New Series, VOL. I, No. 4 Progress in Surgery A ..... lean J . . . . . . I of Surgery 2 3 5

Tile symptoms are those of biliary obstruc- tion, with or without cholangitis, usually intermittent in character, the obstruction later becoming permanent. More rarely a persistent biliary fistuIa is present.

The pathoIogicaI condition present may show a narrow stricture which is very short to 2 cm. or more in length, above which smaI[ stones, mucus or biliary detritus is often found. The ducts above the stricture are dilated and the liver is enlarged and soft, or may be cirrhotic when attacks of cholangitis have persisted.

Methods of repair are numerous and must depend on the condition found. Recurrence of symptoms are reported after alI methods. Examination of folIow-up reports appear to indicate that the best end-resuIts foIIow suture of the ducts when possible. The next most favorabIe resuIt where a number of cases are reported foIIow hepatico-duodenostomy.

Recurrence of symptoms may occur after the patient has been apparently weII for months or years, or symptoms may disappear af ter several months of recurrence.

In two cases reported, the disappearance of Iate symptoms seemed to be influenced by the administration of biIe salts.

STRICTURE OF THE COMMON BILE DUCT. E. Starr Judd, Rochester, Minn. Annals oJ Surgery, September, 1926. Obliterative cholangitis resuIting in stenosis

of the common or hepatic duct is the cause of a considerable proportion of strictures of the common duct that have been cIassified as trau- matic. These cases can often be recognized before the first operation. The symptoms are generally intermittent. Repeated operation is indicated if i~eeessary.

Stricture of the common duct in which a biliary fistuIa exists may be deceptive in that there may be unexpected biliary cirrhosis. Care- fuI study and any indicated preparatory treat- ment shouId be followed out in spite of the Iack of jaundice.

Complete jaundice and severe biIiary cirrho- sis accompany the severance of the duct when the proximaI end is cIosed. It is necessary to spend a great deaI of time in preparing the patient for operation. It is also necessary to give much attention to the post-operative care.

Anastomosis of the stump of the common duct or the opening in the surface of the liver

to an opening in the duodenum over a tube is the most satisfactory operation.

In certain cases recurrence of symptoms follows operation for stricture of the common duct. If these symptoms persist and increase, further operation is indicated and with some prospects of permanent reIief.

CONGENITAL ATRESlA OF THE BILIARY PAS- SAGE. (Uber angeborene GaIlengangsatresie). HeIene Schuster, Lemberg. Frankfurter Zeit- scbriftfiirPatbologie, VoI. XXXII I , Part 3, I916. The author reports two cases of so<ailed

congenital atresia of the biIe passages with compIete cIinicaI and pathoIogicaI findings. She is of the opinion that this condition is due to an infection ascending from the duodenal region either in the periductaI tissue or aIong the lumen of the biIe passages. Because of the embryologic development of the iiver and biliary ducts from an outgrowth of the intes- tine, a true congenitaI agenesis of any part of the ductal system without a coincident absence of the liver or galIbIadder cannot be conceived.

THE OPERATIVE MANAGEMENT OF COMMON

DUCT STONES. George W. Crile, Cleveland. Annals of Surgery, September, I926. ClinicaI experience and experimental re-

searches make it clear that operations upon the common duct require a wide regionaI block with novocain and, when feasible, a splanchnic bIock; a clear exposure; a sharp feather edge dissection; and a bIoodless field, a suction appa- ratus being used to pick up bile or any oozing of blood. Such a technic meets the factor of nerve injury in common duct operations extremely weII.

Nerve injury may be produced, however, after the operation by drainage. There is no excuse excepting absoIute necessity for the introduction of a drain of any kind into the f/eId of the sympathetic ganglia and sympa- thetic nerve fibers when a better drain can be placed in the right flank termination in Morrison's pouch.

Another factor of danger is the drainage of the common duct itself. Sudden decompression of biIe in a jaundiced patient may have the same effect on Iiver function as the sudden decompression of urine in the case of obstruc- tion of the urinary system. The normaIIy cIosed biIiary system maintains adequate biIe pressure within the system, therefore instead of draining

236 American J ..... [ of Surgery Progress in Surgery OCTOBER, I926

the common duct CriIe cIoses it. The function of the biIe with its high alkaIinity, when its pressure is maintained at a normaI degree, is to maintain the alkaIinity of the Iiver ceIIs.

