development of a hypostatic pneumonia prevented surgical interfer-
ence. With the subsidence of the pneumonia the gall bladder tumor
disappeared and a number of calculi were passed in the stools. Ten
days later marked septic symptoms developed with fluctuating tem-
peratures, necessitating urgent surgical interference.
On admission, November 17, 1901, the gall bladder was enlarged
(size of an egg), tender and painful; heart the seat of marked myo-
cardial changes; urine contained trace of albumin and few hyaline
casts; temperature 101.2°, pulse 100.
Immediate laparotomy ; cholecystostomy under chloroform and
ether. Deep-seated gall bladder surrounded by old adhesions, neces-
sitating careful dissection to expose it. Aspiration of the gall bladder
yielded very foul fecal pus, bile-stained, giving rise to the suspicion of
a communication between the gall bladder and colon. Incision of gall
bladder, evacuation of its contents and numerous calculi and gan-
grenous mucosa. On account of the swelling of the mucosa of th<-
cystic duct, fresh bile did not escape into the gall bladder. Drainage
by tube. Partial closure of abdominal wound.
'Required a secondary choledochotomy for common-duct obstruction due to
calculus.
"Discharged with a sinus; probably some obstruction in the ducts.
'Secondary operation.
'In one patient this was a secondary operation.
224 MOUNT SINAI HOSPITAL REPORTS.
Reaction from operation good ; temperatures never rose beyond
100 +", pulse rate between 100 and 112. Purulent discharge of fecal
odor from the gall bladder, mixed with profuse discharge of bile, con-
tinued for six weeks. Throughout the entire period of after-treatment
the patient was very nervous and exhibited indications of myocarditis
in an irregularity of the pulse. The al)dominal wound gradually con-
tracted and closed; the gall fistula closed by -January 1. On Januarj''
2 the patient developed a phle))itis of the right counnon iliac; this
gradually subsided. January 10. patient was iu excellent condition,
wound almost healed, and was preparing to leave for her home the next
day. Immediately after getting into bed in the evening she became
pallid and cyanosed : pulse failed, and. in spite of free stimulation,
death occurred within a few minutes.
Postmortem examination not permitted.
1902, vol. ii., page 274. Acute Gamjrcnous Cholerustitis; Chole-
cystostoniy ; Fncumonia; Death. — Bernard S.. 47 years old. had never
been ill until two days before his admission. wIumi he began to have
general abdominal pain, which localized itself to the right iliac fossa.
He had a severe chill at the onset, and another the following day.
Vomited repeatedly. No movement of bowels, in spite of cathartics
and enemata.
(^n admission, March 12, 1902, his general condition was good. In-
ternal organs normal. The abdomen was slightly distended ; right
rectus rigid; exquisite tenderness in right iliac fossa, extending into
the loin; no tumor could be felt. Rectal examination negative. Tem-
perature 108°. pulse 120.
Innuediatc laparotomy. (Jail bladdei- sun-ounded by adbesions.
Aspiration yielded foul-smelling, bloody fluid. Incision and evacu-
ation of purulent contents and calculi. Drainage of gall bladder.
Partial closure of abdominal wound.
Reaction from operation good. Fresh bile drained from gall blad-
der. Pneumonia of right lower lobe developed on ]\Iarch 14. from
which the patient succumbed on March 23. 1902.
1902, vol. ii., page 279. ('liolelithiasis; Einpiji nui of G<iU Bladder;
Cholemia; Cholecystostomy ; Nephritis; Death. — Elise G., 42 years old,
had suffered with vague gastric symptoms and attacks of biliary colic
for many years. The present attack was of eleven days' duration;
was attended with high fever, 10.3^-104°, a distended and painful gall
bladder, and jaundice.
On admission, December 5, 1901, the general condition was poor;
patient was slightly jaundiced; temperature 102.8°, pulse 120. The
abdomen was lax; gall bladder distended and painful. Urine acid,
1018, some hyaline and granular ca.sts and bile.
December 5: Operation. Gall bladder surrounded 1)y many dense
ndhesions; this viscus was tense; evstic duct much thickened; common
GERSTER : REPORT OP THE PIRST SURGICAL DIVISION — 1902. 225
duct empty. Pancreas normal. Aspiration of gall bladder yielded
mucus and bile. Incision and evacuation of numerous calculi and
gangrenous mucosa and mucus. Drainage.
At first patient did very well. The temperature declined ; bile was
freely discharged from the gall bladder. The jaundice persisted;
gradually her mental condition became clouded ; she passed very little
urine, became uremic, and died in coma on the seventh day.
