Choledocholithiasis

CHOLEDOCHOLITHIASIS* A CLINICAL

STUDY

OF ONE HUNDRED

NINE PATIENTS

OPERATED

UPON

HOWARD M. GANS, M.D. Junior Assistant Surgeon, Wlount Sinai HospitaI CLEVELAND,

the past twenty-five years we have witnessed a remarkable change in our concept of biliary surgery. Cholecystostomy as a procedure of choice gave way to choIecystectomy with the result that the patient subjected to operation was more IikeIy to obtain a higher percentage of permanent relief. In the past, expIoration of the common duct was rareIy resorted to except in instances of persistent jaundice, or when the surgeon was abIe to paIpate a stone in a diIated duct. In recent years with a better understanding of the pathoIogica1 physioIogy of gaJlbIadder disease, carefuI foIIow-up of cases, and correIation with autopsy data, our attention has been focused on the pathoIogica1 findings in the common duct, such as stones, inflammatory changes, interference with the function of the sphincter of Oddi, either by mechanica interference produced by stone at the ampuIIa of Vater, by stricture due to infIammation in the pancreas or by spasm secondary to disturbed physiology of the sphincteric mechanism. The work of Lahey, AIIen, Waiters and others has stimuIated surgeons to be more conscious of disease and pathoIogica1 findings in the common duct. In spite of this there are many patients who have had gaIlbIadder surgery and who stiII continue to have symptoms of biliary disease. A study of the cause and relief of symptoms foIIowing choIecystectomy has been carried out by Carter and MarraffIno at the gallbIadder clinic of the Postgraduate Hospital, New York City’ 485 operative cases were investigated. Th ree hundred seven pa-

D

URING

* From the Department

of Surgery of Mount

OHIO

tients

had a foIIow-up study. Of the above patients there were recurrent symptoms in 193 patients (63 per cent). Eightyfour per cent of these 193 patients were treated medically and in the remaining 16 per cent secondary surgery was required. Pathological Physiology. HistoIogicaI studies of the extrahepatic ducts reveal that the muscular coats cease abruptly at the neck of the gallbladder, at the origin of the cystic duct. The ducts are fibro-erastic tubes Iined with high columnar mucosa covered by a serosa1 layer, with the usual subserosa1 areolar tissue. Only small isolated fibers of unstriped muscle, sometimes indistinguishabIe from connective tissue ceIIs, are found.2 Large gIands offer Iodging to organisms metastatic from other foci of infection, and they may subsequentI], become responsible for a Iow grade choIangitis.3 Nerve fibers are present in great abundance usuaIIy distributed in the outer parts of the wall. obSchrager and Ivy 4 have reported servations on the mechanica distention of the gaIIbJadder and biliary passages in dogs. They found that distention of the gaIIbIadder caused distress, inhibition of respiration, nausea and vomiting. Distention of the biIiary ducts caused more striking symptoms than distention of the gaIIbIadder aJone. ZoIIinger” has shown that mechanica distention of the gaIlbladder in humans gave rise to deep epigastric discomfort, simiIar to the attacks of indigestion observed in galIbIadder disease. Distention of the gaIIbIadder did not cause vomiting. However, mechanica distention of the common duct did produce vomiting and severe epigastric distress. Walters” 307

Sinai Hospital,

323

Cleveland,

Ohio. Service

of Dr. A. Straurs.

