excellent culture ground for the bacteria which are present, and their
GERSTER: REPORT OF THE FIRST SURGICAL DIVISION — 1902. 233
virulence is very apt to be much increased. Drainage of the gall blad-
der is often very unsatisfactory, on account of the numerous diverti-
cula and sacculations that result from ulcerations and cicatrices within
its cavity. Insufficient drainage and retention of the products of
bacterial life result in a progressive septic intoxication to which
the patients finally succumb. During the past year we have in three
acute cases performed cholecystectomy. The three cases made a
smooth and uneventful recovery. Naturally all acute cases are not
suitable for cholecystectomy ; for the separation of numerous and dense
adhesions may spread the infection in the gall bladder to the ducts and
peritoneum, or it may be too formidable a procedure for a debilitated
or already septic patient to endure. It does seem, however, as though
primary cholecystectomy would give better results than simple evacu-
ation and drainage.
Technique of Cliolecystosiomy. — After opening the abdomen, the
gall bladder is isolated and the surrounding adhesions divided. The
contents of the gall bladder are then evacuated by an aspirating
syringe, and the puncture opening temporarily closed by suture or
ciamp. The gall bladder and ducts are then carefully palpated and
the presence of any calculi noted. The gall bladder is then incised at
its fundus and the calculi within it removed. A large-sized tube is
put down to the bottom of its cavity and the edges of the opening in-
verted around the tube by several roAvs of purse-string catgut sutures
{a la Kader), as suggested by Kehr. The gall bladder is then at-
tached to the anterior parietal peritoneum, and the outer wound closed,
except at site of emergence of the drainage tube. The latter is re-
tained in situ by a rubber tube which fits snugly over it, and which is
split into two lateral halves for two-thirds of its extent ; the lateral
halves being fixed to the skin by strips of adhesive plaster. The dis-
charges are carried away to a bottle hanging at the side of the bed,
thus preventing soiling of the outer dressings. Drainage is main-
tained until the bile appears sweet and clean and the interior of the
gall bladder takes on a healthy appearance. "Where the gall liladder is
deeply placed and cannot be brought up to the abdominal wall, the in-
terval between it and the parietes is packed with gan/e. which is made
to surround the drainage tube.
The operation is never done in two stages. The objection to this
procedure lies in the fact that where stones are impacted in the orifice
of the cystic duct, they cannot l)e dislodged, and secondai-y operations
234 MOUNT SINAI HOSPITAL REPORTS.
become necessary for their removal. In two of the four cases in Avhich
cholecystostomy was done in two stages, impacted stones were felt in
the orifice of the cystic duct, but could not be dislodged through the
fistula ; secondary operations were required. A persistent fistula dis-
charging mucus was observed in seven of the cases. In four of these
secondary operations revealed an impacted stone in the cystic duct.
In a fifth case, the persistence of a gall-bladder fistula, discharging
mucus, convinced us of the existence of an obstruction in the cystic
duct. Secondary operation was advised, but declined by the patient.
The fistula has persisted now for nearly five years, constantly dis-
charging mucus ; recently a carcinoma of the gall bladder developed.
AVith the old method of performing cholecyst ostomy, in which the edges
of the incision into the gall bladder were attached to the fascia or skin,
fistulas were frequent, due to the mucosa of the gall bladder growing
out and lining the margins of the drainage canal. Such fistulse had
no dependence upon obstruction in the ducts, and could be closed by
plastic operations.
The persistence of a gall-bladder fistula seems to depend upon a
complete closure of the cystic or common bile duct, either by calculi or
strictures or kinks or external compression. As calculi in the common
bile duct are not apt to be firmly impacted therein, but fioat up and
down, according as it is distended or empty, they rarely cause a
jjermanent complete closure of its lumen. The bile and secretions from
the gall bladder from time to time are afforded free discharge into the
intestine. Calculi in the cysticus, on the other hand, are very likely,
from the structure of the duct, to become firmly wedged at one point
and completely obstruct the channel. Our experience would go to
show that where the persistence of the fistula is due to the presence of
calcidi in the ducts, the site of such calculi is in the cysticus. In two
cases in which a fistula persisted for five and seventeen months, respect-
ively, and then closed spontaneously, the calculi were found to occupy
the common bile duct. It is more than probable, however, that these
calculi originally and during the time of the persistence of the fistula
were lodged in the cysticus, and that when they passed on into the
choledochus the fistulffi closed. This assumption is strengthened by
the fact that the fistulas did not discharge pure bile, but a bile-stained
mucus, showing that the cysticus was obstructed.
