The Illinois [ledical Journal.

The Official Organ ef The Illinois State Medical Society.

Vol. VIII. No.4. 25c per copy

bISEASES OF THE BILE TRACTS.*

CARL E. BLACK, , JACKSONVILLE.

Bewildering Situation. In considering seases and disorders of the bile tracts we e confronted by a situation which is some-

\ hat bewildering.

Rapid Progress.— Progress has been so rapid and the advances so irregular that it is especially difficult for the general practi- tioner who has not kept up with each ad-

nee to understand the new etiology and pathology on which the present surgical treat- ment is based.

Living Pathology.—Surgery has brought

us a knowledge of conditions as they exist

n the living subject, and this has led to con-

clusions at variance with those derived from

dead-room pathology.

Post-mortem Pathology.—The great diffi- culty at present is that the post-mortem path- ology, with its deductions, still possesses the minds of the great body of the medical pro- fession and the deductions of the operating table are only beginning to be understood.

Double Nomenclature—This gives rise to

double nomenclature, and in fact, nearly every book, no matter how recent, is more or less biased by the old conclusions.

Foundation Principles.—In this study the principal thing which one must do is to dis- card, for the moment, details and seek found- ation principles.

Questions are Simple.—After reading a

luminous literature on the subject of “Dis- eases of the Bile Tracts,” it appears that after

the whole question is far simpler than at

st supposed. In fact, a correct understand- ing of any disease or group of diseases always leads to simplicity.

Jaundice Only a Symptom.—At the outset

*,ead at the 55th Annual May 17, 1905.

Meeting, Rock Island,

Springfield, Ill., October, 1905.

SUBSCRIPTION $2.00 A YEAR.

we must dismiss jaundice as only a symptom, and in no other way a part cf the classified diseases of the bile tracts and not essential to them.

The from the practical standpoint of treatment, is the correct diag-

Correct Diagnosis Most Important.

most important thing,

nosis. This paper will be larg: ly devoted to a consideration of some of the important ele- ments in diagnosis. Old Diagnosis Points ar Giving Away to New.—Nothing so strongly impresses itself in reading the literature as the fact that the diagnostic points, which were formerly held as all important, must now give way to others which until recently were either overlooked of significance.

or considered slight

Correct Diagnosis—The question which confronts the surgeon, and prior to him his colleague in general practice, is the correct diagnosis of the case in hand. The practical first, is the disease in the bile tracts; second, what part or parts are in- volved; and third, what is the character of the disorder.

quest ions are:

Operation May be Based on Rither Conclu- sion.—The anatomical relations of the bile ducts and gall-bladder rarely make it possi- ble, to apply direct methods of diagnosis. Their location the differential method. We must often arrive at

necessitates a conclu- sion by exclusion and not infrequently resort to an and direct examination. It will not be difficult usually to determine that

incision

the case is one requiring surgical interfer- ence and as the practitioner gives these dis- eases more careful study it should be almost as easy to arrive at a diagnosis of disease of the bile passages as of disease of the appendix in the female.

Classification of Diseases.—We find in the bile tracts only three classes of disease :

First, That due to inflammation.

276

Second, That due to foreign bodies within the bile tracts.

Third, That due to pressure upon the bile tracts from without.

Injuries and Malformations.—With the exception of injuries and malformations, there is no disorder of the bile tracts which cannot be classed under one of these head- ings.

Inflammatory Disorders. Inflammatory disorders, of course, include all the infec- tions, whether acute or chronic, which pro- duce catarrhal, suppurative, phlegmonous or

DISEASES OF THE BILE TRACTS—BLACK.

ed, which, while they are not very true t nature, may assist in following the subject.

Surgical Treatment.—The surgical trea ment of these tracts was, until a comparativ: ly recent date, confined to operations for ga stones. It would, therefore, seem proper i studying the basis of the diagnosis of the: diseases that we first consider their relati: to gall stones.

Gall-stones, Their Frequency.—It has be estimated that 10% of adults have gall-ston: and that 5% of these have symptoms arisi! from them or in connection with them. Th

BILE TRACTS

AND

THEIR RELATIONS

a ¢ pest

FIGURE. L. Bile Tracts and their relations (after Kehr, 1905) showing Gall-Bladder; Bile Tracts; Kidneys; Spleen; Pancreas and portions of Liver, Duodenum and Arteries

and Veins.

gangrenous inflammations, but these are in no way peculiar to the bile tracts, or the gall bladder. They occur in the appendix, in the tubes and ovaries, and, in fact, are common to every mucous surface and mucous cavity.

