- Anthony Eden's bile duct: portrait of an ailing leader
Anthony Eden's bile duct: portrait of an ailing leader
ANZ J. Surg.
ANTHONY EDENâS BILE DUCT: PORTRAIT OF AN AILING LEADER
University of Melbourne, Victoria, Australia
A BRIEF BIOGRAPHY OF ANTHONY EDEN
This biographical sketch of Anthony Eden was assembled from
four biographies of Eden, his own memoirs, historical chronicles
and from personal communications.
Eden was born in 1897.
Both sides of his family were from the English ruling class. He
was educated at Eton and Christ Church, Oxford. He won the
Military Cross in 1917 for bravery during active service in World
War I. In 1923, he married Beatrice Beckett, the daughter of a
staunch conservative, Sir Gervase Beckett Bt. In the same year he
was elected to the House of Commons in a safe Tory seat, which
he held until 1957 when he retired from politics. In 1935 he
became Foreign Secretary, but resigned in 1938 because he
apparently believed that Prime Minister Neville Chamberlainâs
attempts to appease fascist Italy and Nazi Germany were danger-
ous. Between 1940 and 1945 he was Foreign Secretary in
Winston Churchillâs government. In February 1945, Eden and
Churchill attended a conference in Yalta in the Crimea, where
Stalin and Roosevelt in effect carved up Europe without signifi-
cantly consulting Churchill. The decisions made there were much
to the displeasure of both Churchill and Eden, who believed that
Roosevelt was appeasing Stalin far too much, and that he was not
sufficiently concerned about the future welfare of Europe.
Indeed, it was subsequently revealed that at the Yalta Meeting,
Roosevelt was quite ill and possibly not entirely comprehending
the gravity and consequences of the decisions made. He died
soon after this meeting. In April 1945, Anthony Eden attended
the San Francisco Conference in which he strongly supported the
establishment of the United Nations.
Between 1945 and 1951 he was the Deputy Leader of the Oppo-
sition, and when the Tories regained power in 1951, he once again
became Foreign Secretary in the new Churchill Government.
In 1950 Edenâs first marriage was dissolved, and in 1952,
at the age of 55, he married the 32-year-old Clarissa Spencer-
Churchill, the niece of the Prime Minister.
In May 1945, Eden was diagnosed as having a duodenal ulcer.
In 1952 he had several attacks of upper abdominal pain, some of
which required analgesic injections and one that was apparently
accompanied by transient jaundice. In April 1953, Eden had yet
another attack of severe upper abdominal pain. X-rays revealed
the presence of gallstones and Sir Horace Evans, physician to the
Queen, was called in. Sir Horace advised urgent surgery.
On 12 April 1953 at the age of 55, surgery was performed
in London by Mr John Basil Hume, senior surgeon at St Bar-
tholomewâs Hospital, and assisted by Mr Guy Blackburn, general
surgeon at Guyâs Hospital.
No one can be certain what happened during this operative
procedure, however, putting together the information obtained
from several sources the most likely scenario is that, during
cholecystectomy, Anthony Eden sustained an injury of the proxi-
mal common hepatic duct at its bifurcation and possibly, also, an
injury of the right hepatic artery, as shown in Fig. 1. On 29 April
1953, a little over 2 weeks after the initial operation, further
surgery was performed by Mr Hume, apparently to drain a bile
collection and presumably also to attempt to reconstruct the bile
duct. This was unsuccessful.
In May 1953 while Anthony Eden was still in hospital recover-
ing from his second operation, Dr Richard Cattell, surgeon at the
Lahey Clinic in Boston and an internationally known expert in
biliary and pancreatic surgery, happened to be on a lecture tour in
London and was invited to give an opinion on Edenâs condition.
Cattellâs view was that a further operation should be performed.
At that time, Cattell had more experience with bile duct recon-
struction necessitated by operative injury, sustained usually
during cholecystectomy, than anyone else in the world.
Shortly after this consultation, Eden travelled to Boston, and
Dr Cattell performed a hepaticojejunostomy over a Y-tube, as
shown in Fig. 2, with an entero-anastomosis below the recon-
struction, this being an attempt to divert the alimentary stream
away from the bile ducts. This operation was successful, at least
in the short term.