Cholecystectomy. — "Was performed 6 times, with 5 recoveries and
GERSTEB: REPORT OF THE FIRST SURGICAT. DIVISION — 1902. 235
I
1 death. The Mayo operation (extirpation of the mncous membrane
of the gall bladder) was done 8 times, with no death.
Indications. — The Mayo operation is an excellent one in quiescent
cases. It does not replace cholecystectomy in gangrenous or sup-
purative cholecystitis, nor in those cases in which the inflammatory
pi'ocess has extended beyond the lining mucosa of the gall bladder.
It is especially valuable in those cases in which, as the Mayos suggest,
it is desired to remove the gall bladder and drain the ducts at the same
time. In an ordinary cholecystectomy the cystic duct is closed by
ligature ; if drainage is desired it is found very difficult to retain a
tube in the cystic duct. In the Mayo operation the facilities for drain-
age are just as good as in an ordinary cholecystostomy, as the muscular
tunic of the gall bladder affords an excellent pouch for collecting the
secretions of the cystic and hepatic ducts, whence they are readily and
easily conducted away. We would reserve the ordinary cholecystec-
tomy for the acute cases of gangrenous or suppurative cholecystitis,
employing the Mayo operation in the quiescent cases, with deeply-
seated gall bladders, in which, besides removing this viscus, we desire
to establish drainage of the hepatic and cystic ducts.
Technique of Operation. — Our method of performing cholecystec-
tomy is as follows: A flap is formed on either side of the gall bladder,
of its peritoneal covering, which serves to cover the bed of this viscus
after its ivmo^^al. The organ is then freed from its attachment to
the liver: likewise the cystic duct. The cystic artery and duct are
separately tied with catgut, and the gall bladder amputated distally
to these ligatures. A small cigarette drain is passed doAvn to the
stump. C'losure of the abdominal wound in layers.
OPERATIONS UPON THE DUCTS.
Cysficoionnj. — Was done 4 times, with 3 recoveries and 1 death.
The duct was drained in all cases ; no permanent flstula remained. In
all the eases the cysticotomy was a secondary operation, cholecystos-
tomy l>eing done primarily. Had cholecystectomy been done primarily
these calculi could scarcely have been overlooked.
C^ombined cholecystostomy and cysticotomy was done in 2 cases;
both succumbed, one in collapse shortly after the operation, the other
from a rapid septicemia without peritonitis. It seems that operations
T.pon the cystic duct, when it is deeply seated and surrounded by ad-
hesions, are not well borne. The mobilization of the duct sufficient to
236 ilOUXT SIXAI HOSPITAL REPORTS.
enable the operator to incise it is deeply shocking ; furthermore, drain-
age is unsatisfactory^, for the tube is very likely to be displaced. In
acute cases it is much better to perform a cholecystectomy and then
split up the entire length of the cystic duct, and in the quiescent cases
to incise the gall bladder and eystieus throughout their entire extent,
remove the calculi, and extirpate the mucosa of the gall bladder, leav-
ing the muscular tunic of the latter to serve as an aid to drainage.
Choledochotomij . — AVas done 4 times; all recovered. In one of the
eases a previous cholecystostomy and in another a primary cystieotomy
had been done. Combined choledochotomy and Alayo's operation was
done twice; both recovered. Combined cholecystostomy and chole-
dochotomy was done 4 times : 2 recovered, and 2 died from con-
tinued capillary hemorrhage. Combined cholecystectomy and chole-
dochotomy was done once, death being due to continued hemorrhage.
Simple or combined choledochotomy was therefore done 11 times, with
3 deaths from continued capillary hemorrhage.
Hemorrhage in Jaundiced Valienls. — Persistent and uncontrollable
capillary hemorrhage has been, and continues to be, the most lament-
able sequela to operations in deeply jaundiced subjects. It is espe-
cially apt to follow when the cause of the jaundice lies in a malignant
obstruction of the bile ducts. Its cause has been put down to a re-
tarded coagulating capacity of the blood. It has been urged to im-
prove this coagulating time of the blood by the internal administration
of calcium chloride. Following this suggestion we have systematically
administered the calcium salt in small and in large doses, and have iij
all cases given it at least one week before operation. Yet during the
past year two of our cases succumbed from a persistent, uncontrollable
capillary hemorrhage.
