Medical drainage of the gall-bladder.
J. S. BROWN, M.D., CARLISLE, IND.
I wish to call your attention to a procedure which is at once a great aid in diagnosis of diseases of the biliary system and at the same time one of even greater therapeutic value. This procedure is commonly known as non-surgical drainage of the gall-bladder, and is accomplished by means of the duodenal tube (Einhorn or Rehfuss) and depends on the action of magnesium sulphate on the duodenal mucosa and Oddi's sphincter muscle, which, as you are aware, is located at the mouth of the common duct.
Medical, or, as I started to call it, non-surgical, drainage of the gall-bladder is not a new procedure. Back in 1917 Meltzer formulated his conception of contrary innervation as applied to the filling and emptying of the gall-bladder. Oddi's sphincter and the musculature of the gall-bladder are supplied with inhibitory and motor fibers from the splanchnic and vagus nerves, which act antagonistically to each other, so that when the sphincter is relaxed the gallbladder contracts, and vice versa. He also showed that the application of a solution of magnesium sulphate to the mucous membrane of the duodenum was followed by relaxation of Oddi's sphincter, a result which was not produced when the salt was taken by mouth.
Immediately after the publication of Meltzer's paper, in April, 1917, Lynn, of Philadelphia, was able to demonstrate that the use of magnesium sulphate locally, in solutions of various strengths, in the human duodenum would very promptly deliver bile through the duodenal tube (Einhorn or Rehfuss) in varying quantities and varying quality. It would do this when the duodenum was previously bile free, indicating that the magnesium sulphate had relaxed the sphincter action of Oddi's muscle. Further than this, it was noticeable that the character of the bile recovered underwent certain definite changes in color and viscosity, first a light yellow-green, then a deeper, richer, more syrupy golden, and finally changing to a very uniform light lemon yellow, thinner and less syrupy than either of the first two, and that this sequence occurred in all normal cases. By this method it is possible to drain the gallbladder wholly or partially of its fluid contents; to drain the bile ducts and to obtain bile freshly secreted from liver cells; furthermore, it is possible to segregate these various biles from their numerous sources by collecting them in individual bottles for chemical, microscopical and bacteriological examinations that give us a direct method of differential diagnosis between various diseases of the biliary system.
With this foundation, may I not introduce at this point a case report which will at once explain the method more in detail and at the same time provide material for further remarks?
Early one morning, the tenth of May last year, to be exact, Mr. C. called me to come out to see his wife, who was having one of her regular gall-stone attacks. It was my second time for this patient, and, as before, I gave her the hypodermic of morphine sulphate she usually needed every three or four months. It had been the custom of the previous doctor who had attended her to insist upon operation after each attack, and each time the elderly patient would insist that she would carry the stones to her grave. But as the attacks were becoming more severe and more frequent, something had to be done. So if ever there was a more fertile field for a nice big gall-bladder that needed a draining here was one.
Our patient, due to pain after eating, had been on starvation diet for several days, and was right then ready for drainage, but, due to the effects of the hypodermic, we waited until the next day. In the meantime, of course, we kept the stomach absolutely empty of any food, even milk. The Rehfuss tube was sterilized by boiling for a minute or two, placed on a clean towel with a glass of water convenient and handed to the patient. She was instructed to swallow down to mark No. 1 on the tube. After this was accomplished, a syringe of this nature was used to wash out any mucus in the stomach which might interfere with our drainage and also nauseate the patient. Then the tube was swallowed to mark No. 2. If the patient had been able we would have instructed her to walk about the room, and in the meantime slowly swallow the tube to mark No. 3. But in this case we had her lie down on her back and slowly turn to the right. After waiting about fifteen or twenty minutes for the tube to straighten out, we injected some sterile water and immediately withdrew it. Now we are ready to begin the drainage. A freshly prepared 25 per cent. solution of magnesium sulphate warmed to body temperature is used. I usually inject two or three syringefuls unless the patient objects. Now the tube is clamped off and we mark time for about fifteen minutes more. In our case on hand now we were able to get an almost immediate response from our tube, but sometimes I have had to use the pump to help start. The patient is allowed to lie comfortably on her right side and the bile syphons out over the edge of the bed. The first bile that appeared was light yellow golden color, then suddenly changed to very dark, which we know comes from the gall-bladder. This had a gritty feeling and was very viscid, and required quite a time in passing. In fact, the writer made a call in the neighborhood and returned an hour later, just as the bile had assumed a lemon color, thinner and more limpid than the other two. A year has now passed since this one drainage, and our patient is bothered no more with gallbladder attacks.