FauIty drainage may produce a welI instead of a stream. Too much fluid may accumulate before its escapes, with immediate resuhant functional disturbance and the more remote resuIt of adhesions, which in turn interfere with liver function and consequently with general organic function. This drainage is met or IargeIy eliminated by employing gravity drainage through Morrison's pouch. CriIe has found that the introduction of heat within the abdomen causes an immediate rise, not onIy in the~ temperature of the Iiver, but aIso, syn- chronousIy, in the temperature of the brain. The application of heat to the Iiver shouId in Iarge part counteract the effect of operations upon the liver and biIe ducts. CriIe has been applying heat to the Iiver by means of dia- thermy. One pIate of the diathermy apparatus is placed on the lower chest on one side and the other is brought opposite the dome of the liver. The current can thus be continuaIIy applied during the operation and the temperature of the Iiver and the abdominal viscera can be maintained at or above the normal throughout the operation regardIess of the exposure of the intestines; moreover, the appIication of the diathermy current during the immediate post- operative hours is of great aid in carrying the patient through that critical period.

HYDROPS OF THE GALLBLADDER IN AN INFANT.

Henry MiIch, New York. Annals of Surgery, September, 1926. Hydrops of the gaIIbIadder in young subjects,

and especiaIIy in chiIdren, is rare. MiIch reports an instance in an infant 16 months old, in which the diagnosis was made before operation, a n d in which the condition deveIoped during an encephalitis. No stone or actual obstruction in the ducts was found at operation or post- mortem.

INTUSSUSCEPTION AND ITS T~EATMENT ~Y HYDROSTATIC PRESSURE: BASED ON AN ANALYSIS OF IO0 CONSECUTIVE CASES SO TREATED. P. L. HipsIey, Sydney. The Medical Journal of Australia, August 14, 1925. Whether pIain warm water or saline solution

is used does not matter much. The height of the head of the coIumn must not exceed three feet

six inches and in the majority of cases it did not exceed three feet. An ordinary glass douche is quite suitabIe, but a graduated vesseI enables one to watch the progress of the saIine soIution more cIoseIy, as it runs very sIowIy after por- tion of the intussusception has been reduced. The injection is given through a No. IS.rubber catheter which is passed into the boweI for seven and ~ half or ten centimeters (three or four inches) and then the buttocks are pinched closely round it to prevent any escape of the saIine soIution. It is important not to use vase- Iine or other lubricant on the catheter, as they make the buttocks so sIippery that it is difficuIt to hoId the catheter in. The fluid runs in quickIy at first, then more slowIy as the intussuscep- tion is 'being reduced and then after a short cessation it may run sIowIy on again, as the fluid passes into the smaII bowel and graduaIIy distends it. If the pressure is kept up it may pass right up into the jejunum.

In the whoIe series of one hundred and five patients there were seventy males and thirty- five femaIes. Out of one hundred consecutive intussusceptions sixty-two were reduced by hydrostatic pressure. In forty-four of these an operation was performed and amongst these cases there were ten in which the duration of the intussusception was over twenty-four hours, three over forty-eight hours and one over three days.

The average duration in these cases was over sixteen hours.

In eighteen out of the sixty-two cases a smaII incision was made to confirm the diagnosis of reduction. In two of these the duration was over three days, the average being over seventeen hours.

In only thirty-eight out of the hundred cases was there a faiIure to reduce the intussuscep, tion and in these the average duration was 25.8 hours, that is after excluding the case in which the duration was three weeks.

Hipsley did not incIude in this series any case in which he could not feeI a tumor before treatment.

CONJUGAL ULCERS OF THE PYLORUS AND THE

STOMACH. (Les ulc~res conug~s du pylore et du corps de l'estomac.) X. DeIore, P. Mallet-Guy et P. Ducroux, Lyon. La Presse M~dicale, August 7, 1926. In the statistics of the Mayo clinic, muhipIe

ulcers occur in about 6 per cent of aII the