It seems to us that the cause of this continued, uncontrollable capil-
lary oozing lies not so much in the retarded coagulation of the blood
as in a fatty degeneration of the walls of the arterioles, which inter-
feres with their contraction and retraction. Physiology teaches that
the cessation of hemorrhage is due to two causes: chietiy and pri-
marily, to the contraction and retraction of tlie arterioles into their
sheaths, and, secondarily, to the clotting of the blood. It is hardly
possible that a retardation in the coagulating time of the blood should
be responsible for the persistent oozing that occurs in these cases ; were
this alone the cause we would expect that firm pressure over the bleed-
ing part would arrest the oozing until coagulation occurred and
GERSTER : REPORT OF THE FIRST SURGICAL DIVISION — 1902. 237
permanently checked the hemorrhage. This is not the case; the bleed-
ing goes on in spite of pressure and in spite of coagulation, which can
be rapidly induced by styptics, the actual cautery, etc.
On the other hand, it is well kno\\Ti that chronic jaundice causes an
atroph}^ of all muscular tissue. Such atrophy of the muscular coat
of the arteriole interferes materially with its contracting power.
The arteriole, when divided, does not contract and retract within its
sheath ; its orifice remains patent, and no clot can remain firm over it,
for the arterial pressure behind the clot forces it off as soon as it forms
To support the pressure there is need not only of a clot, but of a
contracted and retracted arteriole.
If this explanation of the causation of continued hemorrhage be
true, we would expect that the longer the duration of the jaundice
the greater would be the tendency to bleeding, for the atrophy should
be more marked. This is exactly so, as every surgeon has experienced.
Furthermore, we should expect that as cancerous cachexia, chronic
sepsis, and other debilitating influences add a fatty or waxy degenera-
tion of the tissues to the atrophy, patients suffering from such con-
ditions would be more apt to bleed than those who suffer from chronic
jaundice alone. This, again, is substantiated by experience.
If we accept this degeneration of the blood vessels as the cause of
this most terrible complication to operations upon such patients, we
can readily account for the absolute failure of all therapy, including
the administration of the calcium chloride, to check the hemorrhage.
We shall have to expect that from time to time Ave shall encounter
cases in which death will follow from persistent bleeding.
Technique of Clwledocliotomy.—X firm, hard, round cushion is
placed across the lower dorsal region ; the common duct is thus brought
nearer to the anterior abdominal wall, and all the manipulations are
thereby rendered much easier. The duct is then exposed and rolled
between the fingers until it alone is grasped, the portal vein and
liepatic artery being displaced to either side. The calculus is steadied
between the index and middle fingers of the left hand, and the wall of
the duct incised over it. The stone is removed Avith forceps or scoop.
In only tAvo of our cases Avas the duct sutured ; no leakage of bile f ol-
loAved. In all the others the duct was drained. Should the stone oc-
cupy the retroduodenal part of the duct, it is displaced upAvard to the
free portion of the latter as it lies in the gastrohepatic omentum. We
have not had occasion to practise transduodenal eholedochotomy.
238 MOUNT SINAI HOSPITAL REPORTS.
R'etroduodenal Choledochotomy . — Transduodenal choledochotomy,
first suggested by McBurney, is an operation by which, according to
the statement of those who have employed it, the removal of impacted
stones in the retroduodenal and papillary portions of the common bile
duct is readily and satisfactorily accomplished. Yet it is a procedure
that is attended with sufficiently grave risks to cause us to resort to its
use only when all other methods of removing the calculus from the
choledochus have failed. The opening of the duodenum is always a
serious procedure ; the danger lies not so much in the possibility of
peritoneal infection as in the insufficiency of the closing sutures. A
very slight leak tends to become larger, spontaneous closure is most
unlikely, and death from inanition would be the natural consequence.
The writer knows of one such case in which, after a transduodenal
choledochotomy, a leak in the duodenum oceurred and death from
inanition resulted. Such insufficiency of the suture line cannot be at-
tributed to an improperly placed suture; for it must be remembered
that in these cases of long-standing, impacted calculi in the gall blad-
der and ducts, the peritoneal covering of these parts has been re-
peatedly inflamed, numerous adhesions have formed, and the peri-
toneum has lost to a considerable degree its quality of adhesiveness.
This alteration in the peritoneum accounts for the failure of a very
carefully and well-placed suture to effect a perfect closure of the
duodenum. To obviate the necessity of opening the duodenum, the
writer has thought of a retroduodenal route of attacking the retro-
duodenal and papillary portions of the common duct. This idea waS
strengthened materially by a recent publication of Kocher's in the
Centmlhlatt filr Chirurgie, 1903, No. 2: " Mobilisierung des Duoden-
ums und Gastroduodenostomie. ' ' For the purpose of establishing
gastroduodenostomy, Kocher has practised the mobilization of the de-
scending portion of the duodenum, by which the latter is rotated
around a longitudinal axis passing along its inner border. The entire
posterior surface of this portion of the duodenum, and the retro-
duodenal structures, among which is the retroduodenal portion of the
common bile duct, are thus exposed. The duct can here be grasped be-
tween the fingers, incised, calculi removed, and either sutured or
drained.
