 
the size of a pigeon’s egg, just to the left of the median line; the two being 15 
freely connected by a canal running transversely under the linea alba. The liver 
tissue could be felt projecting into the cavity in hard nodulated masses, covered 
with a pulpy material which was easily scraped away with the finger. It was 
impossible to touch the bottom of the abscess with the finger, but a probe could 
be introduced for about four inches in a direction backwards, upwards and out- 
wards.” The reader must divine what is meant in this last word, considering 
the position of the incision. Referring to the examination of the pus by the 
pathologist of the hospital, it is stated significantly : “ Nothing that could be 
distinctly identified as liver cells was found.” 
After the immediate perturbation of the operation had passed, he found at 
10.30 p.m., pulse 120, respirations 34, temperature 9G.6°. 
“ Dec. 27.—The lower border of the liver was still at the umbilicus, being 
bound down by adhesions.” It is notable that “ at no time during her illness 
had she been jaundiced.” 
With a proper appreciation of the data appended by the author, let us hear 
a few words in regard to the tumor : “ On its first appearance various theories 
relating to its nature were advanced. It seemed in the beginning as though it 
might be the gall-bladder, for it was in the place where this organ appears when 
distended, and was soft and globular. Careful exploration, however, revealed 
the sharp edge of the fiver below the tumor, a condition which of course could 
not exist had it been the gall-bladder. As the edges became more indurated, it 
was supposed to be an abscess in the abdominal walls, the result of the pus 
from the empyema making its way downward ; for, be it observed here, there 
was no suspicion of hepatic abscess when the woman was admitted, and all her 
trouble was referred to her empyema. From the first the hepatic origin of the 
abscess had been strongly advocated in view of the enlargement of the fiver, and 
the mould-like edge of the tumor, caused probably by the adhesions formed be- 
tween the fiver and the abdominal walls.” 
The contradictory statements in the above paragraph, that “ there was no 
suspicion of hepatic abscess when the woman was admitted,” and “ from the 
first the hepatic origin of the abscess had been strongly advocated,” may per- 
haps be reconciled by supposing that the first referred to the impression prior 
to any examination. But then, how could it be known that the empyema existed 
at that time? 
The internal evidence of inexactness in the use of terms, not to say confusion 
of ideas, is patent in many parts of this record. Though my space has not 
allowed me to follow the report in detail, I have presented the salient points, 
without any intention to change its purport, and for the most part giving the 
phraseology of the author. 
The experienced reader will doubtless have perceived that all is not quite so 
clear as it should be in the history of the case, as there is no reference to the 
fecal evacuations, so that we are uninformed in regard to the presence or the 
absence of bile in the discharges from the bowels. In view of the avowedly 
doubtful nature of the case up to a certain period, it might have occurred to the 
qouse physician to make some observation of a matter so essential to determin- 
ing the implication of the gall-bladder in this suppuration. In an important 16 
surgical case, as this must be regarded by all thinking men, it was much to be 
desired that the medical profession should have had all the light available for a 
proper diagnosis. If the veteran Markoe had been consulted, and his opinion 
reported as to the distinguishing features of the case, it would have enabled 
medical men to decide upon the merits of many points which are left in obscurity 
by the off-hand mode in which they are disposed of by the reporters. As for 
instance, he says, in a matter-of-fact style: “ When the tumor was incised, and 
after evacuating its contents, the finger was introduced into the cavity, of course 
no more doubt regarding its nature remained.” 
If the authorized judgment of such a man as Hammond, who has frequently 
aspirated abscesses of the glandular structure of the liver, could be had upon 
the origin of the pus in this case, it would not appear quite so plain that it 
came from the substance of the organ. 
For my part, I am compelled to dissent from the foregone conclusion of the 
author as to the tissues implicated, and unless I could put my finger in that hole, 
to the bottom of which his could not reach, there must be a doubt as to the 
correctness of his observations. Autopsic investigation has demonstrated that 
extensive collections of sero-purulent matter, or of regularly formed pus, are 
found in the dilated sac of the gall-bladder, occupying the position in which 
this tumor was found ; and, further, that these fluids may traverse the dia- 
phragm by an ulcerative process, or extend around and above the liver, so as to 
be between it and that muscular partition of the abdominal from the thoracic 
viscus. The inflammation thus set up induces adhesions between the investing 
membrane of the lungs and that lining the cavity of the thorax, so an opening 
may be effected directly into the pulmonary structure, and thence the matter 
may be expectorated, as in this case. 