Foreign Bodies.—Foreign bodies include, first of all, calculi; second, parasites; and, third, miscellaneous foreign bodies.

Pressure from Without.—Those disorders which produce disease by pressure from with- out include benign and malignant tumors and diseases of neighboring parts

Diagrams.—Several diagrams are present-

brings up the interesting question, as to what causes latent calculi to become active ?

Gall-stones. Their role in Producing Dis- eases of Bladder and Ducts.—The role of ga stones in diseases of the gall ducts and gal bladder is as yet in much disagreement. It is well known that gall stones are frequentl\ found post-mortem without having produce: symptoms, and in fact cases are on record where gall stones have ulcerated through and caused intestinal obstruction without suifi- cient symptoms from the biliary apparatus t attract attention. They are an indirect caus

DISEASES OF THE BILE TRACTS—BLACK.

f acute catarrh of the bile passages, and in ippurative cholangitis there is frequently a story of one or more attacks of gall stone lic; and, in fact, some recent authors speak ' gall stones as one of the most important uses of suppurative cholangitis. To say e least, suppurative cholangitis is usually ssociated with stones in the gall bladder. At- icks caused by catarrh of the gall bladder ay simulate those due to gall stones so close- that it is impossible to differentiate, ex- pting that in the catarrhal attacks the mptoms are less severe and prolonged. No <‘ones are found in the evacuations. Jaun- ce is either absent or slight and there is no nderness on pressure.

Gall Stones Active Only in Presence of In- ction.—Gall stones rarely become active ithout the presence of infection, and they never produce symptoms until they interfere with drainage.

Obstruction from Gall Stones—When they rovide irritation for infection they produce nflammation and when they try to escape

ey obstruct the flow of bile and produce iundice.

Calculous Formation and Infection.—We will not take up the various questions involv- d in infection and calculous formation. It vill be sufficient to say that there is a wide

fference of opinion. It is not important to

ir consideration whether infection always

precedes, and is the cause of formation of ileuli, or whether calculi are formed with- it infection and by their irritation invite ifection.

Presence of Gall Stones an Incident.—As

matter of surgical experience we never find ileuli without a certain amount of infection, nd the infective disorders are frequently ac- mpanied by calculi,which in themselves may

may not have been symptom producing t would appear that the factor of infection more important, even in the presence of all stones, in the production of symptoms, ian the calculi themselves. The presence of

ill stones is usually an incident of the in- ammatory disorders of the bile tracts rather 1an the cause. However, further studies in ie operating room may change or modify

orn” ~ae

this conception. The point is one which is still under discussion. The phrase “Gall- stone Disease” has given rise to considerable misunderstanding as to the real nature of the process and should be abandoned as mislead- ing. While the formation of calculi is path- ological the symptom producing process in these cases is usually the inflammation rather than the presence of calculi.

Jaundice.—A peculiarity of these diseases is that we have one sign which is absolutely reliable in pointing to diseases of the bile tracts; namely, jaundice. But while the presence of this sign is positive proof of ob- struction to the flow of bile, jaundice alone is a poor guide as to the location or nature of the obstruction, and its absence is no proof that disease of the bile passages does not exist.

A Recent Book on Jaundice.—One of the most recent and up-to-date books upon this subject, published during the present year, introduces a chapter upon jaundice, and in the second paragraph says, “Like albumin- uria, it is a symptom and not a disease ;” that it is caused by obstruction to the flow of bile; that the cause of the obstruction is the dis- ease and jaundice like pain, fever, ete. is only a symptom. After making this plain, fair and eminently true statement, the author proceedes to introduce sixty-four pages upon the subject of jaundice, in which he discusses its pathology, its varieties, its’ signs, symp- toms and diagnosis. He speaks at length of its prognosis and its treatment, and later takes up the etiology, diagnosis, morbid anat- omy and clinical characters of various kinds of jaundice. To one who is really desirous of getting at the truth of diseases of the bile tracts such a mixture of classification savors of ancient history.

