ErFAHRUNGEN UEBER DIE GALLENSTEINKRANKHEIT, MIT END OHNE ICTERUS. 
Von Professor Riedel, in Jena. Pp. viii., 183. Berlin, 1892. 
EXPERIENCE IN CHOLELITHIASIS, 
IT I TH A ND IT ITHO UT ICTERUS. 
Professor Riedel, of Jena. 
| Review from The American Journal of the Medical Sciences.] 
This is a small volume filled with the richest experience in cases of 
gall-stone, given in the form of very full histories of a large number of 
cases arranged under the heads of pathological anatomy, arrangements 
of stones, clinical course, diagnosis, treatment, adhesions, and many sub- 
heads. To it is added an exhaustive tabulated list of the sixty-four 
operations studied in the book. Considering the great interest shown of 
late in surgery of the gall-passages and the wide and many fields from 
which magazine material is gleaned, it has been a matter of surprise that 
this work has received no recognition whatever from the press and no 
attention from individual workers, to judge from their published articles. 
This is the more surprising, since works on the subject are very few 
indeed. Even foreign journal's seem to have all but passed it by. The 
fact is that it is one of the most valuable contributions to surgery ( and 
medicine ) made for a long time, both as to the quantity and quality of 
the surgical work upon which it is founded and as to the clear and 
valuable deductions therefrom. 
After opening with contrasting pictures of the early and late opera- 
tion of the simple procedure the author has devised, with every circum- 
stance favorable on the one hand, and the terrible obstacles to be met 
with in abandoned patients on the other, the changes in the gall-bladder 
are first stated. It has been met with so calcareous as to require break- 
ing with a chisel; a few times so thick and dense as to crunch under the 
knife; never with the walls thinned-a condition generally thought 
quite common. Several unusual cases of diverticulum are worth men- 
tioning: one large one without mucous membrane and with two open- 
ings into the gall-bladder; one without mucous membrane and contain- 
ing a large cup-shaped stone blocking the opening, while in the latter 
was resting another stone; many wallet-shaped, bent upon the duct or 
bladder at an acute angle, and of course entirely blocking the outlet. 
In one-half of the cases stones were in the bladder alone. The cystic 
duct was compromised in 66 per cent, of the cases, but in only one-third 
of these was this from stones resting there, but " mostly from swelling 
resulting from the mutual disturbance which follows inflammatory proc- 2 
esses in the bladder. If the stones are removed from the latter, the 
swollen duct so quickly collapses that by the first change of dressing, 
gall flows from the fistula (fifteen times in twenty-eight cases) without 
any extraction of stone from the duct." This is the key to a great deal 
of the author's plan of work. Only once was the cystic duct obliterated 
without the bladder also. Of many arrangements of the stones in this 
passage one is noteworthy; one of the larger stones blocked the upper 
mouth of the duct, and this formed an intussusception into the bladder. 
The common duct was once so enlarged and thickened as to be mistaken 
for the bladder, and so stitched to the parietes. Only a few times were 
stones found in this duct alone. Once a large stone was found in the 
duct and one in the bladder with obliteration between. On one occasion 
the common and hepatic ducts were one and enlarged, and the bladder 
and its duct obliterated. The contents of this duct were never seen to 
be serum nor pus. 
Of changes in the liver the author has made a distinct discovery: that 
its enlargement often takes the form of a long narrow "tongue-like pro- 
jection " lying directly over the bladder as the latter enlarges. This 
projection, or even the more general enlargement, almost invariably 
occurs in cases " with icterus," for obvious reasons. Its cause is not 
made entirely clear, but that it may be of very rapid growth the obser- 
vations of a colleague, made entirely in the dark as to what it might be, 
testify. To this observer is made this graceful and significant acknowl- 
edgment: "It is seen what great worth the observations of a single 
man have, even when he is practising in a small village, if they are 
quietly and objectively made. For through such observations we are 
advanced in our knowledge, and without them stand still, for we (the 
surgeons ) have before us many completed pictures, while our colleagues 
have the opportunity in their practice of studying the development of 
the disease." Several cases published as enlargement of the liver the 
reviewer suspects to be possessed of this tongue-like projection: is cer- 
tain of it, and was puzzled by it in two cases of his own. Perforations 
close the section on pathology. These are rather infrequent, two through 
the abdominal wall being reported, one into the colon and through the 
abdominal wall, one into an encysted part of the peritoneum and into 
the colon and thoracic cavity, and one still worse, but of doubtful 
origin. 
That the clinical course of cholelithiasis must be various is very evident 
after the above features, which are but a part of the many given. When 
it is added that the fullest histories of each case are given, including 
the operative procedures, it will be seen how valuable, even intensely 
interesting in respect to the latter, the book is. This varying clinical 
course is responsible in part for the differences between the practitioners 
of internal medicine and the surgeons, because the former see mostly 
the typical cases, those accompanied by the extrusion of small stones, 
while the latter have the anomalous cases and those with stones too 3 
large to pass away. But, for his ground for complaint against the 
physicians, the author takes the transactions of a late German congress 
and plainly shows by his exact observations some of their surmises to 
be incorrect. Hardly half of the cases of colic are from wandering 
stones, but from inflamed bladder containing stones; it may be from 
inflammation alone when there are no stones; from inflammation alone 
even while a stone reposes in the common duct. In like manner the 
appearance of jaundice may follow inflammation alone when there are 
no stones in the duct, or stones too large to wander into the duct. In- 
flammation as influencing the course of the ailment must be considered 
in its two aspects also, of chronic and acute. 