Any student of the facts presented in those cases reported by Mr. Artaud 
and Dr. Mendelsen will no doubt discover that one of the essentials of retention 
of the bile, consisting in the icteric discoloration, has been absent; and it 
may not have been remembered that obstruction of the ductus choledochus, 
with a purulent collection in the gall-bladder, should not be attended with jaun- 
dice. The presence of bile confined in the sac is a requisite for its absorption 
and diffusion by the circulation, and if instead of bile there exists pus, jaundice 
should not occur, as, in fact, it has not been found in either of these cases. 
Viewed from this standpoint, I am inclined to consider both of these abscesses 
as proceeding from obstruction of the bile-duct, and hence as included properly 
imder the head of which this paper treats. It is, however, claimed that these 
tumors did not implicate the proper parenchymatous structure of the organ, but 
were purulent collections in the gall-bladder, which being discharged afforded 
relief. In the case of Artaud there was noted a restriction of bilious matter in 
the evacuations, and, unfortunately, in that of Mendelsen nothing is communi- 
cated touching this point, either before or after the operation. 
Neither of the cases had been under observation for a sufficient time to deter- 
mine the final result upon the health of the patients. It is a remarkable coin- 
cidence that these two important surgical cases should have been operated upon 
on the same day of the same year, the 2‘2d of December, 1880, and that they 17 
should have each progressed so favorably as to be dismissed from any special 
supervision within a week afterwards. Let the seat of either be as it may, the 
operations were successful. 
The three cases described by Morgagni, all of whom had tumors in the epi- 
gastrium which were opened either by art or spontaneously, discharging cystic 
calculi at the aperture, need authentication. If the statement that the first was 
cured, the second recovered with a fistula, and the third with an ulcer, can be 
relied on as true, they go very far towards establishing the results obtained in 
the cases of Bryant, Mendelsen and Artaud, and we may take them as a corrob- 
oration of the fact that the suppuration within the gall-bladder, from the pres- 
ence of gall-stones or without them, is not incompatible with preservation of an 
outlet by the gall-duct. 
It is not improbable that, though a stoppage of the gall-duct may occur tem- 
porarily from inflammation of its walls, there may not be adhesion, and with the 
subsidence of the swelling and turgescence of the tissues by the evacuation of the 
contents of the sac, the tract of the canal may be restored. The radical proce- 
dures instituted by Sims and by Keen for dropsy of the gall-bladder are types 
of the operation styled cholecystotomy, and their untoward results only hastened 
the termination of sufferings which were destined ere ldiig to wear out the little 
remaining strength of the patients. 
The extensive collection in the distended gall-bladder removed by the opera- 
tion of Keen was not connected in any way with biliary concretions, as no gall- 
stones were present. It is much to be regretted that the post-mortem examina- 
tion did not reveal the state of the ductus choledochus, as the verification of the 
closure of the duct must be regarded as of great moment in the history of this 
class of cases. 
In the case reported by Sims a most unexpected revelation is made in the 
details of the autopsy made by M. Gaual, which leads one to suppose that com- 
plete obstruction of the ductus choledochus had not at any time existed in this 
patient. In the full, and for the most part satisfactory, account of the case oper- 
ated upon by Sims it is stated, in the observations made after death, that 
“ M. Gaual then passed a director into the gall-bladder, tln'ougli the external 
fistulous opening, showing the continuity of the two. After satisfying himself 
that the operation had been successful in this respect, he cut the gall-bladder 
loose from the parietes of the abdomen, and then introduced his hand into it 
and removed sixteen gall-stones, from the size of a pea to that of a pigeon’s egg. 
They were all sacculated, and this was the reason that they were not removed 
at the time of the operation. He then removed the gall-bladder entire ; it was 
very large, and its walls were much thickened. After doing this he was able to 
pass a probe from the gall-bladder through the ductus communis choledochus 
into the duodenum.” 
