Anthony Eden's bile duct: portrait of an ailing leader

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ANZ J. Surg. 2003; 73 : 341345 COWLISHAW SYMPOSIUM Cowlishaw Symposium ANTHONY EDENS BILE DUCT: PORTRAIT OF AN AILING LEADER G ABRIEL K UNE University of Melbourne, Victoria, Australia A BRIEF BIOGRAPHY OF ANTHONY EDEN This biographical sketch of Anthony Eden was assembled fromfour biographies of Eden, his own memoirs, historical chroniclesand from personal communications. 17 Eden was born in 1897.Both sides of his family were from the English ruling class. Hewas educated at Eton and Christ Church, Oxford. He won theMilitary Cross in 1917 for bravery during active service in WorldWar I. In 1923, he married Beatrice Beckett, the daughter of astaunch conservative, Sir Gervase Beckett Bt. In the same year hewas elected to the House of Commons in a safe Tory seat, whichhe held until 1957 when he retired from politics. In 1935 hebecame Foreign Secretary, but resigned in 1938 because heapparently believed that Prime Minister Neville Chamberlainsattempts to appease fascist Italy and Nazi Germany were danger-ous. Between 1940 and 1945 he was Foreign Secretary inWinston Churchills government. In February 1945, Eden andChurchill attended a conference in Yalta in the Crimea, whereStalin and Roosevelt in effect carved up Europe without signifi-cantly consulting Churchill. The decisions made there were muchto the displeasure of both Churchill and Eden, who believed thatRoosevelt was appeasing Stalin far too much, and that he was notsufficiently 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 comprehendingthe gravity and consequences of the decisions made. He diedsoon after this meeting. In April 1945, Anthony Eden attendedthe San Francisco Conference in which he strongly supported theestablishment 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 againbecame Foreign Secretary in the new Churchill Government.In 1950 Edens 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 ofwhich required analgesic injections and one that was apparentlyaccompanied by transient jaundice. In April 1953, Eden had yetanother attack of severe upper abdominal pain. X-rays revealedthe presence of gallstones and Sir Horace Evans, physician to theQueen, was called in. Sir Horace advised urgent surgery.On 12 April 1953 at the age of 55, surgery was performedin London by Mr John Basil Hume, senior surgeon at St Bar-tholomews Hospital, and assisted by Mr Guy Blackburn, generalsurgeon at Guys Hospital.No one can be certain what happened during this operativeprocedure, however, putting together the information obtainedfrom several sources the most likely scenario is that, duringcholecystectomy, Anthony Eden sustained an injury of the proxi-mal common hepatic duct at its bifurcation and possibly, also, aninjury of the right hepatic artery, as shown in Fig. 1. On 29 April1953, a little over 2 weeks after the initial operation, furthersurgery was performed by Mr Hume, apparently to drain a bilecollection and presumably also to attempt to reconstruct the bileduct. This was unsuccessful.In May 1953 while Anthony Eden was still in hospital recover-ing from his second operation, Dr Richard Cattell, surgeon at theLahey Clinic in Boston and an internationally known expert inbiliary and pancreatic surgery, happened to be on a lecture tour inLondon and was invited to give an opinion on Edens condition.Cattells 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 usuallyduring cholecystectomy, than anyone else in the world.Shortly after this consultation, Eden travelled to Boston, andDr Cattell performed a hepaticojejunostomy over a Y-tube, asshown in Fig. 2, with an entero-anastomosis below the recon-struction, this being an attempt to divert the alimentary streamaway from the bile ducts. This operation was successful, at leastin the short term.Eden recuperated in the USA and returned to London inOctober 1953. While he was away, Churchill took over theForeign Office. At the end of June 1953, Churchill suffered aserious stroke, however he made a most remarkable recovery andcontinued in office as Prime Minister until April 1955. At thistime, Anthony Eden took over from Churchill as Prime Minister.On 26 July 1956 Colonel Nasser seized the Suez Canal. Thisfollowed a long period of Egyptian opposition to what theyregarded as a Canal Zone occupation, starting with King Farouksdemand for total and immediate withdrawal of British Troopsfrom the Suez Canal in 1950.Ten weeks later, on 5 October 1956, Eden collapsed with ahigh temperature of 106 F. This, 3 1 / 2 years after his bile ductrepair, was the first of several major attacks of pain, rigors andfever, which he apparently suffered for the rest of his life. Threeweeks after his collapse on 27 October 1956, Israel invadedEgypt and a further 4 days later, Eden ordered the Anglo-Frenchforces to occupy the Suez Canal Zone, on the pretext of sep-arating Egypt and Israel. This action caused an uproar in theBritish parliament, in the USA and also at the United Nations.In response to this, all parties agreed to an early ceasefire on6 November 1956, and 3 weeks after this occupation, on 23November 1956, the Anglo-French troops began to withdraw G. Kune MD, FRACS, FRCS, FACS.Correspondence: Professor Gabriel Kune, 41 Power Street, Toorak, Vic-toria 3142, Australia.Email: gkune@unimelb.edu.auAccepted for publication 16 January 2003. 