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THE SURGERY OF GALL STONES bile to the body by biliary fistula

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THE SURGERY OF GALL STONES bile to the body by biliary fistula Powered By Docstoc
					               THE SURGERY OF GALL STONES
           Lecture delivered at the Royal College of Surgeons of England
                                          on
                                   16th April 1957
                                          by
                Sir Heneage Ogilvie, K.B.E., M.Ch., F.R.C.S.
                        Consulting Surgeon, Guy's Hospital

THE ALIMENTARY CANAL breaks down the raw materials of food into the
simple constituents that compose them. The liver receives these products
from the portal vein, strips them, turns some of them into the simple
elements of fuel, to be used or stored for future use, and builds others into
the complicated molecules that the body needs to conduct its functions,
and to keep its fabric in repair. The liver is the factory of the body. Bile
is simply the waste of this factory and the biliary passages are the drains
that evacuate the waste. The pigments are breakdown products of
haemoglobin, and they play no part in digestion. The salts are by-products
in the metabolism of the amino-acids. Cholesterol as it is found in the bile
is an excretion without any role in the mechanism of digestion. Loss of
bile to the body, by biliary fistula, can be tolerated over long periods
without serious loss to health. Retention of bile by obstruction to the
outflow builds up a pressure that progressively damages the liver cells, and
eventually kills the patient.
   The gall bladder is a diverticulum from the main biliary passage. The
liver pours out from 500 to 1,000 ccs of bile into the hepatic ducts in the
twenty-four hours. This hepatic bile is concentrated in the gall bladder
by extraction of water to a volume of from 50 to 100 ccs, so that in place
of a constant flow of dilute bile into the intestine, small amounts of con-
centrated bile are discharged at intervals, chiefly at meal times.
   The gall bladder, being the place where the bile is concentrated, is also
the place where gall stones are formed. Like most subjects about which
nothing whatever is known, very much has been written about the aetiology
of gall stones.
   Text books divide them into two main types-pure or metabolic stones,
or mixed stones. The pure stones consist either of pigment or of cholesterol.
The mixed stones are composed of alternating layers of cholesterol and
calcium bilirubinate. The great majority of gall stones are mixed stones.
   That pigment and cholesterol stones are due to some error in metabolism
seems pretty certain. Pigment stones are found in conditions in which red
cells are continually being destroyed-such as acholuric jaundice. They
are said to be the commonest type of gall stone in Japan. They are
composed of bilirubin or calcium bilirubinate. They are said to be
translucent to X-rays, but that is not always true. They are multiple,
black, smooth and hard, or spiky and soft, and seldom larger than 3 mm. in
diameter. They are formed in the bile canaliculi of the liver itself, and may
therefore reach either the common duct or the gall bladder. They are
                                     319
                             SIR HENEAGE OGILVIE
  often symptomless, probably because stones of this size do not obstruct
  the biliary passage but can pass through the bile papilla into the intestine.
     Pure cholesterol stones are often found as solitary egg-shaped con-
  cretions in gall bladders that are macroscopically and microscopically
  normal. More often they are multiple, and seem to be part of a condition
  of cholesterosis, in which the mucous membrane lining the gall bladder
  is loaded with lipoid deposits that stop sharply where the cystic duct
  begins. These deposits are cholesterol esters, but their significance is
  unknown. It is not even known if cholesterol is under normal conditions
  secreted by the gall bladder, absorbed by the gall bladder, or merely enters
  and leaves the gall bladder in transit.
     Cholesterol metabolism is one of the unsolved mysteries of physiology.
  Cholesterol is everywhere, yet no one can tell us what purpose it serves.
  It is in all the tissues of the body, and most plentiful in what are
 considered the " key" organs-the brain, the liver and the kidneys. In
 the blood it occurs both in the plasma and the corpuscles. The cholesterol
 level in the blood is raised in pregnancy, but to a variable and not usually
 a significant degree, and it is not clear that women who have had children
 are any more liable to gall stones than their childless sisters of equal waist
 measurements.