It is a serious omission in the statement of such an important point, that 
nothing should be said in regard to the calibre of this canal and the state of its 
walls. Should the bile-duct have previously allowed a free communication with 
the duodenum, it seems quite unaccountable how the tw enty-four or twenty-six 
ounces of dark-browm fluid withdrawn at the time of the operation should have 18 
remained in the cavity of the gall-bladder without escaping into the intestines. 
If, however, the opening in the canal was so constricted as barely to allow 
the passage of an exploring probe, it might very well have prevented the escape 
of a rather consistent fluid from the cavity of this sac. But why was it kept 
confined earlier, when the fluid must have been thinner and should have escaped 
at an outlet which admitted the probe. That gall-stones form in the gall- 
bladder with an open duct for the partial outlet of bile does not prove that 
any considerable collection of fluid would remain while there existed an open- 
ing for it to flow out by the duct. 
If this examination and the manipulation with the probe had been made by 
Dr. Sims in person, I should not have a doubt of its correctness in every point. 
But when it is stated that M. Ganal, thinking he had cut through the perito- 
naeum, began to separate it from the abdominal parietes, saying, “ Here is peri- 
tonitis with adhesion everywhere,” and that Dr. Sims told him “ to open the 
peritonaeum, which he did, and found that there was not the slightest evidence 
of peritonitis,” it leaves us in doubt as to whether his probe might not have 
been thrust through the softened tissues of an occluded duct. 
It will be seen that this matter should be understood in its bearings upon 
the end contemplated in -this operation for relieving the sac by an external fis- 
tulous opening. 
In a paper by Mr. Lawson Tait, in the British Medical Journal of May 8th, 
1884, the following remarkable statement is made: “ The conclusion of the 
surgical experience in these cases is, that the entire possibilities of the treat- 
ment of gall-stones and distended gall-bladder are exhausted in Dr. Marion 
Sims’ original paper published in this journal, that no further extension of it 
seems possible, and that no further experimentation such as that of Wells and 
Langenbach seems desirable.” This is passing strange. 
While the proposition made by Langenbach for the removal of the gall- 
bladder is, in the words of Tait, “ intrinsically absurd,” it is by n ® means so 
clear that the proposal made by Sir Spencer Wells “ to open the gall-bladder, 
remove the calculi, and to close it by a continuous suture, without attaching it 
to the abdominal wound,” may not be advantageous if it be followed by a sub- 
sequent operation for affording a direct outlet of its contents into the in- 
testinal canal. What he and others have failed to undertake I have now to 
suggest. 
In reporting subsequently the crushing of a gall-stone in the duct with the 
forceps, Mr. Lawson Tait departs from the masterly inactivity which his pre- 
vious teaching would inculcate; and we should not be surprised if the return 
of the normal color to the patient’s motions indicated relief to the obstruction, 
so that his proposed closure of the fistula should be attended with the most 
salutary results. 
The attitude assumed by this distinguished surgeon in the British Medical 
Journal of May 3d differs so entirely from the publication in the same journal 
of July 12th, 1884, that we look with great interest for the report of his closure 
of the fistula in this case. And he was so considerate in undertaking to crush 
the stone in situ, by means of padded forceps applied outside of the duct, as to 19 
say that if a better plan should occur to any of his readers he would be glad 
to hear it; so it is hoped I shall have full credit for my suggestions. 
The entrance of the bile into the upper division of the intestinal canal being 
essential to health, if not to life, is there any assurance, when the bile-duct be- 
comes obliterated, that an artificial communication by catheterization or by 
puncture can be effected, to convey the contents of the gall-bladder into the 
alimentary canal ? This is a requisite for the favorable issue of any operation 
looking to an outward discharge of the contents of the sac in dropsy of the 
gall-bladder, and unless this point can be resolved satisfactorily, surgeons will 
be under the dire necessity of abandoning the subjects of occlusion of the 
bile-duct to their sad fatality, rather than become the active instruments of 
precipitating such a calamity. 
