the surgery of jaundice

THE SURGERY OF JAUNDICE*BY_JOHNAB. DEAVER, M.D.

OF PHILADELPHIA, PA.

IN THE light of my surgical experience with jaundiced patients, it seemsstrange that jaundice should for so long have been considered purely a medicalailment and have been treated as such. It is only natural that in my workI find that the majority of cases of jaundice are not medical conditions, andthat the pathology presented at operation rarely, if ever, lends itself to reliefby other than mechanical surgical means. I therefore would suggest thatjaundice be as much if not more stressed in the category of surgical than ofmedical diseases. The problem therefore is interesting alike to the surgeonand the internist, particularly from a diagnostic point of view. In fact, thereare few other conditions in medicine and surgery in which the results ofmutual cooperation between pathologists, physiologists, internists and sur-geons have been of such value as in the study of jaundice. It is due to thisjoint study that, first of all, the classification of jaundice has been changedfrom a clinical entity to that of a symptom, and likewise that the definitionof the disorder seems likely to undergo modification. Until quite recentlyicterus was defined as an extravasation of bile into the blood, indicating thatthe presence of bile in the blood was an abnormality. But the results ofinvestigations, notably by Van den Bergh and his associates, seem to demon-strate that a certain percentage of bile is normally present in all bloQd sera andit is when that percentage is increased beyond a certain amount that it infil-trates the tissues and jaundice ensues. In fact, it is quite possible that notonly the amount, but also the "quality" of the bile is of importance intissue jaundice, whatever meaning future investigations may assign tothat " quality."

If this theory proves correct, the definition would be changed to read:Icterus-a condition in which an excessive amount of bile of certain qualita-tive characteristics circulating in the blood causes a yellowish pigmentationof the skin and mucous membranes. Naunyn and his followers describe jaun-dice as a diseased condition, or rather a group of pathologic phenomena dueto disturbed secretion of bile and consequent flooding of the system with bile.

Another result of diligent investigation into the true nature of jaundiceis the discovery of the important fact that jaundice is not always limited tohepatic pathology, but that there exists a definite relationship between thespleen, and indeed the whole reticulo-endothelial system and the liver in theproduction of the blood changes that lead to the clinical picture of jaundice.But behind the clinical picture there lies not only the pathogenesis, but alsothe surgical significance of certain types of jaundice, and it is to the latterthat I wish to confine my remarks at this time.

* Read before Inter-State Post Graduate Assembly of America, Tri-State MedicalAssociation, October 28, i924.

is 287

JOHN B. DEAVER

The surgeon is apt to recognize three pathogenic types of jaundice. Thefirst is due to obstruction,-the second to excess and perverted hamolysis, andthe third is a post-operative type due to infection and often to operativetrauma; from a broad' clinical point of view, a division into painful andpainless jaundice also seems logical.

In passing it may be said that in painful jaundice the attacks of acutepain precede the appearance of jaundice. It is also worth while to callattention to the importance of the proper interpretation of the history of pain,for often such attacks of pain are the discomforts due to the accumulation ofgas in the stomach and intestines, and close inquiry will show that the pain hasnever been severe enough to require an anodyne for relief. Painful jaundiceis more amenable to permanent relief by operation than painless jaundice, sothat from the standpoint of the patient's future, it is not so serious a conditionas the painless type.

The most common types of jaundice are the jaundice of gall-stone obstruc-tion, of carcinoma of the head of the pancreas, and of cholangitis, the two latterof the painless type. The jaundice (painless) of the splenomegalies is notso frequent as the ones just mentioned. A type of painless jaundice thesurgeon too often sees is that due to injury of the common or of the hepaticduct following operation.

So-called catarrhal (painless) jaundice, having its origin in a gastro-duodenal irritation, is the result of a mild cholangitis or liver cell damage whichusually subsides in a short time if the mild proper diet is observed. In themajority of cases of chronic catarrhal jaundice that have not yielded to therecognized non-surgical treatment, I have found a mild pancreatitis and cho-langitis, which I believe was caused by the infection having extended from thepapilla of Vater into the pancreatic and common bile ducts. At operationin this type of jaundice the pancreas will be found to be increased in densityand enlarged throughout its entirety, differing in this respect from the casesof chronic pancreatitis caused by lymph-borne infection where the inflam-mation usually involves and is limited to the head of the pancreas. In the-patient with catarrhal jaundice and a decidedly pronounced cholangitis thatdoes not yield promptly to medication, surgical, and not so-called medical, biledrainage should be instituted.

