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THE

AMERICAN

JOURNAL OF OBSTETRICS



AND



Diseases of Women and Children



EDITED BY

BROOKS H. WELLS, M. D.

Professor of Gynecology at the New York Polyclinic and Gynecological Surgeoti to
the New York Polyclintc Hospital; Consulting Gynecologist to Beth Israel Hos-
pital^ New York; Consulting Abdominal Surgeon to the Brattlehoro Me-
morial Hospital^ Brattlehoro^ Vermont; Associate Surgeon to the
Woman's Hospital of the State of New York; Fellow of the
American Gynecological Society; Associate FdUnv of the
American Association for Cancer Research; Fellow of
the New York Academy of Medicine^ the New
York Obstetrical Society j The American
Medical Association,

AND

THOMAS S. SOUTHWORTH, M. D.

Attending Physician, Nursery and Childs Hospital, New York City Children's

Hospital (Randalls Island); The Hospital for Scarlet Fever and Diphtheria

Patients; Physician Out-Patient Department, Babies Hospital; Fellow

of the American Pediatric Society, The American Medical

Association, New York Academy of Medicine,



VOLUME LXL
January- June, 1910



NEW YORK
WILLIAM WOOD & COMPANY

1910



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LIST OF CONTRIBUTORS.



Arteaga, Julio F., Havana, Cuba.

Baer, B. F., Phaadelphia, Pa.

Baldwin, J. F., Columbus, O.

Ballard, Charles Nelson, Oklahoma City, Okla.

Barnard, E. P., Philadelphia, Pa.

BovEE, J. Wesley, Washington, D. C.

Bowes, L. M., Chicago, 111.

Brettauer, Joseph, New York, N. Y.

Brothers, Ajbram, New York, N. Y.

Cannaday, John Egerton, Charleston, W. Va.

Carroll, F. Julian, Summerville, S. C.

Carson, Shelby C, Greensboro, Ala.

Claiborne, J. Herbert, New York, N. Y.

CoE, H. C, New York, N. Y.

Cragin, Edwin B., New York, N. Y.

Crane, Claude G., Brooklyn, N. Y.

Davis, Edward P., Philadelphia, Pa.

Davis, Effa V., Chicago, 111.

De Forest, Henry P., New York, N. Y.

Dickinson, Gordon K., Jersey City, N. J.

GiLLMORE, Robert T., Chicago, 111.

GooDALL, James Robert, Montreal, Can.

GooDHART, S. Philip, New York, N. Y.

GoTTHEiL, William S., New York, N. Y.

Hamilton, B. Wallace, New York, N. Y.

Harper, Paul T., Albany, N. Y.

J-fCOBSON, Sidney D., New York, N. Y.

Johnson, Joseph Taber, Washington, D. C.

Kelly, Howard A., Baltimore, Md.

Kerr, Legrand, Brooklyn, N. Y.

Krusen, Wilmer, Philadelphia, Pa.

McDonald, Ellice, New York, N. Y.

MacEvitt, James, Brooklyn, N. Y.

Macht, David I., Baltimore, Md.

Meister, William Bertram, Brooklyn, N. Y.

Murray, Grace Peckham, New York, N. Y.

Noble, George H., Atlanta, Ga.

Noble, Thomas B., Indianapolis, Ind.

Norris, C. C, Philadelphia, Pa.

Nutt, George D., Williamsport, Pa.

Ott, Isaac, Philadelphia, Pa.

iii



2 J -^ ?'^^ J ^'^'^'"^"^ ^^ Google



IV LIST OF CONTRIBUTORS.

Pendleton, Judson P., Brooklyn, N. Y.

Peterson, Reuben, Ann Arbor, Mich.

Pfaff, O. G., Indianapolis, Ind.

Pinkham, Edward W., New York, N. Y.

Pool, Eugene H., New York, N. Y.

Pool, Willlam P., Brooklyn, N. Y.

Porter, Miles P., Fort Wayne, Ind.

Proescher, Frederick, Allegheny, Pa.

Rabinovitz, M., New York, N. Y.

Rakestraw, C. M., Savannah, Ga.