342 KUNE from the Suez Canal Zone. The British strongly denied Anglo-French collusion with Israel.From the end of November to mid-December 1956, AnthonyEden spent 3 weeks recuperating at Ian Flemings home inJamaica. 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 Edenwas succeeded by Harold Macmillan. In 1961, Eden was createdfirst 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 asecond operation by Richard Cattell. This surgery involvedre-exploration of his anatastomosis, and the finding of a righthepatic duct narrowing which was instrumentally dilated.In 1962 he had a further operation at the Lahey Clinic for theexcision of a benign chest wall tumour, unrelated to his biliarytract surgery.Further episodes of cholangitis followed over the next fewyears. Anthony Eden returned to the Lahey Clinic in 1970. Bythen Richard Cattell had died and the biliary reconstruction workat the clinic was largely undertaken by Dr John W Braasch, whoperformed the next biliary tract procedure in 1970. The stricture ofthe right hepatic duct found previously was again dilated instru-mentally and a small abscess of the right lobe of the liver was alsodrained. Apparently at this procedure, the right lobe of the liverwas 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 righthepatic 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 theEden story which are less certain, partly hearsay and perhaps evensupposition, as compared to the reasonably accurate though briefaccount of Anthony Edens life and death just described. Thewriter asks three rhetorical questions: was the bile duct injuryavoidable; what was the quality of Edens medical care; and didhis 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 firstoperation in London emerged from the operating room, he saidsomething along the lines of, Anthony Eden had two cysticducts. 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 theretwo cystic ducts. 8 A search of the surgical literature revealed onlyone report purporting a double cystic duct a case report inwhich a 30-year-old woman was found to have a very thick-walled gall bladder adherent to an indurated porta hepatis. 9 The so-called double cystic duct may well have been an acquiredcondition of internal fistulization in the case of this chronictyphoid carrier, who apparently had had attacks of cholecystitissince early childhood. 9 There is also a slender bile duct called the subvesical duct, orthe duct of Luschka, present in up to 50% of individuals, whichdrains a small subsegment of the right lobe of the liver, runs closeto the gall bladder fossa and usually enters the right hepaticduct. 10,11 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- Fig. 1. The lesions likely to have been sustained inadvertentlyduring Anthony Edens gallbladder surgery in London in April 1953,involving the common hepatic duct at its bifurcation, and possibly alsothe right hepatic artery. Fig. 2. The type of bile duct reconstruction procedure performedon Anthony Eden by Dr Richard Cattell at the Lahey Clinic, whichinvolved a loop hepaticojejunostomy over a Y-tube with a proximalentero-anastomosis. ANTHONY EDEN 343 hepatic duct. 12 However, this situation did not occur in Edenscase.This is the time to come to the authors choice of a book fromthe Cowlishaw Collection. It is the 1568 edition of De HumaniCorporis Fabrica by Andreas Vesalius, this particular editionpublished just 4 years after his death. 13 Professor Kenneth Russell, one of the present authorsanatomy teachers, describes this in the catalogue as: Vesaliusgreat work in which he introduced truth and fact into anatomyand exploded many myths. This edition contains magnificentillustrations, of which only one is shown, namely, the anatomy ofthe gall bladder and bile ducts (Fig. 3). Vesalius knew that thereis just one cystic duct.Knowledge of the causes, prevention and appropriate treat-ment of bile duct injury has evolved gradually over almost100 years. 