    The common type of gall stone is a mixed stone. It has a nucleus of soft
 blackish material that is usually composed of pigment and bacteria, and
 round this are built concentric layers of cholesterol and calcium bilirubinate.
 It is usually multiple, and the stones are separable into " generations "-
 that is groups of the same size having a similar appearance and the same
 number of rings when cut across, suggesting that the members of each
 group were formed at the same time, and that they have been added to by
 the same series of events, probably attacks of infection.
    The cause of mixed gall stones-the commonest type-is quite unknown.
 The text books tell us that there are three main causes: first infection,
 secondly stasis of bile flow, and thirdly alteration in the proportion of the
 bile constituents.
    Infection may be a cause, and the fact that bacteria are commonly found
in the centre of mixed stones is a strong argument in favour of Moynihan's
aphorism, that " gall stones are tombstones erected to the memory of dead
bacteria." Apart from this solitary wisecrack, there is little to support the
infection theory. We are all infected. We are travelling incubators for
bacteria. Further, as soon as stones are formed, they, in themselves, invite
infection. Cholecystitis without stones, and stones without cholecystitis,
are equally rare. But in my own experience I have not been impressed with
the liability of those who have had typhoid fever, intestinal infections or
suppurative conditions in the territory of the portal vein, or those who
have had septicaemia and recovered, to suffer subsequently from gall
stones. Bile stasis may be a cause, but bile stasis is one of those meaningless
generalisations of which medical text books are largely composed.
                                      320
                       THE SURGERY OF GALL STONES
   My experience has led me to believe that the common mixed stones are
the price we pay for contentment, prosperity and good living, just as
coronary thrombosis is the price we pay for the anxieties of a medical
career, and cancer of the lung is the price we pay for smoking cigarettes
and living in cities. I throw this out as a suggestion, but I cannot put it
any more strongly.
   Three years ago I paid a surgical exchange visit to New Zealand. I
found that in the general wards operations for gall stones outnumber
those for duodenal ulcer by six to one. New Zealand is the land of cream,
butter, eggs, and Canterbury lamb. In Britain, the land of austerity, the
proportion is very different. At Guy's Hospital there were, in a certain
period, 321 operations for duodenal ulcer and 301 for gall stones. In my
own private practice, operations for ulcer outnumber those'for gall stones
by four to three.
   A recent paper gives the following figures for the plasma/cholesterol in
various species:
                Species         Total cholesterol mg./100 ml. plasma
              Man ..        ..       ..     ..   213
              Dog ..        ..       ..     ..   194
              Horse ..      ..       ..     ..   128
              Cat     ..    ..       ..     ..    98
              Mouse         ..       ..     ..    97
              Sheep         ..       ..     ..     64
              Ox      ..    ..       ..     ..     63
              Guinea pig ..          ..     ..     50
              Rabbit        ..       ..     ..     46
              Rat ..         ..      ..     ..     43
              Goat ..        ..      ..     ..     34
   It seems noteworthy that the leaders in the cholesterol stakes, man, the
 dog, and the horse are all creatures that live luxurious lives, or at any rate
 are supplied with food that in quantity and quality usually exceeds their
 metabolic requirements.
    In my youth I became interested in peptic ulceration, a disease limited to
 harassed and frustrated people engaged in the struggle for survival and
 making rather heavy weather of it. Most of my patients are struggling to
 get to the top, or, having failed, are on the way down again. In either case
 they are about as hard up as they can be. If I am advising a young entrant
 to consultant practice I say: "Avoid duodenal ulcer and surgical tuber-
 culosis. Specialise on prostatic enlargement, osteoarthritis of the hip, and
 gall stones. They are the diseases that affect the well to do at the period
 of their maximum prosperity."