424

American Journal of Surgery

Gans-ChoIedochoIithiasis

states that “generalIy speaking, infection, stone formation, and obstruction of the common duct can directIy or indirectIy be related to inffammation which has its origin in the gaIIbIadder.” Lahey’ believes that gaIIbIadder disease is a progressive disease at first Iimited to the gaIlbladder and as infection goes on graduaIIy invoIves the duct system. Stone formed in the gaIIbIadder may pass through the cystic duct into the common duct. There it may remain as a siIent stone or may become Iodged at the ampuIIa of Vater, causing obstruction to the outffow of biIe. Stone or other obstruction in the common duct is foIIowed by diIatation of the duct or thickening of its waI1. DiIatation of the common duct may aIso occur secondary to pancreatitis or to spasm at the sphincter of Oddi. Soft stones or ditbris may form in the common duct, secondary to obstruction of the duct by stones, pancreatitis or sphincteritis.” The stone that had its origin in the gaIIbIadder is usuaIIy hard, faceted and does not crush easiIy. The soft stones found in the common duct crush easiIy and are seIdom faceted. OccasionaIIy, both faceted and soft stones are found in the common duct. This may be expIained by the fact that the faceted stone came down from the gaIlbladder, through the cystic duct, into the common duct and was Iodged at the ampuIIa of Vater causing obstruction with secondary inffammatory changes. The soft stones have formed as a resuIt of this obstruction and secondary inff ammation in the common and hepatic ducts. A suffIcientIy high pressure is maintained within the common duct to force the biIe into the gaIIbIadder where it is concentrated. StimuIation such as is produced by ingestion of food can cause contraction of the gaIIbIadder and reIaxation of the sphincter permitting ffow of biIe into the duodenum. A simuItaneous contraction of the gaIIbIadder and of the sphincter of Oddi produces increased pressure in the biIe ducts. The pain and distress that is produced by

MAY, ‘942

such a phenomenon has been described as biIiary dyskenesia. Best and Hicken IabeIed this physioIogica1 obstruction of the common duct as “biIiary dyssynergia.” Many investigators have pointed out that choIecystectomy is foIIowed by a marked and permanent Ioss of sphincter contro1. DoubiIet and CoIp lo have shown that resistance of the common duct sphincter is about IOO mm. of water. When the gaIIbIadder contracts, a pressure of 300 mm. of water is estabIished. Magnesium suIfate, atropine, nitrogIycerin, and amy nitrite reIax the sphincter. Morphin, stone in common duct, or hydrochIoric acid produce spasm of the sphincter. During the five-year period, from 1936 through 1940, 586 patients were operated upon at Mt. Sinai HospitaI for biIiary tract disease. In 477 cases, operations were confined to the gaIIbIadder. In the remaining Iog cases, expIoration of the common duct was performed, in addition to remova or drainage of the gaIIbIadder. In the Iatter group, common duct stones were found in fifty-three cases, and dCbris was found in tweIve cases. Sex incidence showed the usua1 DreDonderance of femaIes (seventyeight fkm;Ies and thirty-one maIei). TABLE I

-

No. Operations

Died

586 ?n biIiary tract. 477 gallbladder alone.. . . . . 109common duct, galIbIadder and secondary operations. 53 stones f&md in common duct.. . 12 dCbris found in common duct. 65 stones and dkbris.. 78 femaIes. .,. 31 males.

27

IO I7 . .

I

Per Cent

4.6 2. I 15.6 48.6 II.0 59.6

71.5 28.5

The majority of patients operated upon were between thirty to seventy years of age, with aImost an equa1 distribution between the fourth to the seventh decades incIusive. The duration of symptoms in this group of rag cases is shown in TabIe III. In this

New

Gans-ChoIedochoIithiasis

SERIES VOL..LVI, No. 2

series, 30.2 per cent came to operation with symptoms of less than one year’s duration; 8.2 per cent of cases had symptoms from one to two years; 19.2 per cent from two to five years; 23.8 per cent from five to ten years, and 18.3 per cent had symptoms from ten years or over. TABLE II

Age Groups-Years

10

to

17 24 26 28

0.9 4.5 15.5 22.0 23.8 25.6

7

6.4

20..

20 to 30. 30 to 40.. 40 to 50. 5oto6o..... 60 to 70.

5

,o to 80, 80 and over. Total............................