The technique of mobilization of the duodenum, as given by Kocher,
is as follows : Three or four cm. external to the right border of the
GERSTER: REPORT OF THE FIRST SURGICAL DIVISION — 1902. 239
duodenum the posterior parietal peritoneum is incised in a longi-
tudinal direction, extending from the flexure of the duodenum above
to the transverse mesocolon below. The left side of the divided peri-
toneum is then elevated with the finger up to the right border of the
duodenum. The finger now passes behind the duodenum, separating it
from the vertebrge, inferior cava, and aorta, up to its inner border.
The descending duodenum is then rotated U. the left around its longi-
tudinal axis, thus exposing the common bile duct from the duodenal
IJexure to its entrance into the duodenum. The pancreaticoduodenal
artery lies anterior to the duct and separated from it about one-quarter
of an inch. The accompanying veins lie just behind the duct ; in some
instances a branch of the vein crosses the duct just above its termina-
tion. The superior mesenteric branch of the portal vein lies con-
siderably internal to the duct, and the vena cava is posterior to it.
The duct is easily recognized; it can be grasped between the fingers,
incised, and the impacted calculus removed. The site of the incision
into the duct should be drained by a wick of gauze, and the duodenum
allowed to fall back into its normal position; the choledochus is then
incised higher up as it lies in the gastrohepatic omentum, and a tube
inserted into this opening, thus establishing drainage of the hepatic
ducts. The incision into the retroduodenal and papillary parts of the
duct should not require suture.
The writer has had no opportunity to test the value of this opera-
tion in the living subject. By the kindness of Dr. Gallaudet. of the
College of Physicians and Surgeons, an opportunity was afforded liim
of testing its feasibility upon the cadaver.
It was especially noted that the peritoneum in this region, and the
descending portion of the duodenum, is very loosely attaclied to the
posterior parietal wall, and its mobilization and reflection inward
was easily and readily accomplished. In a subject with the arteries
well injected, no vessels of any importance were encounteird. The
pancreaticoduodenal arteries lie about one-quarter of an incli in front
of the duct and run in a course parallel to it. A small vein crosses tlie
duct just before its entrance into the duodenum. The exposure of the
retroduodenal structures was excellent and the manipulations with thft
duct easily carried out. Upon the cadaver the operation appears to be
an eminently satisfactory method of access to the retroduodenal and
papillary portions of the choledochus.
240 MOUNT SINAI HOSPITAL REPORTS.
DISEASES OF THE PANCREAS i CASES; 2 DEATHS.
H C ^ - Q
Acute pancreatitis' 1 . . . . . . 1
Chronic pancreatitis and hepatitis; jaundice.... 1 1
" " jaundice 1 1
Carcinoma of pancreas 1 . . 1
Operations for Diseases of Pancreas — 3 ; 1 Death.
Cholecystendesis 2 1 1
Exploratory laparotomy for carcinoma 1 .. .. .. 1
The two patients with clironic pancreatitis and jaundice gave the
following histories :
1902, vol. ii., page 294. Chronic Pancreatitis and Hepatitis; Jaun-
dice; Cholecystendesis; Cured. — Annie L., 45 years old, admitted
August 7, 1902. Two years before, had an attack similar to the
present one; it was marked by jaundice, chills and fever, and consti-
pation ; it lasted four weeks. Since then she was well uj) to four weeks
before her admission. She was then taken sick with pain in right
hypochondrium, had repeated chills and fever, and became jaundiced.
Was constipated, and vomited at times.
On her entrance to the hospital physical examination showed her to
be in fair condition, intensely jaundiced; temperature 103.4°; lungs
normal; systolic murmur over apex and precordial region; liver slight-
ly enlarged; spleen normal; abdominal wall rigid; marked resistance
below liver ; gall bladder not felt.
August 7-15: Temperatures fluctuated daily between 100° and
102+°- Jaundice diminished somewhat. Urine contained albumin
and casts.
August 12: Had a chill. Diagnosis: Cholelithiasis: stone in com-
mon duct; cholangitis. Was put upon calcium chloride, grs. xxx.. on
her admission.
August 15 : Laparotomy. Right lobe of liver studded on its under
surface with many small, hard nodules. Gall bladder surrounded by
adhesions, otherwise normal; contained no calculi; no calculi in ducts;
latter surrounded by few adhesions. Head of pancreas was harder
and more nodular than normal; no neoplasm could be made out.