After this insight into what may be below the surface we may be pre- 
pared for difficulties in diagnosis, especially since one-fifth of the cases 
before operation had had no colic, the symptom of more value than any 
other, and nearly as many had neither jaundice nor a tumor! The 
cases of cholelithiasis without icterus were mistaken by others twice for 
pyelitis calculosa, twice for tearing of the abdominal muscles, once for 
typhlitis, four times for wandering kidney, and two came with no diag- 
nosis. The " tongue-like projection " contributed to this and other con- 
fusion. The appearance of icterus in the development of a case means 
obviously a step for good or for bad. The first question to be decided 
is: Is the icterus "real lithogenic," i. e., caused by stone obstruction, or 
the "inflammatory " or "accompanying," i. e., caused by inflammation 
accompanying stone? The latter causes little change in the liver because 
of its transient character; the former causes enlargement, and at the 
same time collapse or contraction of the bladder when it loses its concre- 
tions-the reverse pathological condition from cases " without icterus." 
For treatment, " internal medicine and alkaline mineral waters are 
indicated in those cases which, wuthout premonitory symptoms of long 
duration (weight in the stomach, nausea, occasional pain) suffer from 
an acute attack of colic with quickly following icterus. While premoni- 
tory symptoms fail it is generally to be assumed that the icterus is not 
an inflammatory one; further, that only small stones are present in the 
bladder, and they will eventually pass quickly through." For cases 
other than these, operation is alone to be considered, and again is early 
operation compared with late-i. e., operation on the bladder, a trifling 
thing, compared with operations on the ducts, a very difficult thing; but 
" what will one or what will a few persons avail against a custom conse- 
crated through centuries? On the strong walls of Carlsbad will every 
attack be shattered, indifferently whether thousands lose health or life 
through Carlsbad or not." But in spite of these protests against trifling, 
quiet-lying stones-such as are discernible but give the patient no indi- 
cation of their presence-it is declared, are " not to be the subject for 
therapy " of any sort. 
''Ideal cystotomy," even when practicable, is rejected entirely because 
it is apt to bring reproach upon surgery for incompleted work, because 4 
continuous drainage of the bladder is necessary for the restoration of its 
health and that of its appendages, and because dangerous back-pressure 
may occur from a great number of causes, even from swelling extending 
from the disturbance of the operation, or from minute blood-clots (colic 
secondary to operation )-circumstances clearly proven. Even with ten, 
twenty or more successive cases of successful "ideal cystotomy," the 
author would feel that the next, were it unsuccessful, could have been 
avoided by other procedure. The operation which is adopted for the 
bladder and its duct is cholecystotomy in two sittings! In these days, 
when such a procedure is looked upon as working very much in the 
dark, this will be hard to accept, but experience is the surest guide, and 
does not fail here. The chief reason is that continuous drainage pro- 
motes so far the collapse of the swollen mucous membrane that it allows 
the deeper-lying stones to present or extrude themselves. The reviewer 
has seen this; and in the thirty cases of double operation given, sixteen 
were at once successful, and of the remaining, thirteen corrected them- 
selves later in this manner! The several other reasons will be passed 
over; the one of immeasurably greater safety will suggest itself; indeed 
the operation with its minute incision and refined technique, is declared 
devoid of danger. The remaining fistula, so often condemned, is held the 
great advantage, and the rarely-needed operation for its closure is easy. 
The choice of operation for cases "with icterus " will depend on 
whether, again, the icterus is a "real lithogenic" or "accompanying 
inflammatory." Since in fully one-third of the cases it is the latter, 
cystotomy, in two sittings, may often be adopted-provided, of course, 
the distinction can be made. For stones in the common duct the only 
procedure is the direct incision of the passage, and the further course 
depends on the cystic duct. If this is obliterated nothing remains but 
to close the common duct by sewing. If this is open, again is a fistula 
through the bladder provided; or, as stones are likely to be in the latter 
also, the bladder is first opened and provisionally closed, the common 
duct then opened and closed, and the bladder finally opened and affixed 
in the abdominal wall. A relatively long incision is always made in 
operations for " real icterus," and a tube is never used for early drain- 
age, having once caused dangerous irritation. Crushing of stones is 
rejected, because remaining fragments may lead to new formations, and 
no man can operate a second time on the common duct. As the pages 
are turned, still more difficult operations appear: for gall-stones \vith 
appendicitis, with suppurative angiocholitis, with extensive pelvic sup- 
puration, with carcinoma, for old stones in bladder and new in the com- 
mon duct, etc. The technique of establishing fistula when the bladder 
is too short to reach the parietes, as is often the case, is beautifully 
devised. The results, remarkably good, are given, as everything else, 
at great length, and the opinion is broached that this line of surgery, 
with its possibility of great difficulties, is not suitable for the general 
practitioner. J. C. R., Jr.