The surgical proceeding which is indicated for dropsy of the gall-bladder, as 
distinguished from the suppuration set up by the presence of gall-stones, or, 
independent of them, appeals to the discrimination of pathologists, as it is evi- 
dent from the results of spontaneous and artificial processes in the latter that 
the prospect of relief in this class of cases is more favorable, than in the de- 
generation of fluids that characterizes dropsical or sero-purulent collections in 
the dilated sac of the gall-bladder. The burrowing tendency of these vitiated 
fluids, when extravasated by local ulceration, so clearly illustrated in my first 
noted autopsy, by the permeation of different tissues, should afford us a warn- 
ing against delay in resorting to such operative procedures as may be indicated 
for the removal of collections in the gall-bladder. 
There are serious complications connected with scirrhus of the pylorus, t h 
duodenum and the pancreas, involving to a greater or less extent the bile-duct, 
which preclude any hope of permanent relief. 
I co-operated with two of my colleagues in Brazil, during the past year, in 
making an autopsy in the case of a man from the United States that had 
scirrhus of the pyloric orifice of the stomach extending to the duodenum, which 
caused arrest of the bile from implication of the ductus choledochus. 
In a cadaveric examination of a mulatto woman, on the 31st of AugiTst 
of this year, in Atlanta, Ga., with Drs. J. J. Caldwell and K. C. Divine, the 
pancreas was found in a scirrhous state, with thickening and induration of the 
tissues around the course of the bile-duct, it being entirely obliterated through- 
out its length. The distended gall-bladder contained about half a pint of 
decomposed semi-fluid matter, which had evidently been locked up for a consider- 
able time. 
In these cases no operation succeeds, whether the contents of the sac are 
fluid, semi-fluid or solid. It is proper under some circumstances to evacuate 
the distended gall-bladder externally, with a view to establish subsequently a free 
communication from it to the intestinal canal, which is requisite for a successful 
result of the operation. 
Having made an incision into the peritoneal cavity over the most prominent 
part of the distention, a digital or an ocular examinatiou may enable the 
operator to determine upon the propriety of opening the sac, and the process of 
introducing an exploring needle or trocar without making a cutaneous incision, 20 
with a view to detect gall-stones, being more liable to serious consequences, it 
is preferable that this plan of incision, with proper precautions, be adopted, so 
that the exploration and operation which may be indicated may be completed 
on the same occasion. 
If it is found requisite to open the sac, so as to discharge its contents 
externally, and the serous surfaces are not adherent, a portion of the adjacent 
wall of the gall-bladder should be hooked up with a tenaculum and secured with 
a cutaneous suture around the margin of the incision in the abdominal wall. The 
tissue included in the tenaculum may then be clipped out with scissors, offering 
thus a ready exit to the contents of the sac, after which the orifice of the duct 
may be sought with the finger so as to explore the canal entire with a probe. Should 
any communication with the duodenum exist, however small it may be, dilata- 
tion of the ductus choledochus should be attempted. But in the event of 
occlusion an effort may be made to pass a curved trocar along the obstructed 
tract, with a view to establish the canal, leaving the sheath until a fistulous 
communication is effected, with the inner end passmg into the intestine, and 
the outer extremity projecting from the superficial opening. 
Should this measure be found impracticable after evacuating the sac, whether 
it contains gall-stones or fluid matters, the opening in its walls may be detached 
from the abdominal incision, and yet retained under control by a thread passed 
with a needle like a drawing-string around the margin. Thus a finger may be intro- 
duced and bring the surface of the alimentary canal below the insertion of the 
duct in contact with a portion of the wall of the sac, so that a needle with an 
elastic ligature may be passed through the tissues of both, having their adjoin- 
ing surfaces united closely in the loop which constricts the inclosed walls until 
they are cut through, so as to leave a communication between the two, such as 
has been observed in the ulcerated opening of the gall-bladder into the upper 
portion of the small intestine. As the elastic ligature might divide the tissues 
without proper adhesion between the surrounding surfaces, a circular stitcliing 
should be made by alternately catching the wall of the sac and that of the intes- 
tine with a continuous catgut ligature, which would secure adhesion between 
their surfaces. This could be left for absorption, while the elastic ligature 
would naturally find its way into the alimentary canal, and the opening exter- 
nally may be dosed up, with the expectation that the bile shall find its way 
through the artificial connection into its proper channel for intermixture with 
the contents of the alimentary canal. 