    In the last phases of the recent war, a surprising discovery was that the
 majority of the corpses found in Belsen had gall stones, and among the
 afflictions of those rescued in time, one of the most common was gall
                                        321
                            SIR HENEAGE OGILVIE
 stone colic. It was suggested at the time by humanitarians that starvation,
 by causing biliary stasis, had caused gall stones. They forgot that the
 people who died in Belsen had been put there by Hitler largely because
 they had been prosperous and well fed.
    One reason why the subject of gall stones is such an important one to-
 day, is the light-hearted manner in which it is treated in most text books,
 indeed by most teachers of medicine. They speak of it as a minor penalty
 of middle age, a complaint that is a bit of a nuisance because it is apt to
detract from the enjoyment of life just when life is beginning to be
enjoyable, and because it imposes some wearisome restrictions in diet.
They tell us that many people have gall stones for years without suffering
any great inconvenience, that many go to the grave without knowing that
they have them. They point out that if treatment is really needed it can
be conducted (as indeed the treatment of all those ailments that particularly
affect the rich is conducted) under very pleasant circumstances in one of
those Spas in England or the Continent that specialises in the treatment of
the liver. I must emphasise the other side of this pleasant picture, even
though in so doing I risk having my effigy burnt in Harrogate and Vichy.
   It is true that gall stones are often discovered accidentally during a
radiographic examination done for some other reason, or at a post-
mortem examination in a patient who has died from some other cause.
Yet even these so-called silent gall stones are not really symptomless. A
careful enquiry will nearly always elicit many of the prodromal symptoms
of gall stones-a dislike of certain articles of diet, a tendency to upper-
abdominal distension after meals, attacks of vomiting associated with
blinding headaches that have been put down to migraine, long periods of
lassitude, fatigue, and inability to carry out duties that were formerly a
pleasure. Most striking is the fact that after cholecystectomy (and
cholecystectomy must always be advised when gall stones have been
demonstrated), the patient immediately experiences a joy in life and a
feeling of fitness that makes him realise he was unfit before.
   I say with all seriousness that when gall stones have been found,
operation should be advised, even if they are not giving rise to symptoms,
or even if the symptoms of which the patient complains are thought to
be due to something else. Two diagnostic errors are particularly common
in this respect-hiatus hernia and angina pectoris.
   Hiatus hernia is one of the most recent surgical toys. Now that we are
aware of its existence, now that we have learnt its symptomatology, now
that radiologists have learnt to demonstrate it, we are finding it in some-
thing like 20 per cent. of people of middle age, particularly those who are
over-weight. The commonest surgical error to-day is the repair by a
thoracic surgeon of a harmless hiatus hernia when the real trouble is gall
stones. Angina pectoris is a symptom, a painful muscular spasm due to
cardiac ischaemia, but one that can be simulated with a closeness that will
deceive the expert by the muscular spasm of gall stone colic, and by the
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                       THE   SURGERY   OF   GALL STONES
cardio-oesophageal spasm occasioned by a small hiatus hernia. Angina
pectoris cannot be cured. " Angina pectoris " the symptom, is often cured
by the removal of a calculous gall bladder.
   Gall stones may present four different clinical pictures, though the four
types tend to overlap. They are:
      1. Stone in the gall bladder, with chronic cholecystitis, giving rise to
        gastric symptoms only.
      2. Stone in the cystic duct giving rise to gall bladder colic.
      3. Stone in the gall bladder or cystic duct, with acute infection added,
        giving rise to an acute abdominal emergency.
      4. Stone in the common bile duct.
    1. The typical subject of gall stones is said to be a fair, fat, flatulent
 fecund female of forty. Like most generalisations, this one has just
enough truth in it to keep it in the text books. They are usually fat, but
the colour of their hair varies with the fashion of the moment. They are
 often about forty, but gall stones may first give symptoms (and they are
not often discovered till they give symptoms) at any age from sixteen to
ninety-six. The association with pregnancy and various infections is
unproven. Gall stones may be discovered in a chance X-ray. More often
there are dyspeptic symptoms referred to the stomach. The diagnosis is
confirmed by the demonstration of stones in a plain skiagram, or a failure
of concentration of the dye in cholecystography.