Reder, Francis, St. Louis, Mo.

Reilly, D. R., Brooklyn, N. Y.

Robbins, F., New York, N. Y.

Roddy, John A., Pittsburg, Pa.

RoYSTER, Hubert A., Raleigh, N. C.

Sampson, John A., Albany, N. Y.

Sanes, K. I., Pittsburg, Pa.

Schumann, Edward A., Philadelphia, Pa.

Scott, John C, Philadelphia, Pa.

Shoemaker, George Erety, Philadelphia, Pa.

Sill, E. Mather, New York, N. Y.

Smith, Archibald D., Brooklyn, N. Y.

Smith, Charles N., Toledo, O.

Smith, J. LaPTHORN, Montreal, Can.

Stein, Arthur, New York, N. Y.

Stewart, Douglas H., New York, N. Y.

Stockard, Charles R., New York, N. Y.

Stone, I. S., Washington, D. C.

Sturmdorf, Arnold, New York, N. Y.

Tate, Magnus A., Cininnati, O.

Vandiver, Almuth C, New York, N. Y.

Von Ramdohr, C. A., New York, N. Y.

Walker, Edwin, Evansville, Ind.

Walter, Josephine, New York, N. Y.

Ward, Wilber, New York, N. Y.

Wiener, Solomon, New York, N. Y.

Williams J. Whitridge, Baltimore, Md.

Zentler, Arthur, New York, N. Y.

American Gynecological Society.

Chicago Pediatric Society.

New York Academy of Medicine.

New York Obstetrical Society.

Society of the Alumni of the Sloane Maternity Hospital,

New York.
Southern Surgical and Gynecological Association.
Washington Obstetrical and Gynecological Society.



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THE ATVrEBIO-AJSr

JOURNAL OF OBSTETRICS

AND

DISEASES OF WOMEN AND CHILDREN.

VOL. LXl. JANUARY. 1910. NO. 1

ORIGINAL COMMUNICATIONS.



TERMINAL EVENTS IN GALLSTONE DISEASE.^

BY

CHARLES N. SMITH. M. D.,

Toledo, O.

Gynecologist to St. Vincent's Hospital

This consideration of the terminal events in gallstone disease
is presented with the hope that it may provoke a discussion so
vigorous in its nature that renewed and new interest may be
awakened in the subject of cholelithiasis, and, through a more
keen appreciation of the disabling and even fatal disasters at-
tending its terminal events, that physicians and surgeons alike
may be prompted to advise and to institute operative procedures
for early relief in practically every case of gallstones.

That gallstone disease is extremely prevalent, afflicting from
7 to ID per cent, of adults dying in the public hospitals of Eng-
land, (1-2) Germany (3-4) and America, (5) is a contention ap-
parently substantiated by the records of thousands of postmor-
tem examinations. While we may accept as accurate these
findings as to the relative frequency of gallstones, in that they
are a record of facts, certain inferences drawn therefrom are un-
warranted. A number of writers, in commenting upon these
examinations, seemingly assuming the right to speak with
authority for the voiceless dead, dogmatically assert the claim,
defenseless and groundless though it must be, that in the great
majority of instances these gallstones produced at no time in
their history either symptoms or damaging results. This con-
clusion is based upon a misinterpretation of the early and the
mild symptoms of cholelithiasis, which, present knowledge leads

» Read at the Twenty-second Annual Meeting of the American Association of
Obstetricians and Gynecologists at Fort Wayne, September 21-23, 1909.



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2 smith: terminal events in gallstone disease.

us to believe, were present at some time in the life history of the
individuals so afSicted.

The symptomatology of gallstone disease as given in our text-
books, with almost no exception, is but a recitation of terminal
events and of the symptoms produced by them. The late and
terminal complications, rather than the early and initial mani-
festations of the disease, have received consideration, and be-
cause of this, a symptomatology has been evolved which, being
but the symptomatology of terminal events, fails in its pur-
pose in so far as the diagnosis of gallstones at an early period in
their history is concerned. The so-called latent gallstones,
which may have escaped the serious complications of terminal
events, have been passed over unrecognized because not ac-
companied by this stormy symptom complex.