1902, vol. ii., page 283. Calculus in Common Bile Duct; Obstructive
Jaundice; Choledochotomy ; Secondary Hemorrhage; Death. — Minnie
S., 40 years old, housewife, had suffered with numerous attacks of
biliary colic. During the last ten months these attacks were always
associated with jaundice ; attacks came on every ten days. She had
lost much flesh during this time.
On admission, October 13, temperature 103°, pulse 124. Patient
was in fair condition; was deeply jaundiced; liver somewhat enlarged;
gall bladder not felt; pain and tenderness over gall bladder. Urine,
acid, 1018 ; trace of albumin ; few casts. Was put upon calcium
chloride in thirty- grain doses three times a day. Temperature fluctu-
ated between 99 +° and 102°.
October 17 : Operation. Choledochotomy and drainage ; cholecystos-
tomy and drainage. Gall bladder contracted and contained several
calculi; surrounded by numerous adhesions. Common duct dilated
and contained numerous (seven) calculi. Hepatic ducts empty.
Drainage of common duct and gall bladder.
October 18 : Considerable oozing of blood from wound, saturating
the dressings.
October 19 : Bloody expectoration. Secondary hemorrhage from
wound in the evening. Exploration of the abdomen showed that this
came from the cystic artery, which had been divided at the first opera-
tion, and from the entire surface of the gall bladder. Hemorrhage
was easily controlled by suture.
October 20 : Repeated vomiting of bloody material.
October 21 : Oozing of blood from wound ; continued hematemesis.
Died.
No autopsy.
1902, vol. ii., page 282. Calculus in Common Bile Duct; Obstructive
Jaundice; Choledochotomy and Drainage; Persistent Gastric Hemor-
rhages: Death. — Mary G., 44 years old, housewife, had suffered from
attacks of epigastric pain at frequent intervals for the past year, one
attack accompanied by jaundice. Three months before she had a
severe attack of pain, followed by jaundice ; the latter had persisted
ever since ; it varies in degree from time to time. Had several chills
during this time ; lost considerable weight and strength.
On admission, October 30, 1902, she was deeply jaundiced but in
fairly good condition; internal organs normal; pulse soft and slow.;
hemic murmur at base and apex of heart. Liver somewhat enlarged ;
226 MOUNT SINAI HOSPITAL REPORTS.
gall bladder not felt and not sensitive. Temperature 98.8°, pulse 88.
Urine normal. At once patient put upon calcium chloride, thirty
grains every four hours.
November 3 : Operation. Choledochotomy and drainage ; chole-
cystostomy and drainage. Gall bladder contracted, surrounded by
adhesions and containing numerous calculi ; common duct dilated and
contained one movable calculus. No calculi in hepatic ducts. Chole-
dochotomy and cholecystostomy, removal of calculi, and drainage.
November 4 : Vomited considerably ; some oozing of blood through
the dressings.
November 5 : Vomiting continued in spite of lavage. Vomitus con-
tained blood.
November 8 : Vomited bright-red blood several times. Died. Tem-
perature never above 102° ; pulse rapid, 116-120-140. No evi-
dences of peritonitis.
No autopsy permitted.
A REPORT ON 66 OPERATIONS FOR CHOLELITHIASIS UPON 61 PA-
TIENTS TREATED DURING 1898 AND 1899 IN THE ENTIRE
SURGICAL SERVICE AND DURING 1900, 1901, AND 1902
IN THE FIRST SURGICAL SERVICE OF THE
MOUNT SINAI HOSPITAL.
By a. a. Berg, M.D.,
ADJUNCT SXJRGEON.
In the entire surgical service of jVTount Sinai Hospital during 1898
and 1899, and in the First Surgical Division during 1900, 1901, and
1902, we have operated upon 61 patients for cholelithiasis and its com-
plications. Upon these 61 patients 66 operations were performed, with
a mortality of 18, or 29 -|- per cent. This high mortality needs a few
words of explanation. It teaches in itself an important lesson to those
who never advise surgical interference until the patients have be-
come exhausted by the pain of repeated attacks of colic, or septic from
cholangitis or suppurative inflammation of the gall bladder. The
patients who come to the Mount Sinai Hospital are not of the class
who select a quiescent period of their disease as a most fitting time for
operation ; they prefer, as a rule, to Avait until threatening manifesta-
tions of intense sepsis, arising from cholangitis, gangrene, or empyema
of the gall bladder, etc., compel them to seek the surgeon's aid. Thus,
of our 61 patients, 19 had empyema of the gall bladder, 4 extensive
GERSTER: REPORT OP THE FIRST SURGICAL DIVISION — 1902. 227
gangrene, 6 obstructive jaundice at the time of their admission. Only
20 were admitted in, or could be tided over into, a quiescent interval
of the disease.
