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ing stone was removed. Sutures were used in only two cases, and
were satisfactory in one only ; and in the last two suturing could^have
been more easily accomplished, but the condition of the ducts required
drainage, therefore suturing was omitted, as the gall-bladder was not

In two cases the common-duct stones were not found at the first
operation, and only a cholecystotomy was done; relief failing, a second
operation was done to relieve the common duct of the stones.

The symptoms and diagnosis of stones in the common duct, diflFer-
entially speaking, from stones in the gall-bladder and cystic duct have
formerly been neglected. It ii only within a comparatively recent
period that an effort has been made to differentiate and classify the
stones in the biliary passages. So far as our knowledge goes, we are
indebted to Courvoiser for our classification and symptomatology of
common-duct stones ; also to Fenger for valuable work done lately in
this line. Gall-stones in the gall-bladder, so long as no infection
occurs, rarely ever gpive any disturbance, and are not attended with
icterus. When they produce a disturbance, infection has taken place,
plus suppturation, which causes the so-called classical gall-stone colic
(Fenger). When they occur in the cystic duct in upper half, they pro-
duce an icterus (Fenger). When they become impacted at the junction
of the cystic and common ducts, they produce icterus by compression ;
they produce icterus by impaction when in the hepatic duct ; they pro-
duce icterus in the common duct by impaction and by ball-valve action.
The condition of the gall-bladder in stones of the common duct is impor-
tant, being found in nearly all cases atrophied, with the absence of
tumor and tenderness in the gall-bladder region, and points to a choledo-
chus stone, complicated (Courvoiser, Fenger). According to Courvoiser,
icterus is the most important symptom of choledochus obstruction. A
number of small stones may cause complete obstruction, but a large
stone will, either by impaction or by ball- valve action (Fenger), cause
complete obstruction, with intermittent or remittent icterus. During
the time of the obstructions to the outflow of bile by the stone we have
the hepatic colic, icterus, clay stool, bile-stained urine, and the bile-
stained conjunctiva. This constitutes the so-called gall-stone attack.
This may last from a short period to an almost indefinite time, until
relief from the obstruction is obtained, when the symptoms subside for
an indefinite period ; but if, on the other hand, these symptoms recur

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t intervals before the icterus has cleared up,' it points to a floating
3chus stone (Fenger). Continuous jaundice, persisting for so
nonths, may be caused by a stone or non-calculous adhesion,
ists two years or more without signs of cachexia, it is due to
md not malignancy (Tait); and points out that the existence of
, lasting for years, indicates stone rather than tumor,
ic is the natural courier of sudden icterus. Continuous attacks
: point to an occlusion in the common duct; when temporary,
ating choledochus stone ; when permanent, to impaction, which
; loss of weight, which has been constant in my experience in all
mes found in the biliary passages, is, I believe, due, as explained
iger, to ptomaine intoxication Interfering with the function of

* intermittent or remittent character of fever following or preced-
iary colic and icterus is yet a disputed point. Weight of opinion
however, to indicate that it is due to absorption of the products
immation produced by infective desquamative angio-colitis, as the
always contain some form of bacteria, especially the colon bacil-
^he stone causes mechanical destruction of the epithelium ; infec-
iters the duct- wall; inflammation ensuing causes 'the plastic
tion, which accounts for the attending formation of adhesion
n the different neighboring viscera.

mtment. It is only recently that the anatomy and pathology of
jion has received the attention that it merited, as can be ascer-
by looking over the literature, the great mass of which has been
alated within the past few years. We owe much to Courvoiser
lers for the sound basis upon which they have put surgery of the
m duct, making obsolete many procedures that have been in
in the past. Since Courvoiser has taught us the feasibility of
g the common duct and suturing it or draining it, as the case
ds, such operations as cholecyst-enterostomy, etc., will become
e, and cholecystotomy and choledochotomy will be all the
clature we will need, saving in those non-operable cases of cancer
mplete destruction of the duct — so-called stenosis ; when feasible,
1 cases as the last cholecyst-enterostomy may be done to relieve
sing pain from obstruction. These cases, however, will certainly

itruction of the common duct by impactive stone, or floating
was a very serious surgical problem until choledochotomy was

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The American Practitioner and News. 449

suggested in 1884 byXangenbach, but first definitely planned and car-
ried out by Courvoiser in 1890. The success attained by him placed it
at once at the head of all surgical procedures for stone in the common
duct. <

Much experimental wcfrk has been done lately to define the anatomy
of the biliary passages and their relation to contiguous structures,
until at present our knowledge is well-nigh perfect.