Every step should be conducted so that none of the contents of the gall- 
bladder or the intestinal canal shall escape into the peritoneal cavity, and we 
should arrest an external fistulous discharge from the gall-bladder by closure of 
its walls separately from the union of the external incision. 
Notwithstanding the uncertainty of demonstrating surgical procedures upon 
inferior animals, I have undertaken some experiments upon dogs wliich are 
calculated to illustrate the practicability of uniting the walls of the gall-bladder 
and duodenum by an elastic ligature, and encircling this with stitches of cat- 
gut, so as to effect adhesion of the surrounding surfaces, when the opening is 
made by this constriction and cutting of the tissues. I have operated upon five 21 
dogs: on August 9th, 1884, No. 1 ; on the 11th, Nos. 2 and 3; on the 12th, 
No. 4, and on the 13th, No. 5. In case No. 3, on the 14th, the stitches being 
tom loose, perhaps by the tongue or teeth of the dog, the intestines were found 
upon the ground, and with indications of peritonitis. Being washed and re- 
turned, the wound was well closed with interrupted suture, and a broad bandage 
placed around the body of the animal. On the 15th this case was found to 
have died during the night, and the post mortem revealed the interesting facts 
that the elastic ligature had cut through entirely and disappeared in the intes- 
tinal canal, while the catgut continuous stitches used to approximate the adjacent 
surfaces of the gall-bladder and the duodenum had effected a slight adhesion. 
Upon stitching up the duodenum to the point of the opening it was evident that 
too much tissue had been included in the ligature, as the orifice was unnecessarily 
large; and in repeating this experiment I would suggest that the needle and liga- 
ture should only include so much of the respective walls as to secure an orifice 
from the cavity of the gall-bladder into the alimentary canal. While the escape 
of bile left the sac flaccid, there was no evidence of discharge into the peri- 
tonaeum, thus showing the efficiency of the mode of proceeding. 
The remaining four dogs are still alive, and there is a probability that some of 
them may survive, so as to afford an opportunity of testing the ligation of the 
bile-duct and turning the discharge altogether into the artificial opening, of 
which due notice will be given subsequently. 
Taking up the cases in the order of sequence, it may be stated that, after 
escape of omentum on two consecutive days from the tearing out of stitches, case 
No. 4 died on the afternoon of August 18th. A post-mortem examination re- 
vealed the gall-bladder full of bile, and the unknotted elastic strip was lying 
loosely upon the external surface of the duodenum, which presented a minute 
opening into the canal, with some tliickening of its walls adjacent to this orifice. 
Upon a close inspection of the gall-bladder, a small circumscribed portion of its 
surface was found to be adherent to the under surface of the left lobe of the 
liver, and the cicatrix of the wound by the ligation was soldered up by this ad- 
hesion. As the ligature had broken in the application of it originally upon tying 
the second knot, I infer that so soon as the tension ceased, by partially cutting 
through the tissues, it was unknotted by its own elasticity, and as in this case 
there was no circular stitching, the parts immediately separated, thus failing to 
present any solution of the single-ligature problem. 
The opportunity to verify a favorable result was lost by the escape of case 
No. 2 on the night of the 18th, which is a matter of regret, as this was the only 
subject that had no trouble with the external wound, and gave no indications of 
serious disturbances internally. 
On the 20th a puppy of three or four months was operated on, under the in- 
fluence of ether, by making an incision of two and a half inches and passing a 
silk ligature through a very small portion of the walls of the gall-bladder and 
duodenum, by which they were secured in close contact. But the circular 
stitching together of the serous surfaces around the ligature was not used in this 
case, and from the fact that bile tinged the discharge from the wound during the 
afternoon and subsequent morning, I am apprehensive that the silk thread, 22 
though doubled, may have cut out from the gall-bladder. The little animal has 
been playful since the second day, and eats heartily, so that I may have a cliance 
in this case to test the effect of ligating the gall-duct. 