Eden recuperated in the USA and returned to London in
October 1953. While he was away, Churchill took over the
Foreign Office. At the end of June 1953, Churchill suffered a
serious stroke, however he made a most remarkable recovery and
continued in office as Prime Minister until April 1955. At this
time, Anthony Eden took over from Churchill as Prime Minister.
On 26 July 1956 Colonel Nasser seized the Suez Canal. This
followed a long period of Egyptian opposition to what they
regarded as a Canal Zone occupation, starting with King Faroukâs
demand for total and immediate withdrawal of British Troops
from the Suez Canal in 1950.
Ten weeks later, on 5 October 1956, Eden collapsed with a
high temperature of 106
F. This, 3
years after his bile duct
repair, was the first of several major attacks of pain, rigors and
fever, which he apparently suffered for the rest of his life. Three
weeks after his collapse on 27 October 1956, Israel invaded
Egypt and a further 4 days later, Eden ordered the Anglo-French
forces to occupy the Suez Canal Zone, on the pretext of sep-
arating Egypt and Israel. This action caused an uproar in the
British parliament, in the USA and also at the United Nations.
In response to this, all parties agreed to an early ceasefire on
6 November 1956, and 3 weeks after this occupation, on 23
November 1956, the Anglo-French troops began to withdraw
MD, FRACS, FRCS, FACS.
Correspondence: Professor Gabriel Kune, 41 Power Street, Toorak, Vic-
toria 3142, Australia.
Accepted for publication 16 January 2003.
from the Suez Canal Zone. The British strongly denied Anglo-
French collusion with Israel.
From the end of November to mid-December 1956, Anthony
Eden spent 3 weeks recuperating at Ian Flemingâs home in
Jamaica. In spite of this attempt at recuperation, a sick and tired-
looking Eden returned to London, and 3 weeks after his return,
on 9 January 1957, he resigned as Prime Minister. Anthony Eden
was succeeded by Harold Macmillan. In 1961, Eden was created
first Earl of Avon, and entered the House of Lords.
In mid 1957, after many further attacks of cholangitis,
Anthony Eden returned to the Lahey Clinic in Boston to have a
second operation by Richard Cattell. This surgery involved
re-exploration of his anatastomosis, and the finding of a right
hepatic duct narrowing which was instrumentally dilated.
In 1962 he had a further operation at the Lahey Clinic for the
excision of a benign chest wall tumour, unrelated to his biliary
Further episodes of cholangitis followed over the next few
years. Anthony Eden returned to the Lahey Clinic in 1970. By
then Richard Cattell had died and the biliary reconstruction work
at the clinic was largely undertaken by Dr John W Braasch, who
performed the next biliary tract procedure in 1970. The stricture of
the right hepatic duct found previously was again dilated instru-
mentally and a small abscess of the right lobe of the liver was also
drained. Apparently at this procedure, the right lobe of the liver
was small in size and this finding, together with the localized stric-
ture of the right hepatic duct, is suggestive of an ischaemic prob-
lem, and indicates to the author that, at the initial surgery, the right
hepatic artery may have also been inadvertently ligated.
Anthony Eden died on 14 January 1977, at the age of 79.
The writer would now like to approach certain aspects of the
Eden story which are less certain, partly hearsay and perhaps even
supposition, as compared to the reasonably accurate though brief
account of Anthony Edenâs life and death just described. The
writer asks three rhetorical questions: was the bile duct injury
avoidable; what was the quality of Edenâs medical care; and did
his illness influence vital decisions he made while Prime Minister?
WAS THE BILE DUCT INJURY AVOIDABLE?
Hearsay has it that when the surgeon who performed the first
operation in London emerged from the operating room, he said
something along the lines of, âAnthony Eden had two cystic
ductsâ. Thirty years ago the author reviewed five series of care-
fully performed anatomical dissections of the biliary tree, consist-
ing of over 1000 dissections. In not a single instance were there
two cystic ducts.
A search of the surgical literature revealed only
one report purporting a double cystic duct â a case report in
which a 30-year-old woman was found to have a very thick-
walled gall bladder adherent to an indurated porta hepatis.
The so-called double cystic duct may well have been an acquired
condition of internal fistulization in the case of this chronic
typhoid carrier, who apparently had had attacks of cholecystitis
since early childhood.
There is also a slender bile duct called the subvesical duct, or
the duct of Luschka, present in up to 50% of individuals, which
drains a small subsegment of the right lobe of the liver, runs close
to the gall bladder fossa and usually enters the right hepatic
If this duct is inadvertently divided during cholecystec-
tomy, it causes a temporary bile leak postoperatively, and if iden-
tified at operation, it can be mistaken for a second cystic duct.
