1914 Journal of the American Medical Association  
increased to a certain point through carbohydrate, the addi¬ tion of amino acids to the diet may cause no further increase in metabolism. Likewise, it should be remembered that in fever the protein metaboliom can never be reduced to the low level present in the normal person, so that when aminoacids enter the organism under these circumstances they tend merely to replace those already breaking down in large quantity. It is therefore apparent why in fever the metab¬ olism may have already been
more » ... fted to such a level that ingestion of food causes no further increase. Dr. Eugene F. Du Bois, New York : A comparison of the metabolism of enteroptotic persons with that of short, stocky men would be interesting, but we have had no opportunity of making such observations. From a theoretical consideration it would seem that the enteroptotic, undernourished persons would have a rather low metabolism, and it would seem that muscular persons would have the higher metabolism. Yet from clinical observations it appears that the enteroptotic persons have the greater energy requirement. We have at times tried to guess the actual heat production of individuals and groups of patients but have found that sometimes we were as much as 25 per cent, from the true figures as deter¬ mined by the calorimeter. An operative technic which gives a low mortality may be far from perfection, especially when relief is not obtained by the patient from the trouble for which the operation was done, or when other calamities must be endured by the patient which are a direct result of the operation. In no class of operative procedures for non-malignant conditions are secondary operations required in so large a percentage as in those done on the gal l \ x=r eq-\ tracts. In no class of abdominal work is the temptation greater for inefficient or incomplete work, and in none is complete work more difficult than that encountered in many of these cases. Stones in the common duct, at or near the lower end, are found and removed successfully by only a very few operators. The amateur aspirant to surgical honors and perquisites can safely drain a large readily accessible gall-bladder, and if perchance he find a stone, that is the end of the matter with him as covering all requirements and obligations. 1 am reminded that once I opened the abdomen, after having done several thousand abdominal sec¬ tions, and examined carefully for gall-stones and did not find any, but at post-mortem four weeks later seventeen stones were found in the gall-bladder and one in the ampulla of Vater. At another time when doing an abdominal section for other causes I confirmed by direct palpation a pre¬ viously made diagnosis of gall-stones, but six months later when the patient came to operation for removal of the gall-stones, I could not even find a gall-bladder, but encountered pancreatic calculi amounting to over a thousand grains, forming a complete cast of the entire pancreatic duct system. These I was able, with great difficulty, to remove successfully through inci¬ sions in the pancreas after opening through the gastro-hepatic fold of mesentery, which enabled me to reach the affected organ after displacing the stomach down¬ ward. I am convinced that no operation for relief of supposed pathology in the biliary tracts is completed without an examination of the pancreas. The large number of secondary gall-tract operations is due to errors in diagnosis, failure to remove all calculi, allowing the drainage to close while infection is still active, and failure to remove the gall-bladder in all cases in which there is not a free communication or Fig. 1.-Author's technic. Method of incising gall-bladder, the fundus being grasped by flat forceps. passage in both directions through the cystic duct, pro¬ vided the common duct is freely patent. Bile may often pass quite readily from the common duct into the gall-bladder, but returns with much diffi¬ culty or not at all by the ordinary contractions of the gall-bladder. In such cases permanent drainage or removal of the gall-bladder can alone afford perma¬ nent relief. The removal of the gall-bladder or its entire mucosa down close to the junction with the common duct is imperative to make relief permanent and obviate drainage annoyance. In many cases of secondary operations following gall-bladder drainage I find the pyloric end of the stomach, first part of the duodenum, gall-bladder, liver and abdominal wall one continuous mass of adhesions. The result is that such a patient is never free from discomfort by pain, dragging, impaired stomach motility and often partial obstruction of the pylorus, which causes gastric dilatation with its accompanying enter¬ tainment. Unnecessary and rough handling of abdom¬ inal viscera during operation, unnecessary wiping of endothelial surfaces wi;h gauze (especially dry gauze), extensive and unnecessary spreading of infec¬ tion over clean territory and making no intelligent use of Nature's preventive material at hand are the prin¬ cipal causes of these deplorable and preventable com-
doi:10.1001/jama.1914.02570100018006 fatcat:5gml3xvvgjhehlcfmoaxec4qja