   The medical treatment of gall stone dyspepsia is irrational, verging on
the dishonest. It depends on avoiding stimuli to contraction of the gall
bladder, in order to avoid discomfort. This is attained by a fat free diet;
but to combine this diet with the administration of magnesium sulphate,
as is often done, is illogical. Sulphonamides are often given as well to
counteract infection, but sterilisation of a gall bladder containing stones
can be only temporary. The claim that the stones can be dissolved, or that
the gall bladder can be made to empty them down the duct system and
return to its former state of health is the stock in trade of quacks. It has
no basis in fact.
   2. The entry of a stone into the cystic duct is marked by an attack of
gall stone colic. A " gall stone attack " strikes unheralded at any time of
day or night. There may have been a feeling of heaviness beforehand, but
usually the first symptom is an attack of pain that in a few minutes becomes
agonising. The pain is extreme, exceeded possibly by that of a duodenal
perforation or of coronary infarction, but certainly worse than labour
pain. It demands the administration of morphia. It may vary in intensity,
but is more usually a continuous cramp. It lasts at maximum intensity for
one to six hours and then fades away, but usually leaves a soreness for a
couple of days. The site of the pain is described with difficulty. It is deep
in the epigastrium, and may bore through to the shoulder blades, but more
accurate localisation is not found unless there is infection.
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27
                             SIR HENEAGE OGILVIE
     There are few physical signs. The muscles are not rigid. On deep
  inspiration the round outline of a distended gall bladder may be felt,
  and when it reaches the fingers there is an involuntary catch in respiration
 (Murphy's sign).
    The differential diagnosis of a first attack from renal colic or angina
  may be difficult. The pain of renal colic is usually unilateral, and tends
 to spread to the groin. The urine contains visible blood, or red cells when
 it is examined microscopically. The pain of angina may be epigastric,
 but it tends to be felt also in the chest and the arm. Cyanosis, a feeble or
 irregular pulse, visible pulsation in the neck veins, and a low blood pressure
 all point to heart rather than gall bladder. All three conditions demand
 morphia and complete rest, and within a few hours the diagnosis is usually
 clear. If the patient has had gall stone colic he will immediately recognise
 another attack.
    (3) Acute as opposed to chronic infection is seldom seen except in
 a gall bladder whose drainage is obstructed by an impacted stone. The
 attack starts like one of gall stone colic, with sudden agonising pain,
 but the patient also feels ill. The pain, starting as a colic, changes to a
 dull ache. From being vaguely epigastric, it becomes localised to the
anatomical site of the gall bladder. It is made worse by breathing and by
 movement. It is often worse when the patient lies on the left side, since
in this position the drag of the liver subjects the inflamed gall bladder
to negative pressure and increases the tension in its tissues. Shivering
 and malaise are complained of.
   The patient may be of gall stone type but in any case he has the
appearance of a well person who has just become ill. The temperature,
pulse and respiration in an average case seen early are only moderately
raised, 1020 F., 100, and 24 respectively. On inspection the upper half
of the abdominal wall is seen to move poorly, and the inspiratory move-
ment may stop with a jerk. The upper right half of the rectus muscle is
found to be guarded, or even rigid. The outline of a distended gall
bladder usually becomes apparent only when the acute inflammatory
process has started to subside and the rigidity is diminishing. If on the
other hand the infection continues, a mass that moves little or not at
all on respiration may be felt. Tenderness is found over the gall bladder
in mild cases, and is replaced by a fixed tenderness when an inflammatory
mass has formed round it. In many cases firm pressure over the right
eleventh rib behind also produces pain. Hyperaesthesia to the stroke of
a blunt point may be found over the skin of the right upper abdominal
quadrant, over the lower angle of the right scapula, or over the right
acromion. Peristaltic sounds may be absent in the right upper quadrant,
but will be heard elsewhere. There may be jaundice; but more often
evidence of obstruction to biliary flow is shown by a light colour of the
stools and a dark greenish tinge in the urine, which gives the tests for
bile.