1418 One of several important steps of surgery is theclear identification and division of the cystic artery. Thismanoeuvre opens up Calots Triangle, and also allows a gentlemobilization of the cystic duct if it is adherent to the commonhepatic duct. An adherent cystic duct is seen in about every fifthperson.Occasionally there is a looping of the right hepatic artery, espe-cially noticeable with excessive traction on Hartmanns Pouch.This might have happened in Edens case, given it is possible thatthe right hepatic artery was also inadvertently ligated. Also rec-ognized for many years as being critical to successful surgery isthe meticulous dissection of Calots Triangle. This is essential inensuring that there are no structures crossing this triangle andmust be followed by a clear demonstration of the triple junctionof bile ducts. These principles apply equally to the traditionalopen cholecystectomy as to laparoscopic cholecystectomy. Thequestion is: were these cardinal principles adhered to duringEdens 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 19 suggests thatAnthony Edens physician gave him a shortlist of three surgeonswith 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,Mr Hume removed my appendix when I was younger, and Ill goto him. One wonders if Eden would have sustained a bile ductinjury had he chosen any one of these three surgeons? A cruelquestion, the answer to which is possibly, but unlikely. WHAT WAS THE QUALITY OF EDENS MEDICAL CARE? Edens attacks of severe pain caused by gallstones appear to havebeen misdiagnosed for many years or at least from 1945 when hesuffered from acute attacks of upper abdominal pain without radi-ation (commonly misdiagnosed as duodenal ulcers). 17 Even Edenwho wrote little about his health, said in his memoirs For sometime I had been suffering from internal pains which had beenvariously diagnosed . 2 I have already discussed that the first London operation was afailure. Regarding the second operation in London, the generalexperience around the Western world, including Australia, is thatif the original surgeon recognizes that a bile duct injury hasoccurred, the surgeon will go back in about four instances out offive, and despite having a lack of experience in bile duct recon-struction, will attempt such a reconstruction, and this in mostcases fails.The first operation performed by Richard Cattell was unques-tionably of the highest quality attainable at that time. However itcould be argued with the benefit of hindsight that the second andthird US operations may have been a little timid in not attackingthe right hepatic stricture directly and not converting the loopjejunostomy into a Roux-en-Y to ensure against gastrointestinalFig. 3. A beautiful and accurateillustration showing the anatomyof the gall bladder, cystic duct andbile ducts from the 1568 editionof De Humani Corporis Fabricaby Andreas Vesalius,14 one of theimportant tomes in the CowlishawCollection. 344 KUNE reflux particularly in the presence of a right hepatic duct stricture.It could also be argued that the second and third US operationswere entirely appropriate, though the attacks of cholangitis withfever and rigors that Eden continued to suffer from do raise somedoubts.Were there factors other than technical expertize that contrib-uted to the failure of the London operations? Professor MartinAllgwer of Basel in Switzerland has spoken and written aboutwhat he calls surgical autosabotage when at a critical momentof the operation the surgeon starts to perspire and tremor, his orher heart pounds, and judgement falters. 20 Did this happen inLondon? Allgwer believes the reasons for autosabotage arecomplex and include self-criticism, apprehension regarding peerjudgement, and anguish concerning the pitfalls of surgery. To addto this, Mr Hume was 60 years old at the time of the first opera-tion, approaching retirement, and, to cap it all, he was operatingon Anthony Eden. DID EDENS ILLNESS INFLUENCE VITAL DECISIONS HE HAD TO MAKE? We have already noted that President Roosevelt and Sir WinstonChurchill were making major decisions when they were ill.Indeed, there is a long list of world leaders who were in officewhile seriously ill Lenin, Stalin, Brezhnev, Khrushchev, Presi-dents Eisenhower, Reagan and Mitterand, and many others. 6,21 It is known that Eden had suffered since 1956 with majorepisodes of cholangitis, consisting of rigors and high fevers, painand severe debility. He also had a major sleep disorder, he self-administered analgesic injections for his pain, and he frequentlytook stimulants such as benzedrine. 21 Let us examine the condition of severe cholangitis, first char-acterized by Charcot in 1877 as a triad of intermittent fever withrigors, fluctuating jaundice and pain, and named later Charcotsintermittent hepatic fever . 22,23 It is important to realize thatcholangitis is much more than just bile duct infection which givesrise to fever and shaking chills. 