The rarer forms of jaundice due to carcinoma of the bile ducts, diverticu-lum of the common duct, nervous shock, acute haemolysis, retro-peritoneal andother infections are of interest but not so important practically as are theother forms.

Jaundice following infection elsewhere than in the upper abdomen is notoften seen, but it does occur. I have in mind two cases in particular.

In one, a superficial infection of the leg immediately above the ankle, in spreadingcaused abscess formation high up on the leg and the fleshy portion of the thigh withenlargement of the lower chain of inguinal lymphatic glands of the corresponding side,as revealed by deep palpation below Poupart's ligament. This was followed by a retro-peritoneal purulent collection and jaundice. A provisional diagnosis of appendicitis was

288

THE SURGERY OF JAUNDICE

made and at operation the retro-peritoneal collection was found to open into the peritonealcavity; a large amount of pus was evacuated. The appendix was normal.

In the second case, a recent one, jaundice with acute haemolysis occurred in a youngwoman suffering from infection following self-induced abortion. Autopsy showed pelvicinfection, a perforated uterus; the spleen weighed 24o gms., was firm with the notchprominent, and smooth surface. It cut readily and the cut surface, firm, dry and darkred, was the seat of an acute splenic tumor in an early stage.

Sections: I. Gangrenous endometritis. Acute suppurative metritis.2. Acute hyperplastic (infectious) splenic tumor.3. Lungs.-Passive congestion and cedema.4. As No. i.5. Liver.-Jaundice, marked cloudy swelling, acute interstitial hepatitis,

formation of bile thrombi.6. Same as No. 5.7. Kidney.-Acute glomerulo-nephritis, with necrosis of tubular epithelium

and hyaline thrombosis of capillaries.8. Kidney.-Same as No. 7.9. Lung.-As No. 3.

IO. As No. I.Complete blood count on day of admission, July 26, I924:

Hemo ............................................ 75R. B. C. 4,450,000W. B. C. ..... 34,200Poly. Neutr .... 9ILymph .... 6L. Mono .... 2Trans .... IEosin .... 0

Coagulation time 33/4 minutes.Complete blood counts on-

July 27 July 28 (day of death)Hemo . ............... 65 40 25R. B. C. .............. 2,I 30,000 I,650,000 I,920,000W. B. C. - 32,200 I 9,000 5,800Poly. Neutr .92 90 62Lymph .............. 4 6 32L. Mono ............ 1 2 4Trans ............... I 2Eosin ................ I I 0

Jaundice caused by poisons, nervousness, fright, grief and so forth, is notpertinent to our subject.

Obstructive jaundice is the most common type with which the surgeonhas to deal. It has its origin in the liver and is due to gradual or sudden,partial or complete, temporary or permanent obstruction, either within orwithout the ducts, to the flow of bile. Complete or partial obstruction mayresult from tumor formation at the papilla of Vater, in the common duct, inthe head of the pancreas; or it may be due to stone formation and tostricture of the papilla of Vater, or stricture of the common or of the hepaticduct. While it is possible for small stones to pass through the papilla ofVater, larger ones will lodge at this point, with increased obstruction as theresult of inflammation caused by their presence.

289

JOHN B. DEAVER

Sufficient stress is not being placed upon the contracted papilla of Vateras a cause of at least temporary obstruction of the common duct and jaundice.I have met with this condition often enough when witlh the common ductopene(l nothing but the tiniest metal probe properly shaped, followed by rapiddilatation with a series of larger probes, could pass through the papilla, toconvince me that this is one of the many pathologic phenomena of gall-stonedisease. Assuming that in the average patient bile can be aspirated by theduoclenal tube, this condition would preclude any suclh possibility.

The contraction I refer to is not a reflex spasm of the muscle of Oddi, buta stricture in the formative stage. If resolution does not occur or the strictureis not (lilated, it leads to permanent obstruction of the papilla. W;hen thepancreas extends on to the portion of the (luodenal wall including the terminalportion of the common dutict, as is occasionally the case, inflammation of thesame may cause constriction of the l)al)illa of Vater.