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                        THE SURGERY OF GALL STONES
   In the early stages an attack of acute cholecystitis may resemble one
of renal colic or angina, but when the signs of infection have appeared
it is more likely to be confused with other abdominal emergencies causing
peritoneal irritation, particularly with acute pancreatitis, perforation of a
duodenal ulcer and acute appendicitis. Acute pancreatitis usually occurs
in patients with gall stones, but though the onset may resemble that of
an acute cholecystitis, the signs are soon those of a general peritonitis
and include tenderness on rectal examination and the cessation of peri-
staltic sounds. A localised leak from a small duodenal ulcer, and in-
flamnmation in a high appendix may both give rise to difficulty. A plain
radiological examination will often help by showing gall stones, or, in
the case of a perforation, air under the diaphragm.
   Acute cholecystitis with stones is a surgical problem but not a surgical
emergency. The great majority of cases settle down with conservative
treatment, and those that do not, give abundant warning of the need
for operation. Most of the disasters of gall bladder surgery are due to
emergency operations undertaken unnecessarily, rather than to delay.
A cholecystectomy performed some weeks after the acute symptoms
have subsided is easier, safer and more satisfactory.
   The plan of conservative treatment is one of hoping for the best while
preparing for the worst. The patient is kept on a fluid diet. The tempera-
ture, pulse and respiration are charted every four hours, and the leucocyte
count is recorded daily. If a mass is present, its outline is marked on the
skin with ink, and any changes in size are noted on the chart. Chemo-
therapy with penicillin and one of the sulphonamides is instituted, and
the fluid, protein and salt balance is carefully maintained.
   If the fever and the mass are tending to decrease, the attack should be
allowed to subside, and cholecystectomy should be performed after an
interval sufficient to allow the inflammatory oedema to be absorbed,
usually one of at least three weeks.
   If after forty-eight hours the mass is larger, the leucocytosis is increasing,
and the temperature is further elevated, operation should be undertaken.
The primary object of such an operation is to save life. Drainage is all
that should be attempted in the worst cases. If there is an empyema of
the gall bladder but its walls are not gangrenous, the stones should be
evacuated, particularly the key stone which by blocking the cystic duct
precipitated the attack, and a tube should be sewn in. In less severe
infections, the gall bladder may be removed, but the operation is not one
that should be undertaken by any but an experienced surgeon. The gall
bladder can be shelled easily out of its oedematous bed, but the identifica-
tion of the duct junctions and accurate ligation of the cystic duct and
artery can be a matter of great difficulty under these conditions.
   (4) The presence of stones in the common duct cannot be diagnosed
with any certainty. They seldom give rise to more than transient jaundice,
and even jaundice is absent in more than half the cases.
                                      325
28
                           SIR HENEAGE OGILVIE
   Usually there have been repeated attacks of gall stone colic that have
gradually changed their character. Whereas formerly they were dramatic,
short-lived, accompanied by severe pain and separated by intervals of
normal health, they are now frequent, and lead to a gradual deterioration.
The pain is less severe than that occasioned by a stone impacted in the
cystic duct. It is often felt deeply, radiating around both flanks to the
back, and resembling that arising in the pancreas. Jaundice is usually
slight and intermittent, the stools are pale and the urine is dark. There
is intermittent low fever, often accompanied by shivering attacks, itching,
and loss of weight.
   As in the gall bladder, so in the common duct, obstruction leads to
infection. When infection occurs round a stone lying at the lower end of
the duct, the oedema added to the mechanical obstruction can cause severe
jaundice of long duration. The oedema may subside and the jaundice
lessen for a time as the obstruction to the bile flow is relieved, but to the
mechanical obstruction caused by the stone is added that of the biliary
mud that accumulates round it, and jaundice, more severe and persistent,
returns. Increasing infection of the biliary passages leads to enlargement
and tenderness of the liver accompanied by recurring rigors. If the
obstruction is not relieved by surgery a septic cholangitis follows; the
bile in the larger biliary passages becomes turbid or frankly purulent, and
multiple small abscesses form in the liver round the terminal bile ducts.