TABLE III

Duration

of Symptoms

Less than I year I tozyears...... 2 to 5 years.. 5 to 10 years.. 10 years and over TotaI

109

I

American Journal of Surgery

history of jaundice are incIuded as we11 as those cases with eIevated icteric index at the time of admission to the hospita1. In the cases that had definite stones in the common duct, the incidence of vomiting was go per cent. ChiIIs and fever were present in 62 per cent of the patients, jaundice in 75 per cent. In the cases in which onIy ditbris was found in the common duct, vomiting, chiIIs and fever occurred in about the same proportions as in the cases with definite stones, but there was a higher incidence of jaundice. In the cases in which there were no pathologica findings in the common duct, the incidence of vomiting was somewhat Iess (72 per cent). ChiIIs and fever were present in onIy 27 per cent of the cases. Jaundice was present in 42 per cent. Prior to the use of vitamin K, there was postoperative bIeeding in six of the above patients with obstructive jaundice. Three died from hemorrhage, and in three cases, breeding was controIIed by repeated transfusions and by the use of intravenous caIcium gIuconate. In nine of the above cases, of common duct stones, there was associated diabetes. In seven cases, the operative note read, “Pancreas was firm and enIarged.” One patient was a severe diabetic for ten years, and one year prior to operation developed symptoms of pancreatitis. FoIIowing cholecystectomy and remova of stones from the

TABLE

IV Jaundice

Stones in common duct .. Debris in common duct. No stones in common duct.. TotaI..

_.

_.

.

.I .I .1

_.

_. _. ,I

In studying the symptoms of these cases, interest was chieAy directed toward those which point to invoIvement of the extrahepatic biIiary ducts, namely, vomiting, jaundice, chiIIs and fever. In compiIing the statistics of jaundice, those with a cIinica1

425

53 12 441 109

~

48 ) 90

II 91 32 72 ___________ ~

gr

83

Per (Zent

4’1

12’27

, 53

IO

i:

23

42

73

67

common duct, here diarrhea and foul stools cIeared up and she had no further need of insuhn. The vaIue of choIedochography in surgery of the common duct cannot be overemphasized. The work of Mirizzi,” Hicken

426

American JournaI of Surgery

Gans-ChoIedochoIithiasis

and Best12 and others, has stressed the importance of this procedure in determining the condition of the bihary passages as

FIG. I. Choledochogram showing HIing defect in the dista1 end of the common biIe duct and a small amount of dye in the duodenum.

possibIe physioIogica1 or pathoIogica1 disturbances. RecentIy we have used postoperative choIedochography as a routine procedure. Fifty out of rag cases of expIoration of the common duct were thus studied. We have observed cases of spasm at the sphincter of Oddi, which was reIieved by nitrogIycerin or atropine, and cases of narrowing of the intraduodena1 portion of the common duct, due to pancreatitis or edema folIowing diIatation of the sphincter with Bakes diIators. In one case, a diagnosis of obstruction at the second portion of the duodenum was made. In nine cases we have demonstrated stones in the common duct that were overIooked at operation. to

CASE I. A man, aged forty-six; had an attack of middIe abdomina1 pain radiating substernaIIy. This occurred at 3:oo A.M. awakening him from sIeep. He had had a simiIar attack five weeks previousIy. PhysicaI examination was negative, except for tenderness under the right Costa1 margin. Cholecys-

MAY, x94.2

tography, by double-dose method, showed no fIlIing of the gaIIbIadder. At operation, a g allbIadder containing many stones was remov-ed,

FIG. 2. Choledochogram showing normal emptying of dye into the duodenum.

the common duct was Iarge and also contained several faceted stones which were removed; the common duct was drained by a T-tube. ChoIedochogram done postoperativeIy showed obstruction of the duct due to stone at the ampulla of Vater. Some dye went past the obstruction into the duodenum. (Fig. I.) Fragmentation and expuIsion of the stone was accompIished in this case by intraducta1 instiIIation of ether, ether and oi1 and the use of amy nitrite by inhaIation, according to the technique outIined by Pribrami3 and Hicken and Best.14 (Fig. 2.)