In conclusion, I wish to deal briefly with a few of the important
steps in the operation, giving you my personal preference from actual
experience. First, let me deal with the abdominal incision. A great
many incisions have been planned and carried out of late, with a view
of a better exposure of the bile passages, in order to admit of
room for manipulations of structures so deeply situated; the old
incision parallel to the free border of the costal cartilages, and the
straight incision at the outer border of the rectus, have been relegated
to the past, for obvious reasons. The incision I' prefer and have adopted
is one that divides as few important structures as possible, preserving
muscles and the lower intercostal nerves, and gives ample room for
exploration of ducts and gall-bladder. The incision begins opposite '
the eighth or ninth costal cartilage and extends to two and a half inches
above the umbilicus; making an angle, it is extended along a line
parallel to the free border of the costal cartilages; it divides the
outer border of the rectus, and cuts through the rectus at the lower
angle of incision. When the abdominal cavity has been opened, the
gall-bladder is located immediately, if possible. Sometimes from the
adhesion and atrophy in common-duct stones this is very tedious and dif-
ficult ; after the adhesions have been dealt with the liver must be lifted
up and held, while the finger is pushed through the foramen of Wins-
low and the common duct, and its vessels hooked up or worked up on
the finger and examined. Weller Van' Hook has carried out a plan of
inflating ducts through an opening in the gall-bladder which I believe
will be found valuable when the ducts are difficult of exposure. When
the stone in the common duct has been located, and the duct brought in
situiox operation, it should be opened, great care being exerted to prevent
tapping the vein or artery that accompany it, which, with care, should
not be difficult. When a stone has been found do not delude yourself with
the text-book advice, and waste time in trying to push it back into the
gall-bladder, nor try the other expedient of pushing it into the
bowel— the former a bare possibility, the latter an anatomical impossi-

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450 The American Practitioner and News.

bility. I do hope ere long to see soch advice e x pmna ted from qieckJ
chapters in general text-books on snrgery, for let ns remember Aat tbe
dnct, asit passes through, will hardly admit a fine alver probe, and that
the stone small enough to pass will, in all probability, pass itself, or never
cause symptoms demanding intervention* Again, do not lose time with
probes to find more stones, but use the fingers to find them and brii^ them
up to the opening in the ducL Prom my own personal experience I £adl
to find necessary the expedient of using sutures to dose the duct open-
ing, only doing it when it is easier and does not necessarily prolong the
operation. Believing that just as good results are obtained by drain-
age, I would add that my experience forces this conclusion upon me:
That when a choledochotomy is necessary a cholecystotomy is called for
to drain a gall-bladder that is diseased, and to continue the drainage
for a greater period of time than is usually suggested, because it is
essentially a secreting organ, and is primarily, I believe, the starting-
point for future trouble. The only exception is absence of gall-bladder
or contraction making drainage impossible. Where the ducts alone are
drained it should continue from four to eight weeks; in either case irri-
gation should be done daily, but not necessarily continuously. I
have now done eight choledochotomies without a death, and in only
one have I successfully sutured the duct; the remaining seven did
equally well by virtue of the perfect drainage allowing the ducts to
assume a function and become normal more rapidly. If suturing is
done, drainage will be a safeguard for a limited time ; if, on the other
hand, suturing of the duct is perfect, all the more would I advocate
drainage through the gall-bladder. In the two last cases both women
were pregnant, one two months and one four months. Their recov-
eries were uneventful.




It seems unnecessary for me to refer to-night to the history of
malaria, as you are all familiar with the parasite of the disease, discov-
ered by Laveran in 1880.

In considering malaria from a clinical standpoint, it may be divided
into the following forms : First, intermittent ; second, pernicious inter-

^' Read at a meeting of the Chicago Medical Society, May 31, 1S99.