Case No. 1 died August 23d, and although the external incision had not united 
at some points, the inner peritoneal wound seemed to be completely closed 
Upon laying it open considerable discharge of decomposed serum occurred, 
and upon tearing up the adhesions of the abdominal viscera a large abscess was 
opened lying at the posterior part of the right lobe of the liver. There were 
adhesions of the duodenum to the under surface of the liver, so as almost to 
conceal the site of the gall-bladder, which had undergone considerable degen- 
eration of structure, yet presented the internal and lower wall distinctly. The 
securely-knotted elastic ligature was found within its cavity near a fistulous 
opening that communicated with the duodenum, and the specimen is preserved 
illustrating the adhesion of the exterior surfaces, and the orifice through the 
agglutinated walls, which have a striking resemblance to a diminutive human 
mouth, with the mucous membrane of the duodenum reflected over the margin 
of the gall-bladder. 
In case No. 5 death ensued on the 24tli, as, notwithstanding all precautions, 
the wound had been torn open several times, and at last leaving the spleen and 
a large mass of the small intestine on the ground. There were adhesions of 
various tissues about the liver, and firm attachment of the duodenum to its under 
surface and to a portion of the wall of the gall-bladder, while in other parts the 
sac had undergone disintegration ; yet a well-defined opening from the duode- 
num into the gall-bladder resulted from the action of the elastic ligature. The 
slit presented the same characteristics as described in case No. 1, yet being a 
little longer, and the elastic ligature had disappeared in the intestine. The 
parts illustrating the fistulous communication and the surrounding adhesion are 
preserved in alcohol, so as to demonstrate the practicability of effecting this in 
the human subject, and in cases of degeneration and thickening of the walls of 
the gall-bladder there is less liability to take on destructive inflammation. 
The fistulous communication between the cavities of the gall-bladder and the 
duodenum effected by the action of the elastic ligature, and the adhesion around 
this opening caused by the continuous circular stitching of the adjacent serous 
surfaces, proves the correctness of the principle upon which I have proceeded 
in these experiments. The extension of inflammation to the gall-bladder in 
such form as to cause disorganization in No. 1 and No. 5 is not satis- 
factorily accounted for; and there was no evidence of such serious results to the 
walls of the gall-bladder in case No. 3, in which it was noted that the gall- 
bladder was entirely empty and flaccid, as the aperture in its wall joined to that 
of the duodenum gave a direct outlet to the bile, without presenting evidences 
of intense local inflammation. 
The fact is notable that the knotted ligature remained in the gall-bladder in 
No. 1 while it passed off in the canal in No. 5, depending doubtless upon 
the inclination of the knot to one or the other wall when tied. As the 
stitches placed in the incisions of the intestinal canal pass ordinarily into its 
cavity, it might have been supposed that the same thing would occur in this 23 
union of the gall-bladder with the duodenum, but quite a different principle 
operates in the two cases. In the case of suturing the incised wall of the 
abdominal canal alone, coagulable lymph is thrown out exterior to the site of the 
suture, so that it is protected on the outside and cuts its way into the cavity. 
But in the junction of the walls between two loops of intestine by a ligature no 
such process ensues, and in the miion of the bile-sac with the duodenum there 
is a division of the intervening tissues without any chance for such suppurative 
effusion, so that the ligature is most likely to go in the direction of the knot. 
It should hence receive special attention in tying the ligature, that the knot be 
drawn towards the wall of the duodenum, so as to have the ligature carried into 
the canal after the tissues in its loops are entirely divided. 
On the 28th the subject of the experiment for simple ligation of the gall- 
duct to the duodenum with a silk ligature, being case No. 6 that was operated 
upon on the 20tli inst., was found to be apparently free from all trouble. The 
external suture having been removed two days previously, and his jacket re- 
placed, the wound was well-nigh closed, excepting at the anterior extremity, 
where the silk thread used for continuous suture of the internal peritoneal in- 
cision came into view. This was caught with the dressing forceps and removed 
by cutting the knot. Perfect union was effected throughout this line, and no 
opening could be found for the entrance of the point of the director, so that 
a puncture wras made with the point of the bistoury" for this incision. 