Because of the erroneous statement, b^tsed upon conclusions
drawn without warrant from the above mentioned postmortem
examinations, and so frequently repeated in the literature of
cholelithiasis, to the effect that in the great majority of instances
gallstones are unproductive of either symptoms or serious com-
plications, the impression that, as a rule, gallstones are void of
serious danger has obtained widespread credence. This, to-
gether with the fact that the diagnosis of gallstones seldom has
been made prior to the onset of complications, has resulted in
gallstone surgery becoming largely the surgery of terminal
events.

Our distinguished Fellow, John B. Deaver,(6) in a paper read
before the Southern Surgical and Gynecological Association in
1907, made a masterly argument against the performance of
cholecystectomy in all those cases in which it is probable that
the gall-bladder still retains, or can regain through a drainage
operation, its functional powers. In two subsequent papers(7-8)
he reports a total of 254 operations for gallstone disease and
its complications. Of this number, loi or 40 per cent., were
cholecystectomies. The performance of this relatively enor-
mous number of cholecystectomies by a surgeon strongly op-
posed to the operation save as one of absolute necessity, strik-
ingly demonstrates the fact that a large proportion of the
patients with gallstone disease are referred to the surgeon for
relief, or seek such relief on their own initiative, only when
confronted by the serious and destructive lesions of terminal
events.

The formation of gallstones within the gall-bladder is the



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smith: terminal events in gallstone disease. 3

result of a low grade infection of the mucosa of that viscus.
Virulent infections of the gall-bladder are practically never the
cause of gallstone formation, but almost invariably are com-
plications thereof. The combination of infection and a foreign
body within the gall-bladder is sufficient to excite an acute
cholecystitis, which may occur, but with less frequency, in the
absence of the foreign body. This acute inflammation must be
looked upon as a terminal phenomenon in gallstone history,
occurring only after a more or less prolonged occupancy of the
gall-bladder by the calculi, during which time their presence was
fairly well announced by their initial symptoms.

With extension of the inflammation to the cystic duct, oc-
clusion of that duct may occur and thereafter the gall-bladder
forever will remain eliminated from the biliary circuit, void of
function and a constant menace to the comfort and life of its
possessor. Depending upon the activity of the infecting bac-
teria, either hydrops or empyema of the gall-bladder, occurring
independently or sequentially, may follow occlusion of the
cystic duct from inflammation or from blockage by stone.
Either condition frequently necessitates the performance of
cholecystectomy, and in the light of our present knowledge of
the etiology and treatment of chronic pancreatitis, the per-
formance of a cholecystectomy is a distinct disadvantage to the
individual, remote, it is true, but still a disadvantage.

This occlusion of the cystic duct from inflammation excited by
the irritation of gallstones, as weU as the direct blockage of the
duct by stone, so frequently rendered permanent by contraction
of the inflamed duct about the offending concretion, must be
looked upon as a terminal event in the progress of cholecystitis,
itself a complicating and comparatively late event in gallstone
disease. The still later sequential phenomena of hydrops,
empyema, gangrene, ulceration, perforation and rupture of the
gall-bladder, as well as sclerosis, contraction and obliteration,
are terminal events of a higher degree.

In hydrops, occurring in the early catarrhal stage of an acute
cholecystitis, or from the recurrent exacerbations of a chronic
inflammation, the walls of the gall-bladder, greatly distended by
the outpouring of mucus, generally become extremely tenuous.
I have removed such a gaU-bladder, measuring seven inches in
length and one and one-half inches in diameter, in which
the walls were as thin as tissue paper. Rupture of such a thin
walled C3rstic gaU-bladder is an ever existing danger.



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4 smith: terminal events in gallstone disease.