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The American PrcLctitioner and News. 451

mittcnt; third, remittent; fourth, pernicious remittent; fifth, typho^
malaria ; sixth, malarial cachexia and irregular forms.

The clinical manifestations of malaria may also be classified, in
reference to the length of time between paroxysms, into, first, quotidian,,
produced by the segmentation of two groups of tertian organisms on
successive days ; second, tertian, produced by a single group of tertian
organisms; third, quartan, single, double, and triple, produced by the
quartan parasite ; fourth, irregular or continuous, produced generally
by estivo-autumnal parasites. The *first classified variety is much
more complete.

Intermittent fever is caused generally by the tertian or quartan par-
asite, rarely by the estivo-autumnal. It is characterized by complete
disappearance of symptoms between paroxysms. Its course may be
divided into three stages: First, the cold stage; second, the hot stage;
third, the sweating stage.

The first stage may appear suddenly or come on gradually. It is
characterized by sensations of heat and cold, while the thermometer
records a rise of internal temperature ; this is preceded by headache
and general malaise. During the onset the face is pale and pinched^
the skin is cold and clammy, and of the goose-quill appearance. The
pulse is weak and rapid. Abundant covers will not relieve the feeling
of coldness of which patients complain. The patient shakes virtually
all over the body ; the teeth chatter and coherent speech is impossible.
The superficial temperature is found to be subnormal, caused probably
by the constriction of peripheral vessels, resulting in great congestion
of internal organs, especially of the spleen and liver. In some instances
it may last but a few moments, associated with simply a chilly sensa-
tion or a feeling of weakness, or it may last from one to five hours. I
can not see that there is any relation between the severity of the chill
and the following hot stage.

The second stage is characterized by a gradual rise in temperature
to as high as 107° P. The face is flushed, the pulse full, rapid, and
strong, and frequently dicrotic. When the fever runs exceedingly high
the patient may sink into a comatose or delirious state.

The third stage follows the fall in temperature, and is ushered in
with profuse perspiration. This commences upon the face and fore-
head, but soon the whole body is bathed in sweat, which often soaks
the bedclothes. During this stage the patient experiences great relief.
The headache, muscular pain, vomiting, tender abdomen, and splenic

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appear. This is due, in all likelihood, to relaxation of the
I blood-vessels, which relieves the internal congestion. After
iration has ceased the patient is greatly prostrated. This
i from two to twelve hours. During apyrexia the temperature
ly subnormal.

intermittent pernicious fever the classification given in the
Text-book of the Theory and Practice of Medicine seems to
3st complete, and is as follows : First, bilious ; second, hem-
third, algid ; fourth, ai^henic ; fifth, comatose,
bilious form severe abdominal symptoms are present. There
ly flatulency and tenderness over the abdomen, associated
iting of large quantities of bile and water>' discharges from
:1s. The liver and splenic areas of dullness are much

Jaundice may occur within a few hours after the paroxysm,
emorrhagic form is nearly always grave. Hemorrhages may
>m the nostrils, mouth, stomach, skin, rectum, or kidneys,
on of urine soon follows, with violent headache, delirium,
iyne-Stokes respiration, heart failui;e, and pulmonary edema
from uremic and malarial poisoning.

algid form great prostration is present, associated with purg-
ing, and muscular pains. Temperature may be normal or even
1 ; urine is often diminished or even suppressed. This con-
y persist, with slight exacerbations of fever, for several days,
sthenic form is accompanied by g^eat nervousness and feeble

comatose form the patient may immediately enter a comatose
a which he can not be roused. If the first attack is survived,
i is certain to prove fatal. This form may be present in any
ceding types.

ame stages characterize the remittent forms of malaria as
littent, with the exception that the temperature rarely falls

P. This form of the disease is associated especially with
1 cycle of the estivo-autumnal organism. Remittent fevers
nence as intermittent, or they may immediately assume this
r a severe initial paroxysm. The second stage often lasts
o twenty hours. The third stage is less prominent than the
ding stage of intermittent fever, and between attacks the
not so free from symptoms. They complain of fever, nausea,

and muscular pains. The remission generally occurs at


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night. The fever may subside gradually, retaining its remittent char-
acter, or first become intermittent before disappearing.