Death from liver failure follows.
   As in cholelithiasis generally, operation should, if possible, be per-
formed during an interval between attacks, but jaundice that is not
obviously clearing is an indication for exploration when it is known
that the obstructing stone is in the common duct, since the risks of an
ascending cholangitis exceed those of operation in a cholaemic patient.
   The preparation for operation should be that for cholaemia: abundant
fluids, high proteins and high carbohydrate diet, and vitamin K. Chemo-
therapy should be started, and continued for a week at any rate after
operation.
   The operation cannot follow any set rule, but the one essential step is
drainage of the common duct. Unless the risk of prolonging the operation
appears to be prohibitive, the duct should also be cleared of stones and
the gall bladder that formed the stones should be removed, or at any rate
 emptied and drained. The gall bladder is usually left to the end of the
 operation, as it forms a useful handle with which the assistant holds the
liver out of the way and brings the proximal part of the common duct
into view.
   The course of gall stone disease can be divided into two stages, of which
the first always precedes the second. In the first stage the stones are in
the gall bladder; in the second stage some of them have entered the
common duct. The first stage is a nuisance and a warning, but it is not
particularly dangerous. The second stage brings the likelihood of a number
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                        THE SURGERY OF GALL STONES
of complications, all of them dangerous, some of them fatal. The difference
is very like that between a precancerous lesion and a cancer. We advise
the removal of a precancerous lesion before it becomes malignant. We
should advise removal of a calculous gall bladder before the stones enter
the common duct.
   To any young surgeon I would say " Leave the common duct alone."
To you I would give the same advice, but with the qualifying rider that
you should use it very carefully at the Fellowship examination, for surgical
writers, in England and America and on the Continent, delight in playing
about with this very delicate structure.
   If the common duct contains stones it must be opened. The stones
must be removed and the duct drained, but never for longer than three
weeks. But if the duct does not contain stones it must not be opened
out of curiosity, or because the author of " What's what in Surgery"
says so. A duct whose diameter does not exceed 7 mm., whose colour
is light grey, whose contents as sampled by needle exploration are clear
yellow and free from debris or mucus, one that feels smooth from
end to end when felt between the finger and thumb, does not contain
stones large enough to require removal. If, in addition, the stones in
the gall bladder are larger than the cystic duct, we can be certain that
none have gone down.
   I say " Leave the common duct alone," because I have been associated
for many years with two hospitals, The Royal Masonic and the Queen
Alexandra Military Hospital at Millbank, to which the disasters of
surgery are sent from all over the world. Two sequelae of biliary surgery
have come my way; injury of the common bile duct and residual stone in
the common duct, the one due to doing too much, the other to doing too
little. Of the two the first is infinitely the more serious. The operation for
a stone left behind in the common duct is one of the easiest in surgery.
The common duct is dilated, and lies under the hand like the barrel of a
fountain pen. The stone rattles about inside it. All that is needed is a
small incision, removal of the stone, and temporary drainage of the duct.
On the other hand injury of the common duct requires an operation of the
greatest difficulty to repair it, if it can be repaired, an operation that is not
always successful.
   I am anxious to discourage wanton exploration of the common bile
duct, because of the many sequelae of such interferences. The common
bile duct is one of the most delicate structures in the body. Its walls are
thin and contain no muscle tissue, and in its lower third they are almost
cribriform. If it is opened it must be drained, for bile is, to the peritoneum
at any rate, a most irritating fluid. It produces an intense inflammatory
reaction, that leaves adhesions denser than are found following any other
form of peritonitis. If the amount of extravasation is at all large, septic
peritonitis follows. A drain in the common bile duct must therefore be
                                         327
28-2
                            SIR HENEAGE OGILVIE
left in till its track is safely sealed off from the general peritoneal cavity,
that is, for about ten days.