The exploration revealed union of the gall-bladder and duodenum, with adhe- 
sions of the latter to the lower surface of the liver over the line traversed by 
the cystic gall-duct, so that it was not practicable to ligate it as was intended. 
Neither could the ductus choledochus be reached, and yet no doubt exists of the 
exit by opening between the gall-bladder and duodenum, as the small size of 
gall-bladder indicates that it is kept drained. 
Dr. W. S. Elkins, of this city, who has published some experiments on the 
liver, was with me in this examination of the result, and concurred in the con- 
viction that a communication had been effected. The original operation was 
made in the presence of Dr. J. A. Gray and Dr. W. G. Owens, so that all the 
stages of this successful experiment are thus verified by my colleagues. 
It should be stated that besides the persons named eleven other medical men 
have witnessed different steps in the various experiments; and I am under 
special obligations to Dr. K. C. Divine, who has very kindly co-operated with 
me in most of the cases. WITH THE COMPLIMENTS OF 
THE AUTHOR. 
ERRATA. 
Page 362, line 17 from top, for “ material” read natural. 
Page 362, line 23 from top, for “ destruction ” read distention. 
Page 362, line 22 from bottom, for “ of” read or. 
Page 364, line 13 from bottom, for “destruction” read distention. 
Page 366, line 12 from bottom, for “tremor” read tumor. 
Page 368, line 7 from bottom, for “circuitous” read concomitant. 
Page 370, line 10 from bottom, for “ 1S84” read 1881. 
Page 373, line 3 from bottom, for “ serious ” read serous. 
Page 378, line 21 from top, for “ 8th” read 3rd. 
Page 380, line 8 from tflf), for “ cutaneous ” read continuous. 
Page 380, line 8 from bottom, for “arrest” read avert. 
Page 381, line 11 from top, for “stitching” read slitting. 
Page 383, line 7 from top, for “ suppuration ” read subsequent. 
('Reprinted from “ Gail lard's Medical Journalf October, 1884. 
Gaston's Opebation, as it will hereafter be called, is well described in the article 
contributed by its originator in this number of the Joubnal. 
Most weli-informed physicians have been aware that, from a variety of causes, the 
duodenal or inferior extremity of the ductus communis choledochus becomes closed,pro- 
ducing a series of pathological phenomena too well known to require description. Dr. 
J. Marion Sims and others have endeavored, by the operation of cholecystotomy, or the 
establishment of a fistulous discharge of the bile externally, to correct the evils and 
remove the danger of a closure of the duodenal end of the common duct; but, as is well 
known, the operation has been attended with fatal results. But even had it for the 
time so far succeeded ns to secure the establishment of the fistulous discharge desired, 
all who are familiar with the physiological problems presented must realize that such 
success would be only apparent or temporary, and not real or absolute; as the outward 
dischage of the bile would practically so destroy nutrition, or so impair it, as to render 
death, as a rule, inevitable. Indeed, the fear of such a result must have deterred Hugh- 
lings Jackson, Petit, Thudicum, Langenback, Tait and others from performing the 
operation of cholecystotomy, for they have often discussed its feasibility, and have had 
abundant opportunity for performing it. Sims, it is well known, really did perform the 
operation, and with his usual enthusiasm hoped for wonderful results. He did not re- 
member, or apparently did not remember, that had he succeeded in saving the life of 
his familiar patient, death must have resulted finally from the diversion of the bile 
from the duodenum, with the consequent subversion of the digestive processes. 
It has occurred to Gaston, and only to Gaston, so far as is known, to establish for 
the bile a fistulous opening, not through the abdominal walls (cholecystotomy) with an 
external discharge, but through the walls of the sac and the neighboring intestine, the 
bile being thus delivered in the intestine and not externally. His method of accom- 
plishing this ingenious, great, novel, and original operation is carefully described in his 
paper, as published in this number of the Journal. 
Gaston has succeeded in his effort, and has created and contributed a new, bold, and 
life-saving operation. He is entitled to honor and distinction, and his countrymen and 
his brethren everywhere will fervently and cheerfully accord to him all that he so de- 
serves and has so fairly and fully won. 
Note—xn 34 chofecystotomies nine died soon afterwards. How many died from 
malnutrition subsequently no one knows.—Editob.