It is not necessary to describe the symptoms of pernicious remittent
fever, as they are identical with the symptoms of pernicious intermit-
tent fever.

Typho-malarial fever consists in a combination of the symptoms of
malaria and typhoid fever. It begins with a chill, followed by fever.
The symptoms of this disorder may be most markedly those of either
of these diseases ; however, the typhoid symptoms are generally most
prominent, the malaria manifesting itself only in the variation in tem-
perature. It is claimed that typhoid fever, when associated with mala-
ria, is not as fatal as where existing ^lone.

Malarial cachexia, symptomatic of chronic malarial poisoning, is

very varied. The most pronounced symptoms are anemia and an

. enlarged spleen. The blood count in some cases may be as low as

500,000 per cubic millimeter; the skin has a saffron tint; the spleen is

greatly enlarged, firm and hard.

The general symptoms are those of anemia, breathlessness on exer-
tion, edema of the ankles, and hemorrhages which may be severe.
Temperature may be below 99.5°, or the fever may be irregular,
temperature rising gradually to 103°.

Under the head of irregular forms are found many disorders of mala-
rial origin, which may escape the diagnostician. It is in these that the
blood examination is of greatest importance. Often the chill is entirely
absent ; in others the sweating stage is not present ; and again both the
foregoing may be absent. The entire paroxysm may be wanting, in
the place of which malaise is noticed, headache, diarrhea, or vomiting,
with perhaps a very slight rise in temperature, or the paroxysms may
appear in the form of severe neuralgic pain. In the pure types of
intermittent fever the diagnosis is usually easily accomplished without
blood examination. The peculiar tertian or quartan paroxysms and
splenic tumor make a diagnosis almost certain. The onset of these
forms may simulate pneumonia, but later they are easily differentiated.

From a clinical standpoint, the diagnosis of the remittent and per-
nicious forms is at times very difficult. In many cases it is only pos-
sible to arrive at an accurate diagnosis by the use of the microscope,
for they are likely to be confounded with typhoid fever, cholera, ulcer-
ative endocarditis, pyemia, septicemia, and meningitis. In the absence
of rose spots in typhoid fever — a condition which sometimes exists — ^it

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454 ^^^ American Practitioner and News.

is closely simulated by the typho-malarial form of malaria. It is prob-
ably a fact that many malarial soldiers in the late campaign in Cnba
were being treated for typhoid fever. In yellow fever the characteristic
symptoms, peculiar onset, black vomit, jaundice, and suppression of
urine are all simulated by pernicious malaria.

Without a blood examination it would be impossible to diagnose
the algid stage of malaria from the algid stage of yellow fever. Ulcer-
ative endocarditis can be differentiated by a careful physical examina-
tion of the heart, and septicemia by locating the infection atrium.
Uremia can pnly be differentiated from the uremia of pernicious malaria
by the use of the microscope. In meningitis the coma comes on later
than in comatose pernicious malaria, and in meningitis photophobia
is always present.

As to the treatment of malaria, quinine has been the great panacea.
But there are obstinate cases of intermittent fever observed in which
quinine has no effect, and this is especially true of the parasites that have
been brought home by our soldier boys from Cuba. My friends tell me
that nearly all their comrades are in as bad, or nearly as bad, condition
as when they reached Chicago last September ; that they have grown
disgusted with doctoring ; that all physicians do, or try to do, is to give
them quinine, and that they are as capable of treating themselves as
are the physicians.

In patients with idiosyncrasy to quinine I have tried other drugs,
the most important of which is methylene blue. It has no particular
advantage over quinine, excepting that it is tasteless and can be admin-
istered to children more easily than quinine. During the past seven
weeks I have been making a more or less extensive trial of guaiacol in
the treatment of malarial fever, and, from the result obtained, I am of
the opinion that in many cases it is a very valuable remedy, and that
its therapeutic properties deserve wider recognition. The dose used
by me in all cases varied from five to forty-five minims, beginning with
five drops in capsule after meals and gradually increasing the dose
unless disturbance of digestion resulted from its use. In the last few
weeks I have treated four cases, all boys who were in the army in Cuba.

