1909 Journal of the American Medical Association  
esting demonstrations in the cadaver showing that the cecal tube may be utilized for flushing the intestinal tract above the ileocecal valve. Properly predigested food introduced directly into the colon is absorbed much more readily, much more certainly and in much larger quantities than when given by the rectum, and the same fact is true of water, even by the drop method. I wish in conclusion to urge that cecostomy rather than appendicostomy should always be adopted as the operation of choice.
more » ... peration of choice. As compared with the presenting part of the cecum, the ceco-appendiceal juncture is an inch or more further away from the abdominal wall. The mesocecum is, furthermore, ordinarily so short and is always so inelastic that the appendix can not be drawn and held forward without a degree of tension that is fatal to its integrity. The distensive pressure of any tube inserted and retained in the narrow lumen of the -appendix is another influence that causes it always to perish during the first few days after the operation. Thus an appendicostomy always, sooner or later, resolves itself into a cecostomy. It is better, however, to do a cecostomy as an elective operation The Groton. Foreign bodies of various kinds have been found occasionally in the gall bladder in association with gallstones. It is probable that the presence of a foreign body in the gall bladder may, under certain conditions, be concerned in the etiology of the stones. The question of whether any foreign body can produce gallstones quite unaided by micro-organisms has been rather conclusively answered in the negative. It is certain that smooth foreign objects may occupy the gall bladder for a long period without retention of precipitated bile salts. Jaques Meyer introduced small ivory balls into the gall bladders of test animals and found no stones after a year. Mignot1 also found that certain foreign bodies, if aseptic, may be retained in the gall bladder for a long time without causing inflammation or precipitation of solids from the bile. Mignot, in his investigations found, also, that foreign bodies impregnated with virulent micro-organisms, singularly enough, did not lead to the formation of gallstones. Such virulently infected foreign bodies produced more or less violent cholecystitis and precipitation of solids but so long as the bacteria retained their virulence they could not, even with the help of the foreign body, form calculi. There resulted a sediment mixed with pus, but the sediment had no tendency to adhere to the foreign bodies. To form stones, he says, the bacteria must be attenuated. Such attenuated bacteria used in his experiments caused precipitation of the bile solids on cotton wool quite promptly, that is, within five or six months. The above observations concerning the necessity of attenuation proved true of the Bacillus typhosus, Bacillus coli. staphylococcus, streptococcus and even the nonpathogenic Bacillus subtilis. Reports2 of similar experi-1. Robson, Mayo: Diseases of the Liver and Gall Bladder. 2. Riforma med., 1901: quoted by Moynihan: Gallstones and Their Surgical Treatment, p. 45. ments show that if attenuated bacteria and foreign bodies be introduced together into the gall bladder, stones will be formed. In the absence of direct proof it seems reasonable to presume that much must depend on the character of the foreign body. The smooth ivory balls of Meyer doubtless produced little irritation; whereas a jagged body, if large, must produce decided irritation and if such irritation be alone unable to produce obstructive inflammation of the gall bladder or ducts it is nevertheless easily seen that the essential bacteria may readily be attracted to such a focus for, as Gilbert has demonstrated, bacteria are frequently sent out from the liver with the bile. The Mayos3 called attention to the circumstance that the Bacillus prodigiosus placed in the anus appeared after two hours in the mouth and that reverse mucous currents in the intestines and ducts will similarly carry up particles of indigo carmine. It seems not unfair to assume that bacteria may readily pass up the gall ducts from the intestines. It is well known that entozoa are frequently found associated with gallstones. Such entozoa in their entrance into the gall bladder doubtless furnish at once the foreign bodies and the atria for infection. This is, perhaps true also of the globules of metallic mercury which have been found in gallstones. That intestinal parasites may find their way into the gall bladder and carry with them the necessary infection is abundantly shown by many reported cases : Lobstein4 found round worms associated with gallstones; Gautrelet5 found bilharzia or intestinal flukes in connection with biliary calculi; Carless6 found pieces of hydatid membrane in the gall bladder and Buisson7 found the Distoma hepaticum in the gall bladder in a case of cholelithiasis. Homans found gallstone incrustations on sutures introduced through the gall bladder wall at a previous operation, here the suture presumably established an atrium. Nauche reported a case in which he found a steel needle forming the nucleus of a gallstone (Mayo Robson). I have recently observed a similar case in which the incrustations on the needle were slight and easily removed with gauze and the gall bladder was filled with small stones. In my case adhesions were present between the gall bladder fundus and the pylorus. It seems most likely that the needle passed directly from the pylorus into the gall bladder carrying bacteria with it. This seems also the most rational explanation of the presence of a fruit-seed in the gall bladder in the case reported by Frerichs. If, however, the ova intestinal worms may travel up the ducts with the aid of reversed mucous
doi:10.1001/jama.1909.25420470026001f fatcat:ssgoeupr25ehxbc2h4ueajqvha