The most serious complication, and one which threatens
every case of hydrops, is a secondary empyema resulting from
reinfection of the gall-bladder and its imprisoned contents.^In.
October, 1908, I operated on a woman in whom hydrops had
been present for over one year, the enormously distended gall-
bladder being readily grasped through the relaxed abdominal
walls. While feeling remarkably well, she was taken with a
severe chill, followed by a high temperature, sweating, and a
drop in temperature to 97®. I saw her within a few hours,
transported her thirty miles, and performed a cholecystectomy
immediately after her arrival at the hospital. The gall-bladder,
which had not ruptured, could be likened in appearance only to
the viciously inflamed and distended bowel of complete intestinal
obstruction. It was enormously distended with a thin, turbid,
muco-purulent fluid. The cystic duct was completely occluded,
the result of inflammatory action. One gallstone occupied a
pocket in the sigmoid twist of the duct. Recovery followed the
operation. This was one of those "innocent** or "latent"
gallstones which we are told, so repeatedly, should be treated,
in the poor, by the administration of sodium phosphate;
in the rich, by a trip to Carlsbad. When a secondary empyema
thus occurs, rupture, with infection of the general peritoneal
cavity is a practically certain termination, unless anticipated by
surgical relief. Such terminal events in gallstone disease are by
no means rare.

In empyema resulting from an acute cholecystitis with an
infection of a high degree of virulence, the gall-bladder is enlarged
and its walls are edematous, swollen and thickened. Suppura-
tion, ulceration, and possibly gangrene and perforation, are
synchronously occurring phenomena. Gangrene may be limited
to a small area or involve the entire gall-bladder. Perforation
into the intestine may take place, affording relief of tension and
efficient drainage, followed by contraction, practically amount-
ing in some instances to an obliteration of the gall-bladder.

Rupture of the suppurating gall-bladder into the general
peritoneal cavity is by no means an unusual terminal event,
having occurred five times in my own experience. Of these
five cases, four made a complete recovery after operation, while
the remaining one, a desperate and delayed case, with a wide-
spread peritonitis, died on the table as the abdominal incision
was completed.

From observation of these and other cases, and from a study



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smith: terminal events in gallstone disease. 5

of the literature of the subject, I am convinced that the frequency
with which rupture of the gall-bladder occurs as a terminal event
in gallstone disease is scarcely appreciated. In my opinion
these cases are commonly diagnosed as peritoneal infection from
appendicitis, operated on as such and so recorded unless gall-
stones, correcting the diagnosis, are found in the peritoneal
cavity. All of us, knowing the vagaries of the appendix and
its possibilities as a mischief maker, readily can excuse the
error.

One of my cases, a few months before coming to me, had been
operated on for a supposed appendicitis and the appendix removed .
When a gauze drain was being removed, some days following the
operation, a gallstone escaped from the cavity and others were
expelled at subsequent intervals. Pus was discharging from
the incision when she consulted me, and several gallstones
were removed from the sinus by the scoop. The gaU-bladder,
containing one immense stone and a number of small ones, was
removed and recovery followed.

Two others were brought for operation with a diagnosis of
appendicitis, because of pain, tenderness and swelling in the
right half of the abdomen. Correction of the diagnosis prior
to operation was not diflScult. Free incision, removal of gall-
stones, cleansing of the cavity, abundant drainage, with the
patient in the Fowler position, were followed by slow but
eventual recovery.

The following case presents many of the disastrous terminal
events of latent gallstones — suppuration, rupture, peritonitis,
chronic pancreatitis and duodenal obstruction — all of which
could have been avoided by an early operation, which had been
advised.

Miss D., aged fifty-four, a patient of Drs. Rohn and Reynolds,
of Defiance, Ohio, was operated on, November 4, 1908, for
rupture of the gall-bladder occurring about sixty hours previously.
For twenty-seven years this patient had been the subject of
gallstone disease, in its " innocent" or *' latent" form, as indicated
by the stomach symptoms so invariably present and so frequently
mistaken for indigestion, gastralgia or gastroduodenitis.
During this twenty-seven years she had never missed a day
from her duties as teacher in the public schools, so slight had
been the disturbances created by the gallstones. That chronic
pancreatitis had been present for a considerable period was then
shown by disturbances in digestion and in carbohydrate metab-



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6 smith: terminal events in gallstone disease.

olism, by loss in weight and repeated hemorrhages into the
skin, by local signs and a positive Cammidge reaction in the urine.
Suppuration in the gall-bladder had been indicated by the usual
symptoms through a period of four days. Rupture was announced
by sudden, severe pain, exquisite tenderness and a degree of
collapse closely approaching death. I operated in that deceptive
period of repose when all warning symptoms were in abeyance.