This delay in resorting to surgical interference until the exigencies
of the case urgently demand it, accounts for the wretched physical
condition in which our patients come to the hospital. They are mostly
emaciated, nervous, and exhausted from their oft-repeated and pro-
longed attacks of pain, fever, and jaundice ; their tissues frequently in
a condition of fatty and hyaline degeneration, their kidneys function-
ally bad, and their hearts very often the seat of chronic interstitial
changes. This accounts for the three deaths from collapse immediately
or shortly after operation, even though the latter was not severe or
unduly prolonged. Further, the resisting power of their tissues is so
bad that bacteria which are present in the gall bladder find a favor-
able soil for rapid increa,se and development; thus 8 cases of rapid
and fatal septicemia, with no peritonitis arising from septic foci in the
gall bladder or ducts, occurred during these five years.
These facts show conclusively that if good results are to follow the
surgical treatment of this disease, the patients must be operated upon
early. In a previous communication the writer has stated the indi-
cations for the medical and surgical treatment to be as follows.^
Medical Treatment. — Cholecystitic pain or attacks of biliary colie^
in either case unattended with fever.
Surgical Treatment. —
1. Operations of choice, undertaken in the quiescent period; mor-
tality, 2-3 per cent.
(a) Severe cholecystitic pain or oft-repeated, uncomplicated at-
tacks of biliary colic, persisting in spite of medical treat-
ment.
(h) After the first attack of acute cholecystitis attended with
fever.
2. Compulsory operations, undertaken at any time of the day or
night, often amid unfavorable surroundings ; high mortality.
(a) Foudroyant or intensely acute attacks of cholecystitis.
(h) Hydrops, empyema, gangrene, or perforation of gall bladder;
cholemia ; abscess of liver ; diffuse peritonitis.
We do not advise surgical interference at the first attack of chole-
cystitic pain or biliary colic. We base this action upon our knowledge
'Medical Record, 1902.
228 MOUNT SIXAI HOSPITAL REPORTS.
of the genesis of the lesions that follow upon cholelithiasis. Calculi
themselves do not give rise to any alterations in the gall bladder ; the
pathological changes are dependent upon a secondary or mixed in-
fection of this viscus. A primary infection, of a diminished virulence,
coupled with stasis of the bile, determines the formation of calculi
within the gall bladder ; a secondary infection of varying intensity of
virulence determines the acute and chronic inflammatory conditions
that result in marked structural alterations and general septic intoxi-
cation. The calculi, as foreign bodies in an irritable viscus, may excite
cholecystitic pain or biliary colic ; the secondary infection gives rise
to hydrops, empyema, gangrene, cholangitis, etc.
^Medicinal, dietetic, and hj-gienic therapy usually succeed in re-
lieving the pain and colic in uncomplicated cases ; surgical interference
will only be called for when the pain is continuous and severe and is
not benefited by general therapeutic measures. The addition of a
secondary infection in a gall bladder the seat of calculi marks a strong
indication for surgical interference. Our experience teaches us that
sooner or later such a secondary infection will give rise to such
severe local lesions and general intoxication as to demand operation.
If the onset of severe local and general disturbances is to be forestalled,
recourse to operation must be made as soon as possible after the in-
ception of a secondary infection of the gall bladder.
AS TO OPERATION IN THE ACUTE ATTACK OR DURING A QUIESCENT PERIOD.
The surgeon naturally prefers to operate during a quiescent in-
terval. At such a time the mortality is considerably less, and the
search for stones in the gall bladder and ducts can be made much more
thoroughly and satisfactorily. It is in the operations performed dur-
ing an acute seizure that calculi are left behind in the gall bladder and
ducts, necessitating secondary operations for their removal.