Obstruction of the common duct mav also result from outside compression,as from neoplasms, either primary or metastatic. It is a well-known factthat the numerous lymphatics along the course of the hepatic vessels arefavorite sites of carcinomatous infiltration.

Complete obstruction may also result from compression due to syphiliticprocesses, as well as from the scars of duodenal and gastric ulcers, also fromcarcinoma of the gastro-hepatic omentum at the site of the transverse fissureof the liver. Obstructive jaundice is also sometimes the result of conditionsin the smaller ducts and the tiniest ducts within the liver itself, due to infec-tious cholangitis or to the presence of stone in the hepatic duct. And thenthere is the most commllon type of obstruction, w,Nhich usually is partial andintermittent, associated with stone or stones in the common duct with ball-valve action. These types of jaundice can only be relieved by operation.

Hanmolytic jaundice was formerly considered as purely of havmatogenousorigin. That is to say, the phenomena of increased fragility of the red cellswith subsequent disintegration and formation of bile pigment, to which thejaundice is due, takes place independent of the bile-forming function of theliver. Here again investigation has modlified our conception of the process.A host of investigators have established a close relationship between h,emo-lytic jaundice and the behavior of the liver cells. As a result of diminishedresistance (possibly one of the basic causes of hemolytic jaundice) the redblood-cells are destroyed by the spleen in large numbers and the liver isflooded with pigment which increases the viscosity of the bile and producesinspissated plugs in the small biliary ducts. Since the pressure of the bileitself dioes not suffice to send it onward, it accumulates and is forced intothe lymphatic system and thence into the blood stream with icterus as a result.In fact, there is the same thrombosis of the bile capillaries as in obstructivejaundice. The term h-emolytic jaundice is usually associated in our nmindswith (lisease of the spleen and to the surgical mind it generally suggeststhe association of so-called splenic ananmia, pernicious anxmia, or Banti's

290


disease. It must be borne in mind, however, that these original splenic condi-tions are more often than not related to disease of the liver and the gall-bladder,particularly cholelithiasis. This relationship is explained by William J. Mayosomewhat as follows: The predisposition to the formation of gall-stones isdue to the viscosity of the blood caused by the flooding of the liver with bloodpigment set free by the destruction of numerous red blood-cells in the spleen.This may lead to cholangitis and finally to cirrhosis of the liver. The clinicalpicture of haemolytic jaundice, as you are aware, consists of splenomegaly,acholuric jaundice and more or less marked anaemia. The condition can becured only by removal of the spleen, which cannot be done too early.

In addition to the cholangitis and peri-cholangitis associated with chronicpancreatitis, either of the head or of the entire pancreas, there will occasion-ally be present a chronic splenitis with jaundice from which relief is onlyolbtained by removal of the spleen and establishing bile drainage, by either acholecystostomy or a cholecysto-duodenostomy or a choledochostomy.

The chronic jaundice of biliary cirrhosis can be relieved only by a drainageoperation, but it must be done early if any good is to be accomplished.William J. Mayo has made this clear in a recent description of biliary cir-rhosis, which he divides into three types. He states, and rightly too, thatbiliary cirrhosis is most often the secondary result of infectious and obstruc-tive processes having their origin in the gall-bladder or the common duct,usually from gall-stone disease. Obstruction of the small bile ducts leads toearly and continuous jaundice. The most common cause of obstruction isstone in the common duct and enlargement of the head of the pancreas. Inthis type of biliary cirrhosis the splenic enlargement is not marked, but theliver is definitely enlarged and is dark in color, soft, bleeding easily on theslightest injury. Removal of the spleen is not indicated, but the infection mustbe removed, which means removal of gall-stones or of the infected gall-bladder and perhaps in addition also drainage of the common bile duct. Thistype of cirrhosis is very promising if operated early.

In the second type, less common than the first type, there is no demon-strable infection or obstruction in the bile ducts. The ducts are much thick-ened; jaundice is chronic and splenic enlargement is much more pronouncedthan in the first type. The liver is also enlarged and rather firm. In thesecases bile drainage and sometimes removal of the spleen is the indicatedprocedure. When the gall-bladder is in comparatively good shape with thecystic duct distended with bile, but patulous, cholecysto-duodenostomy shouldbe considered. In the third type of cirrhosis described by Mayo as the splenictype, the disease is very chronic and little can be done. Removal of the spleenmay sometimes be of value. Although the relationship of these various typesof cirrhosis of the liver to the spleen and haemolytic jaundice is still obscure,Mayo's observations, nevertheless, are of great practical value.