17,24 Normally, culture of bile shows only an occasional entericorganism, which gets in from the gut through the portal vein. If itgets through the reticulo-endothelial system of the liver intact, itis excreted into the biliary tract. In the normal situation, theseoccasional 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 ductgallstones 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 bacteraemiaor septicaemia due to bile duct infection, almost invariably theywill say that during the attack their mind was hazy and theirnormal judgement was clouded. It is this that Eden suffered withintermittently for many years.Now we go back to Edens story.On 26 July 1956, Nasser seized the Suez Canal Zone. Tenweeks later, Eden collapsed with severe cholangitis and it tookhim a long time to recover. Nevertheless, he returned to workquickly, and 3 weeks after his collapse the Anglo-French forceswere 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 manybiographers as a cool composed man, an expert in the use ofdiplomacy even under the most difficult circumstances. Hebelieved in the rule of the law and in the supremacy and effective-ness of the United Nations. Calling in the Anglo-French forceswas, therefore, most uncharacteristic. It was recorded by hissenior advisers and by others in his biographies, that at that timehe 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 resigned10 weeks later, citing poor health and he remained in poor healthfor the rest of his life, suffering many bouts of cholangitis.Anthony Edens tragedy was that the many successful aspectsof his career including his time as Churchills Foreign Secretary,were largely forgotten because of the Suez Canal debacle, adebacle which, in the present authors view, was significantlycontributed to by the disastrous and tragic consequences of hisbile duct injury. ACKNOWLEDGEMENTS It is a pleasure to thank Dr John W Braasch, MD, FACS (anacknowledged expert and leader in the field of bile duct recon-struction and past surgeon at the Lahey Clinic) for his assistancewith several factual aspects of this case and bile duct reconstruc-tion surgery in general. The late Lord Smith of Marlow and thelate Dr Kenneth Warren, MD (past surgeon and past chief ofsurgery at the Lahey Clinic) also provided the author with impor-tant insights. REFERENCES 1. Churchill RS. The Rise and Fall of Sir Anthony Eden . London:Macgibbon and Kee, 1959.2. Eden A. The Memoirs of the Rt Hon Sir Anthony Eden . London:Cassell, 1960.3. Aster S. Anthony Eden . London: Weidenfeld and Nicolson,1976.4. Carlton D. Anthony Eden. A Biography . London: PenguinBooks, 1981.5. Lord Blake, Nicholls CS (eds). The Dictionary of National Biog-raphy 197180. Oxford: Oxford University Press; 1986. Eden(Robert) Anthony, First Earl of Avon (18971977); 26272.6. Ross J. Chronicle of the 20th Century. London: Chronicle andPenguin Books, 1990.7. Braasch JW. Personal Communication 2002.8. Kune GA. Current Practice of Biliary Surgery . Boston: LittleBrown, 1972.9. Paul M. An important anomaly of the right hepatic duct and itsbearing on the operation of cholecystectomy. Br. J. Surg. 1947; 35 : 3835.10. Hobsley M. Intra-hepatic anatomy. A surgical evaluation. Br. J.Surg. 1958; 58 : 63542.11. Kune GA. The influence of structure and function in the surgeryof the biliary tract [Arris and Gale Lecture]. Ann. R. Coll. Surg.Engl. 1970; 47 : 7891.12. McQuillan T, Manolas SG, Kune GA. Surgical significance ofthe bile duct of Luschka. Br. J. Surg. 1989; 76 : 6968.13. Vesalius A. De Humani Corporis Fabrica . Venetiis: Apud Fran-ciscum Franciscium Senensem & Joannem Criegher Germanum,1568.14. Mayo WJ. Some remarks on cases involving operative loss ofcontinuity of the common bile duct. With the report of a caseof anastomosis between the hepatic duct and the duodenum. Ann.Surg. 1905; 42 : 906. ANTHONY EDEN 345 15. Smith R. Obstructions of the bile duct. Br. J. Surg. 1979; 66 : 6979.16. Kune GA. Bile duct injury during cholecystectomy: Causes, pre-vention and surgical repair in 1979. Aust. N.Z. J. Surg. 1979; 49 :3540.17. Kune GA, Sali A. The Practice of Biliary Surgery . Oxford:Blackwell Scientific Publications, 1980.18. Braasch JW, Rossi RL. Reconstruction of the biliary tract. Surg.Clin. N. Am. 1985; 65 : 27383.19. Lord Smith of Marlow. Personal Communication, 1995.20. Allgwer M. Equanimity of the Surgeon . GB Ong Lecture, HongKong, 1985.21. LEtang H. Ailing Leaders in Power 19141994. London: TheRoyal Society of Medicine, 1995.22. Charcot JM. Lecons sur les Maladies du Foie des Vois Biliareset des Reins . Paris: 1877.23. Ellis H. Bailey and Bishops Notable Names in Medicine andSurgery , 4th edn. London: Lewis, 1983.24. Kune GA, Hibbert J, Morahan R. The development of biliaryinfection: An experimental model. Med. J. Aust. 1974; 1 :3013.