This case, in addition to showing the vaIue of choIedochography is of interest because it ihustrates the fact that expulsion and fragmentation of stones is possibIe by the use of ether, by increasing intraducta1 pressure and relaxation of sphincter of Oddi by amy nitrite. We were successfu1 in using this method in four simiIar cases. CASEII. A woman, aged fifty-three, gave a history of attacks of pain in the epigastrium precipitated by fatty food, heartburn and

NEW

SERIES

VOL.LVI, No. 2

Gans-Choledocholithiasis

belching. There was no history of nausea, vomiting or jaundice. The symptoms were of several years’ duration and were getting pro-

FIG. 3. Choledochogram showing Ming defect at ampulla of Vater with diIatation of bile ducts. gressively worse. Cholecystography showed poor fiIIing of the gaIIbIadder and a cIuster of large stones was visuaIized. At operation, the gallbladder containing six faceted stones, measuring I cm, in diameter, was removed. The common duct appeared to be normaI, stones couId not be palpated and was not explored. The patient was we11 for two years. She was readmitted to the hospital two years later, severely jaundiced and semicomatose. Four days prior to her admission to the hospital, she had a sudden attack of coIicky pain in the right upper quadrant of her abdomen with radiation of pain to her back. On the day of her admission to the hospital, she had three severe chills, temperature 102%F., icteric index 130, white bIood cells, 16,000. The liver edge was feIt three fingers below the costal margin. A diagnosis of septic choIangitis, with obstruction of the common duct was made. At operation, the duct was Iarge and edematous, and on opening it, pus under pressure, escaped. A T-tube was inserted; further exploration of the common duct was not attempted because of the poor condition of the patient. Her stools continued to be achoIic and on the eighth postoperative

American

Journal

of Surgery

427

day, choledochogram demonstrated obstruction of the common duct at the ampuIIa of Vater, due to stone. (Fig. 3.) This stone could not be

FIG. 1. Choledochogram showing normal emptying of dye into the duodenum.

dislodged by intraductal administration of ether, ether and oil and the use of amyl nitrite. Eighteen days later, the stone was removed transduodenaIIy. The patient made an uneventful recovery. (Fig. 4.)

This case iIIustrates the necessity of exploration of the common duct even in some cases without jaundice, and that stones may be overIooked if the operator is satisfied with paIpation alone. CASE III. A man, aged sixty, was admitted to the hospita1 with a history of upper abdominal pain, chills, fever, vomiting and jaundice of two weeks’ duration. He had a gastric resection for duodenal uIcer five years previously. At the present admission, a diagnosis of septic cholangitis with stones in the gallbladder and common duct was made. At operation the gallbladder was acuteIy inflamed, contained many stones and pus. The common duct was large, thickened, contained many stones and debris. The gallbladder was drained, stones were removed from the common duct and a T-tube was inserted. During the postoperative

428

American Journal of Surgery

Gans-ChoIedocholithiasis

course, stooIs continued to be acholic. Choledochogram showed a stone impacted at ampuIIa of Vater. (Fig. 5.) Intraductal administration of

FIG. 5. Choledochogram showing fiIIing defect at ampulIa of Vater with marked dilatation of ducts.

MAY. *g&2

who had previous choIecystectomy. Under this heading, we might aIso incIude severa cases that were subjected to secondary

FIG. 6. Choledochogram showing norma emptying of the dye into the duodenum.