The literature of jaundice is voluminous, notwithstanding the fact that it is only a symptom and not the disease. It is the one conspicuous and unmistakable sign of disease of the bile passages and, as a consequence, has been loaded down with the whole weight of diagnostic evidence. It has had so much prominence that it is not surprising that ob- servers have regarded it as the disease rather

DISEASES OF THE BILE TRACTS—BLACK.

than only one important symptom which may be absent even in cases of great severity. We must return to fundamental principles and recognize the fact that jaundice has only one cause—namely, obstruction to the discharge of bile. This obstruction may be multiple from occlusion of the minute bile cappilaries as in inflammation of the liver; it may be from multiple calculi in the small hepatic ducts; from a stone in one of the larger hepatic ducts or in the main hepatic ducts: from a stone in the cystic duct or in the com- mon duct. Instead of stone, the obstruction

may be from swelling and induration or

these disorders. Pain is often difficult t understand. All are familiar with the pai of hepatic colic.

Pain.—It may vary from slight vagu pains in the region of the stomach to the mos’ acute localized colic. Pain is most marke: in those cases of obstruction in the commo1 duct, in which dull aching alternates wit! acute severe pain, coming on suddenly, usu ally in the right hypochondrium and ofter shooting up toward the right shoulder, and i1 severer cases the pain is over the whole ab domen. Of course, if we have severe par- oxysms of pain accompanied by chill, sweat

BILE TRACTS «0 THEIR RELATIONS

FIGURE. Il. _. Bile Tracts and their relations, showing Gall-Bladder; Bile Tracts; Liver; Right Kidney; Stomach; Duodenum and portion of Pancreas; Spleen and Left Kidney.

mucous plugs or foreign bodies or from pres- sure from without, but, in all these condi- tions and locations, the underlying and ulti- mate cause of jaundice is always the same— obstruction to the flow of bile through the ducts and its resorption into the circulation where it is carried to all parts of the body and discolors by deposit of bile pigment. We will not undertake to discuss the effect of re- tained bile on the blood and blood vessels al- though this is very important when consider- ing surgical operation.

Next to gall stones and jaundice, pain has been one of the most important symptoms in

ing and fever, and deepening jaundice, th: diagnosis, as far as the bile tract is concerned is plain, but an examination of the histories of operated cases shows that neither jaundic: nor pain can alone be relied upon, as a basis for diagnosis.

Pain is frequently entirely absent in sup- purative cholangitis, while acute catarrh of the bile passages is not accompanied by pain. In cases accompanied by severe paroxysma! pain, occurring at irregular intervals, begin- ning in the right hypochondrium and radiat- ing over the whole abdomen and through th: right scapular region we can feel reasonabl)

DISEASES OF THE BILE TRACTS—BLACK. 279

re that we have inflammation of the bile ssages and that it may be accompanied by ill stones and that the conditions have given yse to more or less complete obstruction. Flying Pains.—Flying pains in the limbs e occasionally present in acute catarrh of e bile passages, and in a recent case we have served pain in the great toes, simulating e pain of gout accompanying a moderately vere catarrh of the bile passages. Occasion- y we will see cases in which the pain indi- tes the presence of gall stones, but the ob- ruction is caused not by stone, but by thick- ed and hardened mucus. I have recently erated on such a case. Pains Simulating Other Disorders.—Pain iy be in the pre-cordial region and simu- te angina-pectoris, or in the epigastric re- on, as in gastric ulcer, or it may be low wn, as in renal calculus. The pain may general; it may be between the scapulae, in the extremities. 1 have seen a case in vhich both the pain and tumor were in the sion of the appendix, and another with pain and tumor in the region of the um- icus, and diagnosed first an omental carcin- a on account of the nodular form of the We cannot base a diagnosis upon n alone, but must be guided by the pres- ce or absence of other symptoms which go » make up the differentiation. Pain is an portant symptom, but only important in nnection with other signs and symptoms.

mor.

C'hree Directions for Micro-organisms to nter—In considering the symptomotology the inflammatory diseases of the bile tracts must bear in mind that there are three rections through which the organisms of in- fection may enter.

First, and probably most commonly, they ay come through the common duct from the testinal canal.

Second, through the liver, which receives ud takes care of so much of the waste pro- icts of the body.