The gall bladder is not to be compared to the appendix vermiformis
in regard to the urgency of operative interference during an acute
period of inflammation. The walls of the latter organ, poor in mus-
cular and elastic fibres, can distend very little to accoimnodate the
products of inflammation that accumulate in it. With its orifice of
exit closed, the rising tension of these confined products is very likely
to result in perforation. The gall bladder, on the other hand, is rich
in elastic and muscular tissue ; its walls readily stretch and its cavity
distends to accommodate the inflammatory exudates : perforation is
GERSTER: REPORT OP THE FIRST SURGICAL DIVISION — 1902. 229
therefore comparatively rare. Whereas, early operation is necessary
in acute appendicitis, in order to forestall perforation, such action is
not often required in acute cholecystitis. Immediate surgical inter-
ference is chiefly called for in the face of an advancing septic condi-
tion or in extreme distension of the gall bladder ; otherwise it is usually
safe to wait for a subsidence of the acute manifestations and operate
during the quiescent period.
THE LATE RESULTS AFTER GALL-STONE OPERATIONS.
The subsequent histories of most of the hospital ward patients can-
not be ascertained ; they have either changed their places of residence
or do not respond to our letters of inquiry. However, as a rule, we
have found that our patients return to the hospital for examination,
if they suffer from a recurrence of the old malady.
Of those returning to the hospital in this way, a number complained
of dragging, dull pain in the right hypochondriac regions. The pain
did not radiate ; they stated that it was of an entirely different char-
acter from that Avith which they had previously suffered. These
patients while under our observation never had an attack of biliary
colic; no stones were passed in their stools; they were not jaundiced.
After a time the pain became very much less; we considered it was due
to the adhesions around the gall bladder and ducts. In a number of
cases post-operative hernia through the scar followed. The herniae
were reducible in most of the cases. Radical operation was only once
required, the hernia and its attendant unpleasantness being easily con-
trolled by a well-fitting abdominal belt.
Six of the patients in this series had to be reoperated to remove
calculi from the cystic or common bile ducts that had not been taken
out at the first operation. In 4 of these cases the stones were impacted
in the cystic duct ; in 2 of the latter a previous cholecystostomy in two
stages, and in 2 a cholecystostomy in one sitting, had been done ; the
impacted calculi could be easily felt with a probe introduced through
the fistula in the gall bladder.
Another case, in which cholecystostomy had been done for em-
pyema, returned to the hospital after several months with a diffuse
purulent peritonitis originating in a rupture of a recurrent empyema.
The gall-bladder fistula had completely closed, but the common duct
was obstructed by a large calculus, which prevented the free discharge
of gall-bladder secretions and bile into the duodenum. Immediate
230 MOUNT SINAI HOSPITAL REPORTS.
laparotomy and drainage of the ruptured gall bladder and cleansing of
the peritoneum saved the patient's life; and at a third operation the
common-duct stone was removed, the patient making an uneventful
convalescence.
In the sixth patient a cholecystostomy and cysticotomy had been
done two years prior to her readmission to the hospital, when she
presented all the indications of eomm.on-duet obstruction. The gall-
bladder fistula had healed. Exploration revealed an impacted stone
in the choledochus.
In the above patients there can be no doubt that the calculi which
were removed at the second operation were present in the ducts when
Ihe first operation was performed. In 2 cases in which cholecystos-
tomy in two stages had been done, the calculi could be felt impacted
in the cystic duct when the gall bladder was opened. Though their
dislodgmcnt was repeatedly attempted, the efforts were not successful.
In the other 2 cases of cholecystostomy evidence of the presence of
obstruction in the cystic duct was afforded by the persistent patency of
the gall-bladder fistula.
In the 2 cases in which at the secondary operations calculi were
found in the common duct, the gall-bladder fistula had remained
open for a long time. One patient remained well only eight
months after its closure, when a rupture of the gall bladder
occurred ; in the other the fistula closed only after seventeen months,
and from the time of its closure the patient complained of repeated at-
tacks of biliary colic, chills, and fever. It is to be noted in these last
2 cases that the gall-bladder fistula closed some time after the primary
operation — in one seventeen months, in the other about five months.
Neither of these patients presented the symptoms of, or gave a history
of, attacks of obstructive jaundice. The tardy closure of the gall-
bladder fistula would indicate that the obstructing calculi were at
first lodged in the cystic duct, and when they had passed into the
common duct the gall-bladder fistula closed. Our experience would
soem to show that obstruction in the common duct, unless it be a very
firm impaction, does not interfere with closure of a gall-bladder fistula ;
v/hereas an obstruction of the cystic duct, where firm impaction is the
rule, prevents such closure. Reference to this point will be made
under cholecystostomy. To our knowledge, only one of the other pa-
tients in this series presented evidences of a return of symptoms due
to the presence of calculi in the gall bladder or ducts: furthermore.