Separation of adhesions around gall bladder and ducts. Closure of
abdominal wound.
'Not operated.
GERSTER: REPORT OF THE FIRST SURGICAL DIVISION — 1902. 241
Convalescence uneventful. Temperature subsided to normal after a
week. Jaundice and tenderness in right hypochondrium disappeared.
General condition improved. Discharci:ed cured September 27.
Subsequent History. — Patient remained well for four months, then
became jaundiced again, with fever and chills; had disgust for meats;
no sugar in urine.
1902, vol. ii., page 301. Chronic Pancreatitis; Obstructive Jaun-
dice; Exploratory Lapa^'otomy ; Improved. — Israel G., 37 years old,
had a slight attack of jaundice, with pain in right hypochondrium, five
years ago. This lasted one week. Had a similar attack six months
ago. The present illness commenced two weeks before his admission
on April 23, 1902, marked by jaundice and pain in right hypochon-
drium; stools clay-colored; no vomiting; no chills or fever; lost 20
pounds in weight in last six months.
On admission there was noted : Internal organs all normal. Indis-
tinct mass in the right hypochondrium, not especially tender ; appears
to be continuous with liver. Leucocytes, 11,000. Temperature 100°-
101°. Urine: albumin, casts, no sugar.
From April 23 to May 2 jaundice gradually increased; no new
physical signs appeared.
May 2, 1902 : Exploratory laparotomy. Liver enlarged downward ;
surface and free margin smooth. Gall bladder small and contracted.
Behind the pylorus was felt a hard, nodular, spindle-shaped mass; it
corresponded in position with the common duct. It was impossible to
decide whether this nodular mass was a neoplasm or calculus; a few
isolated nodules could be felt in lesser omentum. Closure of abdom-
inal wound.
May 9 : Wound closed per primam. Jaundice still present.
June 2 : Jaundice disappeared ; no cachexia ; tumor in right hypo-
chondrium larger and more nodular. Discharged improved.
1902, vol. ii., page 299. Acute Hemorrhagic Pancreatitis ; Death. —
Josei)h H.. 30 years old, was taken suddenly sick, three days before ad-
mission, with general abdominal pain, vomiting, and constipation ; no
chills or fever.
On admission, ]\[arch 9, 1902, internal organs normal. Abdomen
was distended; generally tender, especially in right iliac fossa; dul-
ness in both flanks. General condition so poor as to forbid operative
interference. Died same night.
Autopsy. — Liver: Enlarged; fatty; nutmeg. Pancreas: Somewhat
enlarged, firm consistence, grayisli color ; surrounding it a large mass
of blood which extended into the retroperitoneal tissues and between
the layers of the mesocolon. Ducts of pancreas swollen ; likewise the
duodenal papilla. In the blood around the gland are chocolate-colored
granules. Intestines normal. Mesenteric nodes normal.
242
MOUNT SINAI HOSPITAL REPORTS.
DISEASES OF THE FEMALE GENITAL ORGANS^ 17 CASES; 2 DEATHS.
Chronic endometritis 1
Prolapse of vaginal walls (cystocele and recto-
cele) 1
Ruptured ectopic pregnancy 1
Catarrhal salpingo-oophoritis 1
Pyosalpinx; pelvic peritonitis 1
" and ovarian cyst 1
Bilateral tubercular salpingitis 1
Tubo-ovarian abscess 1
Ovarian abscess; pelvic peritonitis 1
" " acute salpingitis 1
Right ovarian cyst with twisted pedicle 1
(dermoid) 1
Bilateral intraligamentous ovarian cysts 1
Traumatic rupture of uterus; hemorrhage; acute
anemia 1
Fibroids of uterus 2
Epithelioma of cervix and endometrium 1
Operations upon the Female Genital Organs — 16 Operations;
2 Deaths.
Curettage 1 1
Plastic operation for cystocele and rectocele 1 1
Laparotomy for ruptured ectopic pregnancy 1 1
" " diseased adnexa 6 6
" " twisted ovarian cyst 2 2
" " intraligamentous ovarian cysts. .1
Hysterectomy for fibroids 2 2
" " epithelioma of cervix 1 1
" " ruptured uterus; acute anemia. 1
1902, vol. iii., page 412. Bilateral Intraligamentous Ovarian Cysts;
Death from Acute Septicemia. — Mary L. suffered with pelvic pres-
sure symptoms due to the presence of intraligamentous cysts on both
sides.
April 24, 1902 : Removal of cysts. Many dense adhesions to rectum
and omentum and intestines. Closure of abdominal wound without