Post-operative jaundice constitutes perhaps the most difficult type for thesurgeon to treat. While to some extent it may be a reflection upon histechnic, the entire blame does not always fall on him, for oftentimes it is

291

JOHN 13. DEAVERunavoidable owing to the extent and degree of pathology present which I haveno doubt is frequently due to belated operation.

What are the conditions that lead to this post-operative phenomenon?Most often injury to the common bile duct and occasionally the hepatic duct,and stirring up infection by the traumatism of the operation. For example,after cholecystectomy or cholecystostomy, more likely the former, where thepatient was not previously jaundiced, jaundice occasionally appears two orthree days after operation and, in my experience usually clears up in a com-paratively short time. It is evidently cholangitic due to disturbed liver func-tion the result of manipulation during operation. To the inexperiencedobserver the occurrence of such jaundice may give considerable unnecessaryanxiety and naturally bring up the question of possible injury to the commonor to the hepatic duct. Post-operative jaundice occurring some time afteroperation resembles carcinoma of the head of the pancreas in that it graduallyincreases in, intensity and is accompanied by itching, weakness, loss of weight,loss of appetite and nausea, the last, however, not so conspicuously prominentas in the jaundice of carcinoma. While the history of a previous operationsuggests chronic pancreatitis, it is difficult, and I might say almost impossibleto differentiate between chronic pancreatitis and carcinoma of the head of thepancreas except by operation. A distinguishing feature of carcinoma may begeneral and rapid decline in health, and marked loss of weight. The jaundiceis greenish in tint and unvarying and preceded by nausea, loss of appetiteand increasing weakness. While in chronic pancreatitis there is loss ofweight, the jaundice is mild, increasing in intensity and accompanied by itch-ing, and the appetite remains good.

In calculous obstruction of the common duct the jaundice is intermittentand varying in intensity, the urine and stools showing the same variations;chills, sweats, fever and colicky pain usually precede the jaundice.

Sudden onset of clay-colored stools, and jaundice accompanied by colickypain may be taken to indicate obstruction within the bile ducts.

On the other hand, jaundice in a young person, preceded by symptomsof gastric catarrh, is probably a catarrhal jaundice. In this and certain typesof non-obstructive jaundice the stools are not clay-colored.

I have digressed somewhat from the subject of post-operative jaundice togive these few guiding points in the differential diagnosis of some kinds ofobstructive surgical jaundice which may be of value when properly correlatedwith the history, physical examination and laboratory findings.

In the jaundice of cholangitis not due to calculous obstruction of the com-mon duct, but to choledochitis with thickening of the walls of the duct,anastomosis of the gall-bladder to the duodenum, where the cystic duct ispatulous and the gall-bladder practically normal, is perhaps the bestoperative procedure. Where the gall-bladder is present and intact and thelesion is a non-traumatic stricture of the common duct, this operation willterminate the. jaundice, and still it is not the operation of choice. The betterprocedure is dilatation of the stricture by opening the duct and the introduc-

292


tion of a T-tube. Some years ago I operated upon a colleague who wasthought to have carcinoma of the head of the pancreas, and in whom wasfound a stricture of the hepatic duct. I dilated the stricture, as described, andintroduced a T-tube, which was worn for several weeks. The doctor contin-ues well now ten years since the operation.

The exposure of the field of operation in these secondary cases requirescare, especially in the presence of extensive and well-organized adhesions,which often present a conglomerate mass, entangling alliances, as it were, oftendifficult to disentangle. It has been my experience that in the cases wherethe gall-bladder has been removed, the adhesions are more troublesome todeal with than when a cholecystostomy has been done. A common finding isthe great omentum, the hepatic flexure of the colon, the duodenum and thepylorus adherent to each other and to the under surface of the liver corre-sponding to the gall-bladder bed. When the gall-bladder has been drainedthe adhesions are not so deeply placed. In the former type of cases I oftenhave had to spend more time in freeing adhesions and adherent viscera thanin the operative technic upon the duct.