ether, ether and oil and amy nitrite by inhalation, failed. The stone was removed on the thirtieth postoperative day by secondary exploration of the common duct. The patient made an uneventful recovery. (Fig. 6.) Every surgeon must face at some time or other the probIem of secondary operations on the biIiary tract. These procedures are usually diffrcuIt no matter whether he himseIf performed the origina operation, or whether the primary operation was performed by someone eIse. In our series, secondary operations were performed on twenty-six patients. This study was primariIydirected toward determining the factors that necessitated the secondary operation. It was found that these cases may be subdivided into the foIIowing groups : which expIoraI. Errms in judgment-in tion of the common duct was indicated and was not done as iIIustrated in Case II. There were eight patients who had a choIecystostomy done previousIy and seven

operations with the thought of finding stones in the common duct, but at expIoration, no stones were found. 2. Error of technic-in nine cases studied by choIedochography, there was evidence of Ieft-over stones. 3. Unavoidable operations-in which the condition of the patients was such that it was impossibIe to compIete the operation without undue risk to the patient, or in which it was intentionaIIy pIanned as a two-stage procedure. 4. Recurrent formation of stones-due to persistent infection in the common duct. There were eIeven such cases in this series. In three cases, choIedochography foIIowing the primary operation showed no evidence of remaining stone, the ducts were not diIated, there was no spasm at the sphincter of Oddi demonstrabIe, and yet within a year, there was recurrence of symptoms reformed stones were and at operation, found.

NFW SERIES VOL. LVI, No. z

Gans-CholedochoIithiasis

was CASE v. A man, aged seventy-two, admitted to the hospital with a history of abdomina1 pain, chiIIs, fever and jaundice of six months’ duration. Cholecystography showed no f3Iing of the galIbIadder and six fairly Iarge stones. A choIecystectomy and expIoration of common duct was done. The

common duct contained severa stones and dkbris. They were removed and the common duct was drained by T-tube for severa months. Choledochogram done postoperatively was normal. Eight months Iater the patient began to compIain of epigastric pain, attacks of vomiting and Iater of chiIIs, fever and jaundice. He was readmitted with obstructive jaundice. After a short period of preparation, the com-

mon duct was again explored and a soft stone which crumbIed easily was found impacted at the ampuIIa of Vater. The stone was removed and the duct was thoroughIy cleaned out. His jaundice persisted for a long duration, postoperatively, but eventuaIIy cleared up, and the choledochogram was normal. CASE VI. A woman, aged sixty-eight, complained of attacks of epigastric pain, vomiting of two years’ duration. There was no history of jaundice. PhysicaI examination showed: Heart enIarged, chietIy Ieft ventricIe; E. K. G. bundIe branch block; flat pIate of upper abdomen showed many stones in the gaIIbIadder area. No choIecystogram was done. Under novocain block and nitrous oxide anesthesia, the gaIIbIadder containing many stones was removed. The common duct was large, and contained one stone and dCbris. This was removed, and a T-tube inserted. ChoIedochography later demonstrated a stone remaining in common duct. Ether and oi1 was injected several times and after two normal choIedochograms, the T-tube was removed. The patient remained we11 for a year, and then returned complaining of epigastric pain radiating to the back. The Iiver was Iarge and tender. Diagnosis of recurrent stone was made, and at operation, three rounded soft stones were removed from the common duct. The patient made an uneventfu1 recovery.

With an accurate method at our disposa1 to study the common duct, and abiIity to visuahze stones overIooked at operation, we also must recognize that recurrent stones in the common duct, foIIowing expIoration, is not a rarity, especiaIIy when