   Surgeons are not happy about draining the duct. Most of us use a T
tube, and most of us agree that a T tube is a traumatic piece of apparatus.
The bile duct is easily torn. In exploration, the mere insertion of a probe
may enlarge a three-eighth inch cut into an inch long tear. How much worse
is it to withdraw a tube in the lumen by a pull at right angles to its length?
Thinning out the junction of the T tube with scissors lessens the trauma,
but does not abolish it. Some surgeons now close the incision in the duct
and drain down to it, a method that avoids direct damage to the duct,
but does not prevent a certain amount of bile leakage.
    Symptoms indicating partial or recurring obstruction to the common
bile duct are not uncommon after biliary surgery, but they are seldom
seen unless the common duct has been explored. The mere introduction
of an exploring instrument into such a delicate structure constitutes
trauma. Injection of an irritating chemical, such as the iodine com-
pounds used for chromo-radiography, is more traumatic. Dilatation
of the sphincter at the lower end to a diameter of over 7 mm. is most
traumatic. In contradistinction to the more dramatic disasters of dog
surgery, the results of injury by lesser trauma and by chemical insult are
not apparent for some time. Signs of duct obstruction occurring within
the first two years after cholecystectomy suggest that a stone has been left
behind. Signs appearing later are more often due to the results of
inflammation, to stricture at the bile papilla, or to stenosing choledochitis,
a diffuse inflammatory change involving the whole common duct.
    There has been much talk within recent years about disturbances of
 function in the biliary track, particularly after cholecystectomy. There
 is a striking difference between the result of cholecystectomy for stones,
 and cholecystectomy for non-calculous cholecystitis. The results in the
 first case are eminently satisfactory. In the second case they are unsatis-
 factory in about 30 per cent. A calculous gall bladder has usually ceased
 to function for some time, and its removal does not affect the hydraulics of
 the biliary system. The non-calculous gall bladder is usually a normal gall
 bladder wrongly accused, at any rate one that is still able to fill its roles
 of concentration and synchronised evacuation. When such a gall bladder
 is removed, the amount of bile reaching the lower end of the duct is
 suddenly increased, and the flow is continuous instead of intermittent.
 The sphincter of Oddi, designed to relax in response to a chemical stimulus
 that also causes the gall bladder to contract, responds to the unwonted
 pressure by painful spasm, a spasm that is made worse by morphia. This
 unfortunate sequal of unwise cholecystectomy is dignified by the name of
 choledocho-dyskinesia. It seldom persists longer than a year, but in the
 few cases in which it persists, it can be cured by division of the sphincter
 of Oddi.
    Dysfunction of the common duct has been studied by Mallet-Guy of
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                       THE SURGERY OF GALL STONES

Lyons by recording intra-duct pressure and by cholangiography. He
tells us that the normal pressure in the duct varies between 8 and 14 mm.
of water. A pressure above this range indicates hypertonus, due to spasm
of the sphincter or to mechanical obstruction. Pressure below this range
indicates hypotonus. He treats hypertonus by a low vagotomy, since the
sphincter is said to be innervated by the vagus. He treats hypotonus by
division of the right splanchnic nerve.
   I have visited Mallet-Guy at Lyons, but, like Omar Khayam, I have
come out by the same door as in I went. I was impressed, as any visitor
must be, by his enthusiasm and his sincerity, but I was not convinced by
the soundness of his theory or the success of his treatment.
   I would agree that increased pressure may be found in the common bile
duct after cholecystectomy, but it is a temporary dysfunction following
unwise removal of a functioning gall bladder, it is recognised by ordinary
clinical means, and it usually cures itself. I am not convinced by the
importance of hypotonus. The pressure in the duct may be low, but it is
difficult to understand why that should be a cause of symptoms. Pain in
structures innervated by the sympathetic system is due to traction, to
spasm, or to distension, but never to lack of tone. Still less am I convinced
of the soundness of Mallet-Guy's treatment by nerve division. The
autonomic system has guided and controlled all those functions of the
body that require adjustment to meet changing needs for at least a
thousand million years. In that time it has come to do the job very well.