What are the usual operative findings in the case of bile duct injury?The free border of the gastro-hepatic (lesser) omentum presents a more orless cicatrized and thinned out appearance. The foramen of Winslow isoccluded. The portal vein is more than usually prominent. Delicate dissec-tion fails, except in a few instances, to find the lower end of the common duct.The lower end of the duct can sometimes be identified by opening the duode-num, locating the papilla of Vater and passing a probe through it into thelower portion of the common duct, but I do not recommend this procedure.Careful and painstaking dissection will expose the upper end of the duct,often in a mass of cicatricial tissue or in the shape of a bulbous end; thelatter being identified by hypodermic aspiration. Where only cicatricial tissueat the site of or close to the transverse fissure of the liver is seen, a carefullydirected incision through this inflammatory tissue at its thickest and densestpoint will yield a free discharge of bile, and thus the duct is identified. Therepair of the duct in the conditions described is one of the most tryingoperations, calling for anatomic knowledge, patience and determination, alongwith the gentlest manipulation. But the results of operation have givenme much satisfaction and the patients great comfort. The successful issueof these cases depends primarily upon the proper exposure of the anatomyinvolved, for to operate blindly is to operate unsuccessfully.

When the ends of the duct cannot be brought in apposition and sutured,I consider it best to anastomose the proximal end with the duodenum eitherwith or without the aid of an in-lying catheter. But when the proximal endof the duct is long enough to anastomose without the aid of a catheter, thisshould be done. (Fig. 3.) Hugh Williams, and also Lahey, of Boston, haverecently reported successful transplantation of a common duct fistula into theduodenum, basing the procedure on the established fact that the pressure ofthe bile being sufficient to keep an external fistula open, there seems to be no

293

JOHN B. DEAVER

reason why the same pressure should not act sinmilarly oni an internal fistula,that is, keep it permanently open. Lahey also suggests that in case thissimple operation did not prove successful one or the other of the more triedout, but more complicated ones, can later be done. I have mentioned thesesuggestions because they differ somewhat from the methods in vogue by othersurgeons. Almost every active surgeon has a method of his own for recon-structing the common bile duct injured at operation. It is my own intention to(lescribe these, but rather to show the different procedures which 1, personally,have found useful.

The post-operative dangers to the jaundiced patient are hepatic insuffi-

FIG. I.

ciency and bleeding. But the latter is rarely seen since we are giving chlorideof calcium intravenously before operation. But hepatic insufficiency is to bereckoned with and in my experience when decidedly pronounced proves fatalin spite of all measures, such as plenty of fluid consisting of water by mouth,saline and glucose solution by enteroclysis or intravenously. The relationshipbetween hepatic and renal insufficiency is so close that these patients practicallydie of uraemia. The old saying, an ounce of prevention is worth a pound ofcure, here means careful pre-operative examination and pre-operative treat-ment. Operation, except in some emergency cases, where the urine containsacetone and diacetic acid, should not be done until the urine is negative tothese. It also means early recognition of a surgical condition. Faith inmedical drainage and negative X-ray findings are responsible in part fordelayed operation, and to no less a degree for failure to make an early diag-nosis. The determination of liver function by phenoltetrachlorphthalein hasbeen somewhat unsatisfactory in our hands, using both the duodenal tube and

294


the blood methods, inasmuch as when the liver function was decidedly low, itcould be determined by other means, as for instance, the symptoms. On theother hand, we have had disappointing complications which we feel were duein large measure to hepatic breakdown when the results of this test indicatedthat we were safe. Irrespective of the analysis employed, and the one deter-mining the dye in the blood seems the only rational way, we believe, that thefunctions of the liver are so manifold, that any one method, i.e., with dyes,etc., is theoretically liable to large errors. In addition, the large margin of

FIG. 2.

safety provided in the liver is a factor making finer distinctions quite difficultto attain. I am convinced beyond a doubt that those of nmy colleagues whohave seen the greatest number of living autopsies in jaundiced patients havethe best grasp of the diagnostic situation. Fortunately, or unfortunately ifyou will, these patients are not as a rule seen by the surgeon until they havebeen treated for a period long enough to have missed the best chance whichearly surgery could' have given them. The nearer the patient is to beingwell when operated the surer he is of getting well.

Next to early diagnosis the essentials of success are preparatory treatmentin the shape of careful examination, which must include the study of thecirculation, the blood sugar, the urine, urinary output, cardiac function andcareful scrutiny for focal infections; finally, the patients should be dividedinto the lean and the fat, and especial treatment accorded the latter.