Hence, in the past it has been incorrectly named the cholecysto-
The lesions likely to have been sustained inadvertently
during Anthony Edenâs gallbladder surgery in London in April 1953,
involving the common hepatic duct at its bifurcation, and possibly also
the right hepatic artery.
The type of bile duct reconstruction procedure performed
on Anthony Eden by Dr Richard Cattell at the Lahey Clinic, which
involved a loop hepaticojejunostomy over a Y-tube with a proximal
ANTHONY EDEN 343
However, this situation did not occur in Edenâs
This is the time to come to the authorâs choice of a book from
the Cowlishaw Collection. It is the 1568 edition of
by Andreas Vesalius, this particular edition
published just 4 years after his death.
Professor Kenneth Russell, one of the present authorâs
anatomy teachers, describes this in the catalogue as: âVesaliusâ
great work in which he introduced truth and fact into anatomy
and exploded many mythsâ. This edition contains magnificent
illustrations, of which only one is shown, namely, the anatomy of
the gall bladder and bile ducts (Fig. 3). Vesalius knew that there
is just one cystic duct.
Knowledge of the causes, prevention and appropriate treat-
ment of bile duct injury has evolved gradually over almost
One of several important steps of surgery is the
clear identification and division of the cystic artery. This
manoeuvre opens up Calotâs Triangle, and also allows a gentle
mobilization of the cystic duct if it is adherent to the common
hepatic duct. An adherent cystic duct is seen in about every fifth
Occasionally there is a looping of the right hepatic artery, espe-
cially noticeable with excessive traction on Hartmannâs Pouch.
This might have happened in Edenâs case, given it is possible that
the right hepatic artery was also inadvertently ligated. Also rec-
ognized for many years as being critical to successful surgery is
the meticulous dissection of Calotâs Triangle. This is essential in
ensuring that there are no structures crossing this triangle and
must be followed by a clear demonstration of the triple junction
of bile ducts. These principles apply equally to the traditional
open cholecystectomy as to laparoscopic cholecystectomy. The
question is: were these cardinal principles adhered to during
Edenâs operation? No one can answer this question with cer-
tainty, but subsequent events indicate that the answer is no.
Anecdotal information from a late colleague
Anthony Edenâs physician gave him a shortlist of three surgeons
with expertize in biliary tract surgery, namely Rodney Maingot,
Edward Muir and Rodney Smith. However, Anthony Eden appar-
ently responded to these suggestions with words to the effect of,
âMr Hume removed my appendix when I was younger, and Iâll go
to himâ. One wonders if Eden would have sustained a bile duct
injury had he chosen any one of these three surgeons? A cruel
question, the answer to which is âpossibly, but unlikelyâ.
WHAT WAS THE QUALITY OF EDENâS
Edenâs attacks of severe pain caused by gallstones appear to have
been misdiagnosed for many years or at least from 1945 when he
suffered from acute attacks of upper abdominal pain without radi-
ation (commonly misdiagnosed as duodenal ulcers).
who wrote little about his health, said in his memoirs âFor some
time I had been suffering from internal pains which had been
I have already discussed that the first London operation was a
failure. Regarding the second operation in London, the general
experience around the Western world, including Australia, is that
if the original surgeon recognizes that a bile duct injury has
occurred, the surgeon will go back in about four instances out of
five, and despite having a lack of experience in bile duct recon-
struction, will attempt such a reconstruction, and this in most
The first operation performed by Richard Cattell was unques-
tionably of the highest quality attainable at that time. However it
could be argued with the benefit of hindsight that the second and
third US operations may have been a little timid in not attacking
the right hepatic stricture directly and not converting the loop
jejunostomy into a Roux-en-Y to ensure against gastrointestinal
Fig. 3. A beautiful and accurate
illustration showing the anatomy
of the gall bladder, cystic duct and
bile ducts from the 1568 edition
of De Humani Corporis Fabrica
by Andreas Vesalius,14 one of the
important tomes in the Cowlishaw
reflux particularly in the presence of a right hepatic duct stricture.