Third, directly through the walls of the ll bladder.

The Bile Tracts—We have in the bile racts long, narrow tubes connecting with a sed mucous cavity. These tubes have their

origin in the liver and their exit in the in- testinal canal, and may become infected from either direction.

Fever.—The fever in acute catarrh of the bile passages is usually due to the gastro- intestinal catarrh, and disappears with it. In the more severe inflammations the fever is continuous and frequently associated with chilliness and rigors. These are more mark- ed after formation of adhesions. While the fever is not characteristic, its presence, ac-

DIAGRAM SHOWING | VARIOUS SITUATIONS WHICH MAY BE OCCLPIET BYCALL STONES |

ay

» SP ( /

~

) a

FIGURE. IIL.

Showing positions in which calculi may be found in the ampullaof V ater; common duct; Cystic Duct; Gall- Bladder; Main Hepatic Duct and small Hepatic Ducts.

l P.

companied by chills and rigors, gives an important hint as to the nature of the process.

Mouth Conditions.—A bitter taste in the mouth, the foul breath, and the furred tongue are usually present in acute catarrh of the bile passages. Loss of Appetite-—In all the inflammatory diseases loss of appetite is prominent and important and is almost al- ways accompanied by nausea, and, sooner or later, by vomiting. Vomiting.—Vomiting is usually present in acute catarrh, and is often a prominent symptom in suppurative cholan-

280

gitis. The initial symptoms of cholelithiasis are often accompanied by vomiting, which is continuous, and may cause death by exhaus- tion. It is also a very common symptom of stone in the common duct.

Stomach Symptoms.—Indigestion or dys- pepsia, accompanied by loss of appetite, nau-

sea and vomiting, in which a diagnosis of

disease of the stomach or of the intestinal canal cannot be made and in which a movable kidney cannot be demonstrated are almost certainly dependent upon some disorder of the bile tract.

In arriving at a diagnosis we should care- fully study the diseases and disorders of the gastro-intestinal tract ; those from which the patient has suffered in the past as well as those present.

Dyspepsia.—Dyspepsia is frequently pres- ent in acute catarrh, or comes on as a se- quence of such disorders. It often accom- panies cholelithiasis, and is usually associated with chronic cholangitis, which, in most cases, is preceded by gastro-intestinal catarrh.

Gastro-intestinal Catarrh. Gastro-intes- tinal catarrh, diarrhoea, and dysentery are exceedingly important factors in the produc- tion of the inflammatory diseases, and a care- ful study of them is of the utmost import- ance in arriving at a diagnosis. Intestinal worms may be a factor in these diseases.

Enteritis—On the other hand, a mem- braneous or croupous enteritis is frequently associated with attacks of pain, like gall stone colic or inflammation of the gall ducts and apparently is caused entirely by obstruc- tion to the flow of bile by the inflammation in the intestine at the point of exit of the common duct without any disease of the bile passages.

Malaise—General malaise is also a prom- inent feature of inflammation of the bile tracts, suppurative cholecystitis and empyema of the gall bladder prior to ulceration and there is marked prostration. Loss of Weight. —Almost all the diseases of the bile passages give rise to loss of weight and they are often accompanied by severe constitutional symp- toms, especially where suppuration and septic absorption are present. Collapse.—Choleli-

DISEASES OF THE BILE TRACTS—BLACK.

thiasis may lead to collapse and death in severe attack. Occasionally the catarrhal o suppurative conditions occur during tl course of typhoid fever and are caused b the organism of that disease. Such a con plication is exceedingly serious.

Constipation.—Most of these diseases ar accompanied by chronic constipation, whi: may, from the accumulation of the feces : the hepatic flexure, interfere with the regula emptying of the gall bladder, or the const pation may be the result of the inflammator process. Offensive Stools——Fermentation i: the intestinal canal is often increased, givin rise to gaseous distention and very offensi\ stools, while interference with the discharg of the bile into the intestine leads to th characteristic clay colored _ stools. Cl Stools——Clay stools are coincident wit! jaundice and arise from the same cause.