we have choIedochographic evidence that no stones were Ieft over at the previous operation. We must concIude, therefore, that continued infection within the ducts is frequentIy the cause of their formation. In our series of secondary operations, we had eIeven cases of recurrent stones in the duct. Three cases had norma choIedochograms folIowing the first expIoration. Such positive proof is Iacking in the other cases, but the possibiIity that stones have reformed cannot be excIuded. Lahey’” states that long continued infection within the ducts, is undoubtedry more frequently the cause of formation of stones within the ducts, than is their passage from the gaIIbIadder into the ducts. Out of the 586 patients who were operated upon for biliary tract disease during the five-year period, there were twenty-seven hospita1 deaths (4.6 per cent). The common duct was expIored in 109 cases, in eighty-three as a primary operation, and in twenty-six as a secondary duct cases acoperation. Th e common counted for seventeen hospita1 deaths (I 5.6 per cent). TabIe v iIIustrates an analysis of the seventeen fata cases, whose average age was sixty-two years, operative procedures performed, and detaiIs reIative to death. In eight out of the seventeen deaths, we had the benefit of postmortem examination. Three patients died of postoperative hemorrhage. These deaths occurred before the use of vitamin K. In the past two years, vitamin K has been used routineIy in preparation of jaundiced patients for operation, and no deaths from hemorrhage occurred. associated carcinoma In two cases, of the Iung was found on postmortem examination. One patient had a carcinoma of the galIbIadder compIicated by common duct stone, and septic choIangitis. One patient died from pulmonary emboIism and three from coronary thrombosis. Three patients died from pneumonia, and one from hepatorena1 insuffIciency. Three patients died from peritonitis.

Gans-ChoIedochoIithiasis

American Journal of Surgery

430

Some of the patients who were admitted for secondary operations, had two or three previous operative procedures on the common duct. Most of the above patients had associated cardiovascuIar disease, and a history of attacks of obstructive jaundice for years. At first gIance at TabIe v, one notices the tremendous increase in mortaIity in the common duct cases, and an impression may ONE

HUNDRED

DUCTS

AND

WITH

NINE

OPERATIONS

SEVENTEEN

-

THE

BILE

DEATHS

Details

Operation

Sex

ON

HOSPITAL

3llYS Post-

-

-

54

F

Cholecystectomy Choledocholithotomy

50

F*

Cholecystectomy Choledocholithotomy

52

M*

Cholecystectomy Choledocholithotomy

53

M*

Cholecystectomy Choledocholithotomy

54

F

66

F*

Drainage of common duct Cholecystectomy Choledocolithotomy Drainage of commor duct Cholecystectomy Drainage of common duct Pus and stones Cholecystectomy Choledocolithotomy

64

F*

50

F

70

F

75

M

65

M*

62

F

69

F

68

M

66

M*

76

M

64

M*

Severe postoperative hemorrhage 48 hrs after Postoperative hemorrhage, “cute necrosir of liver Gas baciIl”s peritonitis; Lannec cirrhosis of liver Generalized peritonitis; stones in extrahepatic ducts Thrombophlebitis; pubnonary embolis” Metastatic carcinoma of lung Metastatic of lung Carcinoma bladder

ChoIecystectomy Choledocolithotomv Cholecystectomy Choledocolithotomy Chokcystectomy Chokdocolithotomy Cholecystectomy Choledocolithotomy

* Postmortem.

I

4

4

33 I

carcinoma

7

of the gall.

19

Complete obstruction st ampull” due to stone; bronchopneu. m&a Arteriosclerotic heart disease; myocardial insuff~ciencv Arteriosclerk arctic stenosis; coronary occlusion Diabetes mellitus; coronary occlusion Hepatic renal insuff. ciency; third operation Pneumonia

Cholecystectomy Exploration of common duct Cholecystectomy Drainage of common duct Cholecystectomy Choledocolithotomy Chokdocolithotomy

2

Peritonitis and pneumonia Postoperative hemorrhage Bronchopneumonia; bronchiaI asthma: hypertrophy of prostate