It could also be argued that the second and third US operations
were entirely appropriate, though the attacks of cholangitis with
fever and rigors that Eden continued to suffer from do raise some
Were there factors other than technical expertize that contrib-
uted to the failure of the London operations? Professor Martin
AllgÃ¶wer of Basel in Switzerland has spoken and written about
what he calls âsurgical autosabotageâ when â at a critical moment
of the operation â the surgeon starts to perspire and tremor, his or
her heart pounds, and judgement falters.
Did this happen in
London? AllgÃ¶wer believes the reasons for âautosabotageâ are
complex and include self-criticism, apprehension regarding peer
judgement, and anguish concerning the pitfalls of surgery. To add
to this, Mr Hume was 60 years old at the time of the first opera-
tion, approaching retirement, and, to cap it all, he was operating
on Anthony Eden.
DID EDENâS ILLNESS INFLUENCE VITAL
DECISIONS HE HAD TO MAKE?
We have already noted that President Roosevelt and Sir Winston
Churchill were making major decisions when they were ill.
Indeed, there is a long list of world leaders who were in office
while seriously ill â Lenin, Stalin, Brezhnev, Khrushchev, Presi-
dents Eisenhower, Reagan and Mitterand, and many others.
It is known that Eden had suffered since 1956 with major
episodes of cholangitis, consisting of rigors and high fevers, pain
and severe debility. He also had a major sleep disorder, he self-
administered analgesic injections for his pain, and he frequently
took stimulants such as benzedrine.
Let us examine the condition of severe cholangitis, first char-
acterized by Charcot in 1877 as a triad of intermittent fever with
rigors, fluctuating jaundice and pain, and named later âCharcotâs
intermittent hepatic feverâ
It is important to realize that
cholangitis is much more than just bile duct infection which gives
rise to fever and shaking chills.
Normally, culture of bile shows only an occasional enteric
organism, which gets in from the gut through the portal vein. If it
gets through the reticulo-endothelial system of the liver intact, it
is excreted into the biliary tract. In the normal situation, these
occasional bacteria pass back into the gastrointestinal tract. How-
ever, with biliary tract obstruction, and for some reason espe-
cially with partial obstruction such as in the presence of bile duct
gallstones or a biliary stricture, these gut bacteria accumulate.
Continuing obstruction leads to cholangiovenous reflux of bac-
teria, and the development of bacteraemia and septicaemia,
and eventually, if untreated, a most serious situation ensues.
With bacteraemia and septicaemia, there is high fever with rigors.
If one talks with those who have had these bouts of bacteraemia
or septicaemia due to bile duct infection, almost invariably they
will say that during the attack their mind was hazy and their
normal judgement was clouded. It is this that Eden suffered with
intermittently for many years.
Now we go back to Edenâs story.
On 26 July 1956, Nasser seized the Suez Canal Zone. Ten
weeks later, Eden collapsed with severe cholangitis and it took
him a long time to recover. Nevertheless, he returned to work
quickly, and 3 weeks after his collapse the Anglo-French forces
were ordered by Eden to occupy the Canal Zone.
Prior to his collapse in July 1956, Eden was widely acknowl-
edged by public servants working with him, and by his many
biographers as a cool composed man, an expert in the use of
diplomacy even under the most difficult circumstances. He
believed in the rule of the law and in the supremacy and effective-
ness of the United Nations. Calling in the Anglo-French forces
was, therefore, most uncharacteristic. It was recorded by his
senior advisers and by others in his biographies, that at that time
he was irritable, quick tempered, often tired, and most uncharac-
teristically, conspiratorial with France and possibly with Israel
(although the latter has been denied). Uncharacteristically also,
he upset the USA, especially John Foster Dulles. He resigned
10 weeks later, citing poor health and he remained in poor health
for the rest of his life, suffering many bouts of cholangitis.
Anthony Edenâs tragedy was that the many successful aspects
of his career including his time as Churchillâs Foreign Secretary,
were largely forgotten because of the Suez Canal debacle, a
debacle which, in the present authorâs view, was significantly
contributed to by the disastrous and tragic consequences of his
bile duct injury.
It is a pleasure to thank Dr John W Braasch, MD, FACS (an
acknowledged expert and leader in the field of bile duct recon-
struction and past surgeon at the Lahey Clinic) for his assistance
with several factual aspects of this case and bile duct reconstruc-
tion surgery in general. The late Lord Smith of Marlow and the
late Dr Kenneth Warren, MD (past surgeon and past chief of
surgery at the Lahey Clinic) also provided the author with impor-
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