Liver Tenderness. Liver tenderness very important in connection with diseas: of the bile ducts. While in acute catarrh t! tenderness is either slight or not present, in suppurative cholangitis and cholecystitis it very marked. In fact, we believe a mor careful palpation of cases complaining 0! pain in the upper abdomen or indefinite ga-- tro-intestinal symptoms will reveal circun scribed tenderness much oftener than is get erally supposed: This tenderness will not accompanied by swelling or tumor until ¢! ducts are blocked so that the bile is fore back into the gall bladder or liver. Empyen of Gall Bladder.—Empyema of the gall blad der will give rise to marked tumor.

Other Diseases.—We should always be o: the lookout for the history of other diseas: and illnesses. Acute inflammations or i! fectious fevers, as pneumonia, typhoid fev appendicitis, or diathetic diseases as gout an syphilis are among those which may be t! indirect or occasional cause of acute catar! or inflammation, while suppurative append citis may be the direct cause of a suppuratiy cholangitis.

Micro-organisms Present.—The charact: of the inflammation in the gall bladder an ducts is largely determined by the micro-or- ganisms present.

DISEASES OF THE BILE TRACTS—BLACK.

’osture and Position of Patient—The te, dency in the patient to bend toward the richt to contract the right rectus and other m. scles on the right side, and to draw up the

it thigh, and especially if accompanied by a ‘celing of fullness in the right hypochon-

im, are exceedingly suggestive. mmobility of Abdomen.—Immobility of

th: abdomen, which is especially marked after | peritonitis, has given rise to adhesions, ccompanied by tenderness on palpation, dulness on percussion are important

: in arriving at a diagnosis of suppurative ecystitis or cholangitis, empyema of the bladder, or recurrent catarrh of the bile

ages with adhesions.

erforation.—In the catarrhal inflamma- s there will be no adhesions if gall stones not been present. In the diagnosis of icted stones or suppurative inflammations usual symptoms of peritonitis are pres-

t and of great importance.

\dhesions Found.—In the course of these mmations, and especially those accom- ed by suppuration, and more particularly

hose in which gall stones are present, ad- hesions to neighboring organs are formed and {ten give rise to symptoms similar to those if gall stones. Usually where adhesions have formed there is an increase of fever, pain, tenderness, immobility of the abdomen, tym-

tes and in fact all the symptoms of a ized peritonitis.

\\here suppuration is followed by perfora- of the gall bladder, symptoms of acute onitis develop. Gall stones are usually nt in such cases.

Vbliteration Inflammatory Congenital.— n the diagnosis and operative treatment of lesions of these parts we must not forget

congenital as well as inflammatory ob- literation of the ducts and of the gall bladder and may lead to a futile search on

orc r

the part of the surgeon who, in his great fear

of overlooking a gall-bladder, contracted and

covcred in by adhesions, greatly prolongs his search,

\

‘must bear in mind that these disorders ery frequently secondary to other dis- . occurring even several years before. A

281

careful inquiry into the history of such dis- eases as well as the condition of neighboring organs will give important information and be of material assistance in arriving at a correct diagnosis. It is impossible in the brief time at our disposal to go into the details of these inter-relations.

The one important thing to remember is that the diagnosis will most often depend upon a careful analysis of the symptom com- plex presented by the patient, including the history of previous illnesses and allied dis- orders as well as the direct symptoms. He who depends upon the direct symptoms of jaundice, clay stools, and pain for the diag- nosis of disease of the bile tracts will over- look more than half the cases requiring sur- gical treatment and in just so far will fail to bring to his patients that relief to which recent medical progress entitles them.

The surgical treatment of these conditions has two objects. First, to remove foreign usually in the nature of calculi but occasionally inspissated mucus, parasites, other foreign bodies or new growths. Also to remove new growths or adhesions which are causing obstruction by pressure from without. Second, to secure drainage, which is undoubtedly the most important indica- tion.

bodies

Obstruction to these ducts is principally from inflammation and swelling which may or may not be associated with calculi or other foreign bodies. The obstruction may be in- complete, intermittent or complete, but the indications are always the same—drainage must be secured. This is the object which should be sought by rest in bed, and the ad- ministration of drugs as well as by surgical interference. We must reduce the swelling and overcome the obstruction in order that these tubes may be restored to a normal con- dition. All] other points in treatment are in- significant compared with the one point of securing drainage, nor is this peculiar to dis- eases of the bile tracts. It applies equally well to every mucous cavity and mucous tracts of the body. Inflammations and ob- structions to the antrum, the sinuses, the mastoid, the bladder, the intestinal canal and

