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.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, 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 the

    Eden 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