GERSTER: REPORT OF THE FIRST SURGICAL DIVISION — 1902. 231
in all but this one of the remaining patients no biliary fistula remained
after the primary operation. We must conclude, thej-efore, that a
re-formation of calculi after they have been once completely removed
must be a very rare occurrence ; in this our experience coincides with
that of Kehr. After a close investigation into the subsequent histories
of patients operated upon by him for cholelithiasis, he was un-
able to find any instances in which a true re-formation of calculi
occurred. In all his cases that presented evidences of new formation
of calculi, he was able to prove that such calculi had been present at
the time of the first operation, and had either been overlooked by the
surgeon or their removal was deemed inadvisable on account of the
poor condition of the patient or extensive adhesions around the ducts.
To avoid the repetition of this most disagreeable occurrence — viz.,
the overlooking of calculi in the bile ducts — we have of late folloAved
in all our cases the following procedure : After opening of the ab-
domen the gall bladder is exposed and examined. » If it is very tense,
its contents are withdrawn with an aspirating needle, the puncture
opening being then closed with a suture or clamp. This relief of ten-
sioii within the gall bladder renders palpation of this viscus and the
ducts much more easy and satisfactory. The exploring hand is then
introduced into the abdomen along the under side of the gall bladder,
and carried along the cystic and common bile and hepatic ducts.
Where these structures are surrounded by adhesions the latter are
divided until all the ducts are freely accessible. By rolling
them between the fingers the smallest calculi are easily and
readily located. In this way we ascertain at the very begin-
ning of the operation the exact site of any calculi within
the gall bladder and ducts; the hepatic ducts beyond the
portal fissure of the liver cannot be palpated, and must, in case
calculi are suspected in them, be probed to ascertain the presence of
the latter. To make our exploration of the gall bladder more certain
— for small calculi may, even Avith this procedure, escape detection —
we always palpate the interior of the gall bladder after it has been
incised ; should the patient 's condition or the presence of numerous
adhesions around the ducts make it more advisable to postpone the re-
moval of impacted stones in the cystic, hepatic, or common ducts to a
subsequent time, we are in a position to know that a secondary opera-
tion Avill be necessary.
'Ueber Recidiv bei Gallensteinkrankheiten. Langenbeck's Archiv.
232 MOUNT SINAI HOSPITAL REPORTS.
OPERATIONS UPON THE GALL BLADDER AND DUCTS.
Abdominal Incision. — We usually employ a straight longitudinal in-
cision through the fibres of the right rectus muscle, commencing at the
costal arch and extending downward for three or four inches, preserv-
ing intact the seventh and eighth dorsal nerves that pass across this
field. Where more room than is afforded by this incision is required
{e.g., in very obese subjects), this is obtained by making a second
transverse incision at right angles to the first one and bisecting it.
In very obese subjects, and in those in whom the liver occupies a high
position, a transverse incision below the costal arch is made. This af-
fords excellent access to a contracted, deeply seated gall bladder and
ducts, and does away with the necessity of resecting any of the costal
cartilages. Post-operative herniai do not very frequently follow even
extensive incisions in this part of the abdominal wall. We have seen
several small hernia} in very much relaxed and obese subjects.
The closure of the abdominal wound is made by layer sutures of
t'hromicized catgut. In very fat subjects the layer suture is rein-
forced by several through-and-through silk sutures. Such through-
and-through sutures have very frequently, in our experience, given
rise to extensive stitch-hole abscesses, and even phlegmons. Though
recognizing this great objection to their use, we do not dispense with
them, because we have found nothing else to afford sufficient guarantee
against a bursting open of the wound.
Cholecysiosiomy . — ^Was performed 88 times, with 27 recoveries and
11 deaths. Of these, 27 were done during the acute period, and 10 of
them succumbed — two in collapse shortly after the operation, the other
from a more or less rapid but progressive septicemia, no peritonitis.
This would indicate that even a simple surgical procedure, performed
at a time when there is a virulent infection of the gall bladder and
ducts, is attended with great risks. It would seem as if the operative
interference increased rather than diminished the intensity of the
infection. The question naturally arises as to the advisability of per-
forming cholecystostomy in the acute cases. We know that the simple
incision and drainage of purulent collections or gangrenous areas in
other organs — e.g., the kidney or appendix — is not attended by results
as good as those which the immediate removal of the affected organ ac-
complishes. The much-inflamed, often gangrenous organ, whose vitality
is further impaired by the necessary operative manipulations, is an