The central nervous system is a comparative upstart, and goes wrong very
easily. When the function of viscera goes wrong, it is not the autonomic
control but the direction or interpretation by the central nervous system
that is at fault. Surgery is seen at its worst when it attempts to remedy
visceral dysfunction. The pexies and the sling operations designed to
remedy ptosis or atony belong to the disreputable past. Operations on
the autonomic nerves to remedy dysfunction, division of the vagi or of the
sympathetic innervation of viscera, belong to the slightly bogus present.
I must allow you to pay lip-service to them while you sit as candidates for
surgical diplomas, but I urge you to put them for ever behind you when
you become surgeons.
   To recapitulate. Biliary stones, except for the uncommon pure pigment
variety, are formed in the gall bladder and nowhere else. For months,
often for years, they remain in the gall bladder, a nuisance and a possible
danger, but one that can be removed by cholecystectomy. The operation
should involve removing the gall bladder and its contents, but nothing
else with the possible exception of the appendix. Appendicitis and
cholecystitis are so often linked that the appendix should be removed
during cholecystectomy if this can be done without adding to the length
of the operation or of the incision.
   When stones leave the gall bladder, they pass from a diverticulum into
                                     329
                          SIR HENEAGE OGILVIE
the main drainage channel of the liver, and the disease enters a new and
more dangerous phase. Any number of complications, some serious, some
fatal, are now not merely possible, but more probable with each week that
passes. The patient with stones in the common duct faces many dangers,
not the least of which is injudicious surgery.


         PROCEEDINGS OF THE COUNCIL IN OCTOBER
   AT A MEETING of the Council on 10th October, with Prof. Sir James
Paterson Ross, President, in the Chair, Mr. N. R. Barrett (St. Thomas's)
was admitted to the Court of Examiners.
   The Mitchiner Medal was presented to Lieut.-Colonel P.D. Stewart by
the Director-General of the Army Medical Service (Lt. Gen. Sir Alexander
Drummond) and the Lady Cade Medal was presented to Squadron-
Leader E. J. McGuire by the Director-General of the Medical Service of
the Royal Air Force (Air Marshal P. B. Lee Potter).
   The Handcock Prize was presented to A. W. Asscher of the London
Hospital Medical School.
   The death of Dr. Rudolph Matas (New Orleans) Honorary Fellow of
the College, was reported (see page 334).
   Diplomas were granted as follows:
Membership (5); Fellowship (1); Fellowship in Dental Surgery (12);
Fellowship in the Faculty of Anaesthetists (23); Orthodontics (14).
   Diplomas were granted, jointly with the Royal College of Physicians,
in Ophthalmology (24); Child Health (80); Tropical Medicine and Hygiene
(38); Physical Medicine (2); and Industrial Health (1).
   Dr. G. H. Sloane-Stanley was appointed Leverhulme Research Fellow
in Biochemistry.
   A memorandum on the welfare of ill children in hospital was approved
for submission to the Central Health Services Council Committee which
is investigating this matter.
   The Council noted that no James Berry Prize Essay had been received
for the quinquennial period ending 1st October 1957.
   The following interesting gifts were gratefully received, in addition to
those reported under Donations on page 333.
   From Sir Cecil Wakeley, Bt., an etching of the old King's College
Hospital in Portugal Street.
   From Sir Louis Fergusson, a portrait of Sir William Fergusson.
   From Mr. Anthony Thompson, relics of his great-grandfather Sir
James Paget.
   From Dr. Howard Naffziger, Hon. F.R.C.S., a visitors' book for use
in the Visiting Professor's Flat in the Nuffield College.
   From Messrs. Cooper Triffitt and Co., a further gift of £1,000 for the
Sims Commonwealth Travelling Professorship Fund.
   From Mr. G. A. Callow (per Prof. Milnes Walker): a gift of £25.
                                     330

				
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