282 DISEASES OF THE BILE TRACTS—BLACK.

the appendix, ete., cannot be treated success- fully without drainage. The inflammatory products must not be allowed to accumulate. The treatment of diseases of the gall tracts, as well as all other mucous cavities, and mucous tracts, will consist of ways and means of establishing and maintaining drainage. The application of this principle has opened up a field of usefulness for surgery which our colleagues of internal medicine must recog- nize and apply much earlier than is their present habit if we are to give that prompt and permanent relief to which modern prog- ress entitles our patients.

In conclusion it is urged that greater care in diagnosis and earlier operation will greatly shorten the period of suffering, greatly im- prove the results, both as to complications

and mortality and hasten the recovery of our patients, and in case of doubt an early explor-

ation will clear up the diagnosis and enable us to apply correct treatment. References to Literature.

The following is a list, arranged alphabetic- ally by authors, of the books and articles to which reference has been made in the prepara- tion of this paper. A few of the articles have not been accessible in the original.

1. Abbe, Robert—The Surgery of Gall Stone Obstruction, Med. Rec. Vol. 43, p. 543, May 6, 1893.

2. Addinsell, Augustus W.—Removal of Gall Bladder in a Woman, aged 75, British Med Jr.. p. 759, No, 2310, Apr. 8, 1905.

3. Alleban, J. E.—RKeport of Cases in Gall Bladder Surgery and Their Sequellae, Ill. Med. Jr., Vol. 49, p. 316, Jan. 1900.

4. Anders, J. M.—Cholecystitis as a Com- plication of Lobar Pneumonia: With a Report of Three Cases, and Remarks on Icterus in Pneu- monia. Am, Med., Vol. [X, p. 431, Mch. 18, 1905.

5 Jaundice with Reports of Interest- ing lllustrative Cases. A Contribution to the Toxic Forms of this Condition. Am. Jr. Med. Sci., Vol. (4) 125, p. 596, Apr. 1903.

6. Bangs, L. Bolten—Illustrative Cases of Calculous Diseases, Med. Rec., Vol. 47, p. 513, Apr. 2, 1895.

7. Barbat, J. Henry—Retention Cyst of Gall Bladder. Jour. A. M. A., Vol. 32, p. 923, Apr. 29, 1899.

8. Beck, Carl—Report of Four Cases of Fat- Necrosis in Connection with Gall Stones—From a Surgical Standpoint. J. A. M. A., Nov. 2, 1901.

9. Becker, Wilhelm—Primary Endothelioma of the Gall Bladder, Jour. A. M. A., Vol. 40, p. 897, Apr. 4, 1903.

10. Berg, Albert Ashton—Surgical Treat- ment of Cholelithiasis, Annals of Surgery, Vol. 38, p. 343, Sept. 1903.

11.

A Proposed Method of Retrod

denal Choledochotomy for the Removal of I: pacted Calculi in the Retroduodenal and Pap lary Portions of the Common Bile Duct. A nals of Surgery, Vol. 38, p. 275, Aug. 1903. 12. Bevan, A. D.—A New Incision for Surgery of the Bile Tracts. Jour A. M. A., \

28, p. 1225,

June 26, 1897.

13. Biggs, H. M.—The Distoma Sinense

Rare Form Sci., Vol. 10 14. Billi

of the Liver Fluke. A. Jr. of M 0, p. 30, July, 1890. ngs, Frank—Gall Stone of the Cys

Duct, with Situs Viscerum Inversus. Phil. M

Jr., Vol. 6,

p. 670, Oct. 6, 1900.

15. Blake, Edward—Intestinal Catarrhs.

16. Boor rhosis with

1e, H. B.—Hypertrophic Billiary Chronic Jaundice. Jour. Mors

County Med. So., Vol. 2, p. 14, Sept. 1899. 17. Brewer, George Emerson—Differen Diagnosis in Diseases of the Gall Bladder

Ducts. Mec

1. Rec., Vol. 58, p. 761, Nov. 17, 1

18. Brown, P. K.—Drug-Poisons Which } Produce Jaundice. Am. Jr. Med. Sci., Vol.

p. 770, 1901. 19. Bud

d, George—Diseases of the Liver

20. Camae, C. N. B.—Cholecystitis Com cating Typhoid Fever: Tapping of Gall-Bladd Cholecystotomy: Death. Am. Jr. Med. Sci., 117, p. 275, Mar. 1899.

