Henry Morris (in Krauss, on 'Gall stones") states that there are several eases on record to prove that, where pain alone or pain with jaundice has been such as to reduce patients to the verge of suicide or death, laparotomy and digital examination of the liver and gall ducts have restored the sufferer to com plete good health, though no tumor nor crall-stones have been found to account for the symptoms. Morris found adhe sions to the abdominal wall in one case, and in another a general enlargement of biliary ducts from some unknown cause. It is possible that in some of these cases a gall-stone in the ampulla of Veer may be pushed through into the duodenum during the manipulation.
The indications for operation in chole lithiasis are thus given by Mayo Rob son: "1. In frequently-recurring biliary colic without jaundice with or without enlargement of the gall-bladder. 2. In enlargement of the gall-bladder without jaundice, even unaccompanied by great pain. 3. In persistent jaundice ushered in by pain, and where recurring pains with or without ague-like paroxysms render it probable that the cause is gall stones in the common bile-ducts. 4. In empyema of the gall-bladder. 5. In peritonitis starting in the right hypo chondriac region. 6. In abscesses around the gall-bladder or bile-ducts whether in, under, or over the liver. 7. In some cases, where, although the gall-stones may have passed, adhesions remain and prove a source of pain and illness. S. In fistulfe: mucous, muco-purulent, or biliary. 9. In certain cases of jaundice with distended gall-bladder dependent on some obstruction in the common bile duct. 10. In phlegmonous cholecys this and in gangrene, if this can be seen and recognized at a sufficiently-early stage of the disease." (Allbutt's "Sys tem of Medicine.") Robson does not approve of sounding for gall-stones through the abdominal walls. He also condemns massage of the gall-bladder.
Among the cases of gall-stones not to he operated upon are those where the first paroxysm of pain is succeeded by all the. typical manifestations, where the patient become!, jamuliced on the sec ond to third day and passes small stones by the natural 1N-ay. Repeated attacks are not indications for operations when each time small stones are passed. When there are numerous attacks with out the passage of small stones then the question of operation arises on ac count of the suspicion that, besides the small calculi, there may also be large ones impacted in the gall-bladder. Those ca.ses should not be operated upon in which after repeated ineffectual attacks larger ealeuli have been passed, for if a large stone has been passed others may follow. If ineffectual at
taeks continue to follow, an operation is indicated. But a single ineffectual attack, without jaundice. indicates operation. A state of latency may be partially at times brought about by aperients, but it is of short duration. Operation is indicated in those cases where, after repeated ineffectual attacks, the uppermost stone enters and becomes impacted in the ductus choledochus. This impaction must be determined by waiting. two to three weeks being sufli eient. Riedel (Berliner klin, \Voch., Jan. 21, 1901).
In one-third of the eases the symp toms were of ten years' or more dura tion. In le.ss than one-fourth the symp toms had persisted for less than two year.s. Choleeystenterostomy is a make shift at the best: the eystic duct may not be patent. Expression of the stone into the duodenum or bladder is not easy. No cases have been operated upon by the transduodenal route. Crushing of the stone leaves darim. In none of the above methods ean it be determined whether or not the ducts are patulous. In six of the cases only one stone was found. For the relief of the late des perate cases a rapid cludeeystotomy may be made. The method of choice consists in incisim.; the duct, removing the stone, suturing the duct, and draining the gall bladder. This procedure was carried ont in 21 of the cases. without a death. M. R. Tinker (Phila. Med. .Tonr., June 21, 1902).
AF; soon as p.all-stones give serious trouble, operation is indicated, for it is only from the complications which in many eases arise sooner or later that any danger after operation need be ap prehended. :Medical treatment may do much to relieve the catarrh associated with cholelithiasis, but no medicine can dissolve gall-stones or produce perma nent relief. It is impossible to say what operation will have to be done until the abdomen is opened and the exact state of affairs made out.
No surgeon should attempt the re moval of gall-stones unless he is pre pared to perform any of the various op erations on the biliary passages, and no operation should be coneluded until it is determined that the ducts, including the hepatic and common. are free from con cretions, otherwise dissatisfaction is cer tain to follow. A gall-stone scoop is the only special appliance that need be em ployed. Rubber gloves impair the sense of touch and cause delay. In jaundiced patients calcium chloride is given in 30 grain (2 grammes) closes by mouth be fore operation and afterward in 60-grain (4 grammes) doses by rectum, thrice daily for two or three days or longer if necessary.