55

24

I

15 19

7 7 I 3

was expIored and no stones were found there was onIy I death and that in a maIe, aged seventy-five, who had advanced myocardial disease. It is believed that the increased mortaIity in the above cases was not due to the operative procedure, but to Iong continued infection in the biIiary tract with associated damage to the Iiver parenchyma. EarIy operations and expIoration of the common duct as a primary procedure wouId greatIy reduce the mortaIity in these cases. SUMMARY I. A series of rog cases of expIoration of the common duct for stones is added to the Iiterature for the statistica vaIue which it may afford. 2. The pathoIogica1 physioIogy of the extrahepatic biIe ducts was discussed. 3. The vaIue of choIedochographic studies was iIIustrated and the postoperative use of this method was adopted as a routine procedure. 4. By the use of intraducta1 ether and by the administration of amy nitrite, fragmentation and expuIsion of an overIooked stone was accomplished in four cases. 5. A group of cases upon whom secondary operations on the common biIe duct were performed was anaIyzed. In eIeven cases there were recurrent stones. Three of these cases had norma choIedochograms after the first operation. We beIieve that continued infection within the duct or disturbance in metaboIism may be the cause of reformation of stones in the duct. 6. HospitaI deaths were anaIyzed. It was beIieved that the increased mortaIity was not due to the operative procedure, but to Iong continued infection in the biIiary tract with associated damage to the Iiver parenchyma, age of patients and advanced cardiovascuIar disease.

-

be formed that expIoration of the common duct is a dangerous procedure. Out of forty-four cases in which the common duct

REFERENCES I. CARTER,R.FRANKLIN~~~MARRAFFINO,BERNARD. New York State J. M., 40: 164l3, 1gq.o. 2. MACDONALD, I. G. The histology of the biIiary ducts. Sung., Gynec. ti Obst., 60: 775-780, 1935.

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SERIES VOL. I.VI. No. 2

Gans-ChoIedochoIithiasis

3. BURDEN, V. C. Observations on the histologic and pathologic anatomy of the hepatic, cystic and common bile ducts. Ann. Surg., 82: 584-697, 1925. 4. SCHRAGER, V. and IVY, A. C. Symptoms produced by distention of the galIbIadder and biIiary ducts. Surg., Gynec. PY Obst., 47: 1-13, 1928. 5. ZOLLINGER, ROBERT. Significance of pain and vomiting in cholelithiasis. J. A. M. A., 105: 1647-1652, 1935. 0. WALTERS, WAI_TMAN. AbnormaI function of the common duct resuIting from benign conditions. Ann. Surg., 106: 726, 1937. -. LAHEY, F. H. Earlier operations in cholelithiasis. Surg. Clin. North America, 17: 725, 1937. 8. WALTERS, WALTMAN. The pathoIogica1 physciology of stone in the common duct. Surg., GJwec. zc Obst., 63: 417-424, 1936. 0. BEST, R. R. and HICKEN, N. F. BiIiary dyssynergia

physiologica obstruction of the common bile duct. Surg., Gynec. ti Obst., 61: 721-734, 1935. IO. DOUBILET, H. and COLP, R. Resistance of sphincter of Oddi. Surg., Gynec. @ Obst., 64: 622-633, 1937. I I. I~IRIZZI, L. P. Cholangiografi durante Ias operaciones de Ins vias biliares. Bol. ,v /r&de. lo Sot. de cir. de Buenos Aires, 16: I 133--1c)p. 12. HICKEN, N. F. and BEST, R. R. and HUKT, t-1. B. Cholangiography: visualization of the gallbladder and biIe ducts during and after operation. Ann. Surg., 103: 210-229, 1936. I 3. PRIBRAM, B. 0. New methods in gall stow surgrry. Surg., cynec. r” Obst., 60: 55-64, 1935. 14. BEST, R. R. Cholangiographic demonstration of the remaining common duct stone and its nonoperative management. Surg., Cy~xe,. c’* Ohsr., 66: ro40-1046, 1938. I 5. L.AHE'I-, F. H. Ed. Surg., Ct-net. P Obst., fq~: (~8 hqc>,1938.

ALL compound fracture patients must be protected perfectIy against movement, muscIe spasm, and Ioss of position. This is accompIished more in easily and more efEcientIy by skeIeta1 fixation of fracture fragments plaster-of-paris casts than in any other way. C. From-“Wounds and Fractures”-by H. Winnett Orr (Charles Thomas).