The walls of the enlarged gall-bladder were thickened and
edematous. The rupture was in the ftmdus. Pus and bile
escaped from the gall-bladder and quantities of seropurulent
fluid and bile from the peritoneal cavity. A second incision
was made low in the abdominal wall into the pelvic cavity and
fluid of the same character obtained. The cystic duct contained
four gallstones but was not permanently blocked thereby, as was
shown by the presence of bile in the gall-bladder and the peri-
toneal cavity. Gallstones were foimd in the peritoneal cavity
and the gall-bladder. The head of the pancreas was indurated,
lobulated and decidedly enlarged, unquestionably from chronic
pancreatitis.

Because of the existence of chronic pancreatitis, necessitating
biliary drainage for its cure, and because the cystic duct was not
occluded, making possible the restoration of function in the gall-
bladder, the latter was not removed but simply drained. A
large split rubber drain was placed alongside the gall-bladder,
another in the right kidney pouch, and a third in the pelvis.
The patient was placed in Fowler's position and normal saline
solution administered by continuous flow through the rectum.
Drainage of the gall-bladder continued for fourteen weeks.
The recovery was slow but, in the main, satisfactory.

This patient consulted me again in July of the present year.
All symptoms referable to the biliary tract and the pancreas had
disappeared. There were present, however, positive symptoms
of nearly complete obstruction at the pylorus or in the duodenum.
Vomiting of stomach contents immediately after every meal
was a regular event. The patient had lost 50 pounds in weight
since the day on which rupture of the gall-bladder had occurred*.
Gastrojejunostomy was performed July 19. The adhesions
resulting from the peritonitis, secondary to the rupture of the
suppurating gall-bladder, had so displaced and angulated the
duodenum that a practically complete obstruction existed.
No attempt was made to separate the adhesions and restore the
duodenum to its natural condition and position.



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smith: terminal events in gallstone disease. 7

The most valuable and interesting information obtained from
this second abdominal exploration, relates to the condition of
the pancreas. Within a period of eight months and following
fourteen weeks of biliary drainage, the pancreas had been
restored to a perfectly normal condition. The induration,
lobulation and swelling had completely disappeared. Several
attempts to obtain Cammidge's reaction in the urine were nega-
tive in result. The patient, seen September 8, is well in every
particular. She retains all her food, digests it with comfort, and
is gaining in weight.

A distinction must be made between rupture of the gall-
bladder, a sudden process in the course of an acute infection, and
slow perforation, a gradual process in the course of a chronic
cholecystitis. The one immediately threatens life; the other,
only remotely. As a result of this ulceration terminating in slow
perforation, gallstones are extruded from the gall-bladder and
are found occupying little pockets, or nests, under preformed
adhesions, such pockets in some instances communicating with
the gall-bladder, in others being entirely shut ofif therefrom.
Occasionally this slow perforation takes place into the substance
of the liver, where the gallstones might be overlooked in the per-
formance of a cholecystostomy, but readily discovered in the
course of a cholecystectomy. Moynihan(9) believes this to be a
not uncommon event, he having found four such cases in his first
twenty cholecystectomies.

While these aberrant calculi undoubtedly may remain for
months or years safely and quietly housed in these extracjrstic
pockets, infection may occur and abscess result; or the calculi
may by ulceration escape into the stomach, duodenum or colon.
This latter termination accounts, in some instances, for large
stones finding their way into the intestine where they may
produce intestinal obstruction, an uncommon but not rare event.
Sclerosis and contraction of the gall-bladder wall may follow
repeated attacks of acute cholecystitis, of hydrops, of empyema,
or the exacerbations of a long continued chronic inflammation.
The gall-bladder becomes distorted in outline, assuming the
shape of the gallstones over which its walls are tightly drawn.
Two or more compartments, connected or separated, may be
found, every one occupied by one or more gallstones. Not



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 1 of 109)