Stones in the common duct and their surgical treatment : with remarks on the ball-valve action of floating choledochus-stones / by Christian Fenger.

Fenger, Christian, 1840-1902.

Date:: 1896

Credit: Stones in the common duct and their surgical treatment : with remarks on the ball-valve action of floating choledochus-stones / by Christian Fenger. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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$the passage of bile into the duodenum. The stone was freely movable in the common and hepatic ducts. The stone was not grasped tightly by the common duct, as Courvoisier states. The wall of the common and hepatic ducts was not thickened, but the ducts were considerably dilated. There was neither pus nor inflammation in or around the duct, nor cholangitis. The stone was probably the cause of the emptiness and atrophy of the gall-bladder and of the cystic duct. That the small gall-ftone, 1 centimetre in diameter, freely movable, floating or swimming in the ductus choledochus, cystic and hepatic ducts might have caused complete stoppage of the flow of bile by acting like the ball in a ball-valve was proved by the following experiment: The duodenum was opened opposite the diverticulum of Yater, and the papilla, on which the opening from the duodenum into the diverticu- lum was found, was seen to be of normal size and shape, and the duode- nal mucosa and wall in normal condition. A silver probe passed readily from the duodenum into the common duct, and when it was pushed down toward the end of the common duct grated against the stone. A silver probe passed down from the gall-bladder into the common duct passed easily through the latter into the duodenum. It is comparatively easy to pass a probe through a dilated common duct, but it is not until search has been made by pushing and sliding the mucous membrane of the duodenum that the exit of the duct is found; because the dilated duct, just above the canal through the wall of the duodenum, forms a pouch or pocket in which the probe is caught until the narrow exit is found. There was no stenosis of the duodenal opening of the common duct, but the common, cystic, and hepatic ducts were all dilated. A canula was now inserted in the gall-bladder (see Fig. 1), through which glycerin, which has about the same consistency as bile, was in- jected until first the gall-bladder, then the cystic, then the common, and finally the hepatic duct were filled and distended. When the stone was now placed in any of the ducts or in any place with the exception of the lower end of the common duct, the glycerin would flow out in a continuous stream through the opening into the duodenum. When the stone was made to slide down as far as it would pass into the common duct, namely, into the cul-de-sac or pouch just above the duodenal opening (Fig. 2), the flow of glycerin into the duodenum ceased, and a further injection through the canula into the gall-bladder made the duct and the gall-bladder more tense and full, but not a drop of the glycerin entered the duodenum. When I now dislodged the stone a little, pushing it up out of the pouch by pressing slightly on the prominence which it formed in the duodenum, \ cm. above the opening, the glycerin immediately began to flow into the duodenum. This flow would continue until I again pushed the stone back into its former position. I repeated this experiment a number of$