Obese patients require particular attention in the way of diet and reducing295

JOHN B. DEAVER

exercises. I do not operate on a fat subject in the presence of higlh bloodsugar or when the urine contains acetone and diacetic acid without suitable

.: .''.:- 9,>.

,.s_|REt,= t.@G^aS

.. ..- -O$4%- -/

k -$-%---%--7

FIG. 3.

FIG. 4-

pre-operative treatment. Insulin, given with judgment, even in the absenceof sugar in the urine, is in place. There is a relationship between high blood

296


sugar and the glycogenic function of the liver, and the high temperature in thehepatic insufficiency following operation is also significant.

Other factors in causing hepatic insufficiency following operation are toomuch anesthetization and the amount of traumatism to which the liver inparticular has been subjected. In the presence of much pathology, and espe-cially if of long standing, I care not how skilful and gentle the surgeon mavbe, a certain amount of operative traumatism is unavoidable. When the struc-tures involved in the dissection are welded together, as it were, the surgeonmay have to resort to the hatchet the crowbar and the trowel. I want toimpress this upon our medical colleagues. Dillydalling, pussyfooting, side-stepping, spa rri ng for FIG. S.wind in these cases is too *: --often disastrous.

Where the common orhepatic duct has been cutcompletely across, whichis rare, and this is recog-nized at the original oper-ation, it goes withoutsaying, repair of the in-jury should immediatelybe made. This will consistsimply of s u t u r e, carebeing t a k e n to obtainedge-to-edge apposition.This can as a rule be ac-complished w i t h o u t theaid of a rubber tube, butif it cannot be d o n e I T-tube-French make. T-tube-American type.advise using a T-tube in preference to a straight rubber tube, first suturing theposterior walls of the ends of the duct, then introducing the tube, when thesuture of the anterior wall is made. The advantage of the T-tube is the imme-diate and prolonged bile drainage obtained, so important in the treatment ofcholangitis which is so often present (Fig. 5.)

The more common accident is perhaps partial division of the duct; suchan opening can be closed by suture with little or no trouble.

In the secondary operation when the two ends of the injured duct can beidentified and freed and the gap between the ends is not so large as topreclude their apposition, the ends may be sutured with or without thepresence of an in-lying rubber tube. Were it possible to have a decalcifiedbone tube of the proper size, this might be more ideal. When the distal endof the duct cannot be identified so that there is no chance of opposing thetwo ends, some other procedure, depending upon the extent of the injury, isthe method of choice. (Figs. 2, 3 and 4.)

297

JOHN B. DEAVER

The length of the time between the introduction of the catheter and itspassage varies in different cases from as early as four weeks to several months.Occasionally the catheter becomes blocked, but usually this is corrected bythe bile flowing around the catheter. Personally, I have never had to removethe catheter, yet I can see this might have to be done. I have used the T-tubein innumerable cases of gall-stone disease and have rarely had any troublein the shape of blocking of the intra-ductal part of the tube. Here of coursewe have the advantage of being able to flush the tube. As I have alreadyreported on previous occasions, I had one patient who wore a T-tube for fouryears without causing any trouble.

The methods of reconstruction of the duct practiced in the past areobsolete. The chief among these consists of rebuilding the duct over anin-lying straight rubber tube, making use of the omentum for reinforcement.Unfortunately when the common duct has been reconstructed in this mannerand covered by omental grafts or by means of a flap of gastric or intestinalwall, the patients as a rule do not remain well, and sooner or later developa stricture with recurrence of jaundice calling for further operation. Afterthese operations drainage is necessary, using rubber dam or rubber tubing,which should be removed not later than the second or third day.

In conclusion I would add that the operative treatment of jaundice ofcourse depends upon its cause. It may consist of gall-bladder drainage, eitherexternally or through the duodenum; removal of the gall-bladder; drainageof the common duct; anastomosis of the common duct to the duodenumn orremoval of the spleen.

Cholecysto-gastrostomy I never perform except when the duodenum can-not be mobilized. I know the latter operation is a great favorite, but I believecholecysto-duodenostomy is more in keeping with nature's manner of dispos-ing of the bile by emptying it into the duodenum.

From what I have said, assuming it is true that pathology of the living doesnot lie, the medical man can take home with him this warning: in a case ofjaundice the surgeon can never be called too early, but he can be called too late.

298

Documents

the surgery of jaundice