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

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  • ANZ J. Surg. 2003; 73 : 341â345 COWLISHAW SYMPOSIUM Cowlishaw Symposium ANTHONY EDENâS 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 from four biographies of Eden, his own memoirs, historical chronicles and from personal communications. 1â7 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 1 / 2 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 G. Kune MD, FRACS, FRCS, FACS. Correspondence: Professor Gabriel Kune, 41 Power Street, Toorak, Vic- toria 3142, Australia. Email: gkune@unimelb.edu.au Accepted 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, 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 tract surgery. 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. 8 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. 9 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. 9 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 duct. 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 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. Fig. 2. 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 entero-anastomosis.
  • ANTHONY EDEN 343 hepatic duct. 12 However, this situation did not occur in Edenâs case. This is the time to come to the authorâs choice of a book from the Cowlishaw Collection. It is the 1568 edition of De Humani Corporis Fabrica by Andreas Vesalius, this particular edition published just 4 years after his death. 13 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 100 years. 14â18 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 person. 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 19 suggests that 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 MEDICAL CARE? 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). 17 Even Eden who wrote little about his health, said in his memoirs âFor some time I had been suffering from internal pains which had been variously diagnosed . â 2 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 cases fails. 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 Collection.
  • 344 KUNE 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 doubts. Were there factors other than technical expertize that contrib- uted to the failure of the London operations? Professor Martin Allgöwer 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. 20 Did this happen in London? Allgöwer 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. 6,21 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. 21 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 . 22,23 It is important to realize that cholangitis is much more than just bile duct infection which gives rise to fever and shaking chills. 17,24 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. ACKNOWLEDGEMENTS 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- 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: Penguin Books, 1981. 5. Lord Blake, Nicholls CS (eds). The Dictionary of National Biog- raphy 1971â80. Oxford: Oxford University Press; 1986. Eden (Robert) Anthony, First Earl of Avon (1897â1977); 262â72. 6. Ross J. Chronicle of the 20th Century. London: Chronicle and Penguin Books, 1990. 7. Braasch JW. Personal Communication 2002. 8. Kune GA. Current Practice of Biliary Surgery . Boston: Little Brown, 1972. 9. Paul M. An important anomaly of the right hepatic duct and its bearing on the operation of cholecystectomy. Br. J. Surg. 1947; 35 : 383â5. 10. Hobsley M. Intra-hepatic anatomy. A surgical evaluation. Br. J. Surg. 1958; 58 : 635â42. 11. Kune GA. The influence of structure and function in the surgery of the biliary tract [Arris and Gale Lecture]. Ann. R. Coll. Surg. Engl. 1970; 47 : 78â91. 12. McQuillan T, Manolas SG, Kune GA. Surgical significance of the bile duct of Luschka. Br. J. Surg. 1989; 76 : 696â8. 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 of continuity of the common bile duct. With the report of a case of anastomosis between the hepatic duct and the duodenum. Ann. Surg. 1905; 42 : 90â6.
  • ANTHONY EDEN 345 15. Smith R. Obstructions of the bile duct. Br. J. Surg. 1979; 66 : 69â79. 16. Kune GA. Bile duct injury during cholecystectomy: Causes, pre- vention and surgical repair in 1979. Aust. N.Z. J. Surg. 1979; 49 : 35â40. 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 : 273â83. 19. Lord Smith of Marlow. Personal Communication, 1995. 20. Allgõwer M. Equanimity of the Surgeon . GB Ong Lecture, Hong Kong, 1985. 21. LâEtang H. Ailing Leaders in Power 1914â1994. London: The Royal Society of Medicine, 1995. 22. Charcot JM. Lecons sur les Maladies du Foie des Vois Biliares et des Reins . Paris: 1877. 23. Ellis H. Bailey and Bishopâs Notable Names in Medicine and Surgery , 4th edn. London: Lewis, 1983. 24. Kune GA, Hibbert J, Morahan R. The development of biliary infection: An experimental model. Med. J. Aust. 1974; 1 : 301â3.