The first case I present to you is a friend of mine, H. G. S., i^ed
twenty-five, single. Company H, First Illinois Volunteer Infantry, taken
ill at Santiago, Cuba, July 23th, with dysentery ; had his first chill
August 5th at 3 A. M. Chills reappeared every morning at the san^
hour until he arrived home in Chicago, September 7th. He was

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The American Practitioner and News. 455

greatly emaciated, weighing only one hundred and fifteen pounds. He
was at once taken to the Presbyterian Hospital. Physical cbndition
very bad, spleen easily palpable. The blood examination revealed
^ndojglobular plasmodia, with numerous pigment granules actively
motile and a number of endoglobular crescents. Patient was very sus-
ceptible to quinine, which always produced symptoms referable to the
brain, such as fullness in the head, frontal headache, and delirium.
However, he was able to take twenty grains a day when combined with
dilute hydrochloric acid. He remained in the hospital twenty-five days,
and gained fifteen pounds in weight. Went to New York City, where he
remained sixty days; 'all this time he continued to take quinine; no
chill, but he claims that during all that time his whole body ached
constantly. One week before departing for home he discontinued
taking quinine, and while en route he had a severe chill, lasting three
hours, his temperature going as high as 106*^ F. After his arrival in
Chicago for three months he had chills about twenty-four days, at which
times he was confined to his bed from four to six days. He was con-
stantly under physicians' care, but they seemed unable to control his
chills and fever. April 4, 1899, he came from Waukegan to see me.
He was greatly discouraged, having had chills ever>^ other day, coming
an hour and a quarter earlier each day, and one week before coming to
me he Had them every day.

Knowing that all the supposed specifics had failed in this case, and
being doubly desirous of relieving him because he was my friend, I
resolved to try guaiacol, hoping at least to control the fever. This was
on Tuesday, April 4th. He began with five drops after meals; he had
' a chill Wednesday and one Thursday, when they disapp^red. He
gained in weight and strength rapidly, and was feeling so well that on
May ist he discontinued his guaiacol, and on May 4th he had a
chill, which was repeated on the 6th.

This incident would seem to prove that the adult segmentating
organism is not affected by the drug, while the free and growing spores
constantly imbibing nourishment from the plasma of the blood are
readily destroyed or prevented from entering new corpuscles. Blood
examination: Fleischl's hemometer showed 40 per cent of faemo-
g;lobin. The hematocrit showed that the blood contained a little over
3,500,000 red corpuscles per cubic millimeter.

Casb 2. Tertian fever. W. B. C, aged twenty-three^ married;
private. Second United States Cavalry. Had yellow fever in Santiago,

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398. After recovering from yellow fever, he began to *liave
y day at first, then every other day. Had been in the hospital
the time since his return home until I saw him, November
Blood examination revealed endoglobular plasmodia with
pigment cells. Physical examination showed a very tender
ly enlarged spleen, extending six inches below costal arch,
orty or fifty and even ninety grains a day, was used to control
ch would come every two weeks in spite of the quinine. On
• 25th, while on a trip to Ohio, he had a severe attack. He
>m under my care, but still continued to take quinine in
ombinations until he came to me, April 9, 1899, complaining
chills and fever every day for a month. He had emaciated
lly, and was unable to retain any thing on his stomach
apples, which he retained and relished. His skin was a saf-
V. Complained of breathlessness on the slightest exertion ;
or hemorrhages. Spleen now extending nearly seven inches
tal arch. He perspired constantly. Temperature 102.5^
I placed him on guaiacol, beginning with five drops,
one drop each day. Returned April 12th ; said he felt first
^erature normal, and had no chill since beginning guaiacol
He was hungry and retained food without any unpleasant-
il iSth, temperature 99.8*^; no chill since beginning treatment
ne ; is now taking guaiacol in fifteen-drop doses.
I St — Stomach seemed a little disturbed; temperature 100*^ F.
5th — Temperature normal, gaining rapidly, appetite difficult

;oth — Temperature normal, looking better, and has resumed

h — Temperature normal, has gained nineteen pounds in two

Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 105 of 109)