The results obtained in this case of long-standing cholelithiasis were more than expected, but it shows what can be done in cases which are poor surgical risks. The same is true and results are more certain in (1) chronic cholecystitis or choledochus, as indicated by flatulence, dyspepsia, muddy skin, anorexia, constipation and malaria, a syndrome commonly known as biliousness; likewise in (2) sick headache, though in cases of long standing several drainages may be required; (3) some forms of asthma where the sensitization tests have not worked out satisfactorily, or where the cause is probably an infected gall-bladder; (4) infectious joint trouble, where the focal infection is difficult to locate: (5) chronic catarrhal jaundice without material obstruction, such as a large stone in the common duct; and (6) last, and I believe most important, that condition of the gall-bladder which follows malaria. typhoid, influenza or constipation, and is a chronic infection with biliary stasis
Biliary stasis or atony of the gall-bladder is the one condition among others named in which medical drainage is the remedy par excellence. I consider it to be of extreme importance, because it can be diagnosed in its very early stages. This diagnosis is suggested in two ways:
First, the recovery of static or off-color bile. ranging from the deeper shades of golden yellow into the green yellows, green blacks and blacks, and possessing an increasing viscosity from that of a thick syrup to that of tar. Where the viscosity is heavy and shows much mucus and desquamating masses of bile-stained epithelium and precipitated crystals, this is considered atonic catarrhal cholecystitis and a potential forerunner of calculus.
Second, in the amount of static bile recovered. If a gall-bladder's normal capacity may be considered two and one-half ounces, and if four ounces or more of this type of bile can be recovered in bottles, it seems reasonable to assume that the gall-bladder in question must be functionally atonic and unable to move its contents promptly or the cystic or common duct must be partially obstructed; such conditions as above enumerated may be the forerunner of gall-stones and pathological gall-bladder conditions.
We are mechanically applying the surgical principles of free drainage for infected sacs, tubes and tissues, of free drainage for gall-bladders that are atonic and contain static bile in which sooner or later these develop stones or a more serious pathological condition, and while applying surgical principles we are doing it non-surgically and avoiding certain surgical risks. Besides this, and even more important, we are preserving tissue which may possess a power of recovery of function beyond our present conception.
Its real sphere of usefulness lies in giving a direct method of treatment in early stages of disease, diagnosed early, before gross pathological changes have taken place. Our aim should be to learn better to diagnose the beginning of these diseases and to institute promptly direct, rational and safe measures of treatment. We may legitimately hope that this method, if intelligently applied, may decrease the number of cases requiring serious and dangerous surgery.
Discussion.
DR. J. C. HUBBARD (Oklahoma City, Okla.): I wish to commend the essayist on this valuable paper, for the reason that gall-bladder and liver affections resulting from gall-bladder affections and infections are too often diagnosed wrongly and faultily treated. In many the introduction of a tube is of service. Dr. Brown did not mention two or three things that I have found essential After washing the patient's mouth and having the tube swallowed to the third mark, many times the tube is swallowed without going into the duodenum. There are two or three important things that happen when the tube enters the duodenum. There is usually a little reverse peristalsis, and upon the litmus paper test we find an alkaline condition, and there is the appearance of sand mixed with the mucus that comes from that part.
The essayist, I think, did not mention the use of atropine. Many times we have used belladonna to its physiological action. The pupils begin to dilate and the face becomes flushed before introducing the tube, and then, after the tube has been introduced to its proper place, we give 1/75 to 1/100 grain of atropine, depending upon the patient, for its relaxing effect.
Dr. Brown spoke of focal infections and intestinal "flu." I have come to the belief in my work that there is "no such animal," as the boy said at the circus when he saw a giraffe for the first time. I think the so-called intestinal flu is always a general infection located in the abdomen, many times around the gall-bladder, and because there is often obstruction at the ampulla or farther down the tract it is rather dangerous in acute cases to institute this measure, especially when the blood count indicates pus formation.
I wish to further emphasize Dr. Brown's statement regarding the early use of this measure. I consider it one of the most valuable things we have ever used. I use it post-operatively in the old cases where we have to operate and cannot remove the sac. We do the drainage, but find that the infection occurs, and we use this non-surgical method many times in post-operative cases of gall-bladder drainage.
DR. SAMUEL G. BOYCE (Little Rock, Ark.): I appreciated this paper, and consider it very scientific, well written and well delivered. I am surprised and chagrined that my colleague. Dr. Hubbard, from down south of the Mason and Dixon line, has called to my attention the ignorance and simplicity of some individuals. He has said there is no such thing as intestinal flu. In 1908 Dr. Hatfield taught me from the text-book of Dr. R. L. Thomas that there are three types of influenza—the nervous type, the gastro-intestinal type and the respiratory type. In eighteen years of practice I have found that to be the case. I have also observed that we often have an appendicitis complicating the respiratory type of influenza during influenza epidemics. The lymphatic tissue is always affected by the micro-organisms that give us the disease known as influenza. I have found that Dr. Thomas is right, and wish to confirm what the essayist has said.
DR. BROWN (closing): I wish to say that, naturally, I do not drain the gall-bladder during the height of the intestinal flu.
May I add a couple of Eclectic remedies that I also use after the gallbladder has been drained and the tube pulled out? Sometimes I put in some echinacea, which I find useful, and also some glycerine and ichthyol, and in case of mucous colitis colonic irrigations along with the gall-bladder drainage are helpful.