21. Carter, Herbert Swift—Some of

Year's Liter

rature of the Liver and Gall-Blad

Am. Jr. of Med. Sci., 126, p. 417, Sept. 1903.

22. Cheadle, Walter Butler—Some Cirrh of the Liver.

23. Cheesman, William S., Cholecystoto with Report of Two Cases. Med. Rec., Vo! p. 225, Aug. 19, 1893.

24. Cheyne, W. Watson—A Manual of § gical Treatment, Vol. VII.

25. Clark, John G.—The Treatment of

Stone Foun

das a Coincidence in Abdomin

Pelvic Operations. Am. Jr. of Obst., Vol. 5:

71, July, 19

04.

26. ——— The Treatment of Gall St

Found as a Operations. 1904.

27. Cole

Coincidence in Abdominal or P: Am. Med., Vol. 8, p- 55, Jul

>, W. C., Maness, S. G., Black, C. |

Discussion—Hypertrophic Biliary Cirrhosis Chronic Jaundice. Jr. Morgan Co. Med. 5 Vol. 2, p. 15, Sept. 1899.

28. Corcoran, G. M.—Jaundice. Med. R Vol. 34, p. 305, Sept. 15, 1888.

29. Cordier, A. H.—Some Pathologic

Clinical Ph Vol. 31, p.

ases of Gall Stones. Jr. A. M 61, July 9, 1898.

30. Crofton, Alfred C.—Experiments

Formation

of Bile Pigments and Bile A

Phil. Med. Jr., Vol. 9, Jan. 18, 1902. 31. Cushing, C.—Cholecystectomy. Jour

Mm. A. Val.

32. Dav

33, p. 279, July 29, 1899. is, Byron B.—Indications for

lecystectomy. Jr. A. M. A., Vol. 40, p. June 20, 1903.

33. Dav

is, Geo. E.—The Physiology of

Liver and the Role it Plays in Digestion

Nutrition. 1898.

Med. Rec., Vol. 54, p. 400, Sept

t

\

DISEASES OF THE BI

+. Davis, Nathan Smith—Principles tice of Medicine.

Davis, W. E. B.—Biliary Calculi, Surg. tment of, President’s Address. Jr. A. M. A., 14, 1901. Vol. 37.

Deaver, John iil.

and

B.—Surgical Anatomy. Surgery of the Biliary Passages. M. A. Vol. 32, p- 359, Apr. 22, 1899. a Surgery of Bile Passages. In- t. Jr. of Surg., Vol. 14, Oct. 1901. ) The Mortality of the Operation ’bstructive Jaundice. Amer. Med., Vol. 1, . Apr. 6, 1901. Amer. Med., Vol. 1, p. 70, 13, 1901. Surgical Diseases of the Biliary Phil. Med. Jour., Vol. III, p. 434, Mar.

Obstruction of the Common Bile Med. Jour., Vol. 6, p. 650, Oct. 6,

Duc Phil.

—— Cholelithiasis. 10, p. 927, Oct. 13, 1902. Diseases of the Biliary Tracts.

Phil. Med. Jour., Vol. II, p. 390, Feb. 28, 1903. / The More Remote Consequences Am. Med., Vol. VIII, p. 15,

Phil. Med. Jour.,

of Infectious Bile. July 2, 1904. 4 The Significance of Jaundice as i Symptom in Disease of the Biliary Tracts. N. Y. Med. Jr. and Phil. Med. Jr., Vol. 78, p. 1, August, 1903. } The Treatment of the Complica- tions Attendant upon Chronic Gall Stone Dis- Annals of Surg., Vol. 38, p. 549, October,

Donaghue, Francis D.—Case of Chole-

tis with Gangrene, Cholecystectomy Recov- Am. Jr. Med. Sci., Vol. 123, Feb. 1902.

Dunsmoor, F. A.—The Call for Explora-

tory Operation in the Gall-Bladder Region. Jr. A., Vol. 40, p. 1694, June 20, 1903.

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