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“
The Object Lessons series achieves something very close
to magic: the books take ordinary—even banal—objects
and animate them with a rich history of invention,
political struggle, science, and popular mythology.
Filled with fascinating details and conveyed in sharp,
accessible prose, the books make the everyday world
come to life. Be warned: once you’ve read a few of these,
you’ll start walking around your house, picking up
random objects, and musing aloud: ‘I wonder what the
story is behind this thing?’”
Steven Johnson, author of Where Good Ideas
Come From and How We Got to Now

“
Object Lessons describe themselves as ‘short, beautiful
books,’ and to that, I’ll say, amen. . . . If you read
enough Object Lessons books, you’ll fill your head with
plenty of trivia to amaze and annoy your friends and
loved ones—caution recommended on pontificating
on the objects surrounding you. More importantly,
though . . . they inspire us to take a second look at parts
of the everyday that we’ve taken for granted. These
are not so much lessons about the objects themselves,
but opportunities for self-reflection and storytelling.
They remind us that we are surrounded by a wondrous
world, as long as we care to look.”
John Warner, The Chicago Tribune
“
For my money, Object Lessons is the most consistently
interesting nonfiction book series in America.”
Megan Volpert, PopMatters

“
Besides being beautiful little hand-sized objects
themselves, showcasing exceptional writing, the
wonder of these books is that they exist at all. . . .
Uniformly excellent, engaging, thought-provoking, and
informative.”
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Review of Books

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. . . edifying and entertaining . . . perfect for slipping in
a pocket and pulling out when life is on hold.”
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“
[W]itty, thought-provoking, and poetic. . . . These little
books are a page-flipper’s dream.”
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“
Though short, at roughly 25,000 words apiece, these
books are anything but slight.”
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“
The joy of the series, of reading Remote Control, Golf
Ball, Driver’s License, Drone, Silence, Glass, Refrigerator,
Hotel, and Waste . . . in quick succession, lies in
encountering the various turns through which each
of their authors has been put by his or her object. . . .
The object predominates, sits squarely center stage,
directs the action. The object decides the genre, the
chronology, and the limits of the study. Accordingly, the
author has to take her cue from the thing she chose or
that chose her. The result is a wonderfully uneven series
of books, each one a thing unto itself.”
Julian Yates, Los Angeles Review of Books

“
The Object Lessons series has a beautifully simple
premise. Each book or essay centers on a specific
object. This can be mundane or unexpected, humorous
or politically timely. Whatever the subject, these
descriptions reveal the rich worlds hidden under the
surface of things.”
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. . . a sensibility somewhere between Roland Barthes and
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Simon Reynolds, author of Retromania: Pop Culture’s
Addiction to Its Own Past
iv
 A book series about the hidden lives of ordinary things.

Series Editors:
Ian Bogost and Christopher Schaberg

Advisory Board:
Sara Ahmed, Jane Bennett, Jeffrey Jerome Cohen, Johanna
Drucker, Raiford Guins, Graham Harman, renée hoogland,
Pam Houston, Eileen Joy, Douglas Kahn, Daniel Miller,
Esther Milne, Timothy Morton, Kathleen Stewart, Nigel
Thrift, Rob Walker, Michele White.

In association with
 BOOKS IN THE SERIES
Bird by Erik Anderson
Blanket by Kara Thompson
Bookshelf by Lydia Pyne
Bread by Scott Cutler Shershow
Bulletproof Vest by Kenneth R. Rosen
Burger by Carol J. Adams
Cell Tower by Steven E. Jones
Cigarette Lighter by Jack Pendarvis
Coffee by Dinah Lenney
Coffee by Dinah Lenney
Compact Disc by Robert Barry
Doctor by Andrew Bomback
Driver’s License by Meredith Castile
Drone by Adam Rothstein
Dust by Michael Marder
Earth by Jeffrey Jerome Cohen and
Linda T. Elkins-Tanton
Egg by Nicole Walker
Email by Randy Malamud
Eye Chart by William Germano
Fake by Kati Stevens
Glass by John Garrison
Golf Ball by Harry Brown
Hair by Scott Lowe
Hashtag by Elizabeth Losh
High Heel by Summer Brennan
Hood by Alison Kinney
Hotel by Joanna Walsh
Jet Lag by Christopher J. Lee
Luggage by Susan Harlan
Magnet by Eva Barbarossa
Ocean by Steve Mentz
Password by Martin Paul Eve
Personal Stereo by Rebecca Tuhus-
Dubrow
Phone Booth by Ariana Kelly
Pill by Robert Bennett
Pixel by Ian Epstein
Potato by Rebecca Earle
Questionnaire by Evan Kindley
Refrigerator by Jonathan Rees
Remote Control by Caetlin Benson-
Allott
Rust by Jean-Michel Rabaté
Shipping Container by Craig
Martin
Shopping Mall by Matthew Newton
Silence by John Biguenet
Sock by Kim Adrian
Souvenir by Rolf Potts
Traffic by Paul Josephson
Train by A. N. Devers
Tree by Matthew Battles
Tumor by Anna Leahy
Veil by Rafia Zakaria
Waste by Brian Thill
Whale Song by Margret Grebowicz
Bicycle by Jonathan Maskit
(forthcoming)
Fat by Hanne Blank (forthcoming)
Fog by Stephen Sparks (forthcoming)
Gin by Shonna Milliken Humphrey
(forthcoming)
Office by Sheila Liming
(forthcoming)
Signature by Hunter Dukes
(forthcoming)
Snake by Erica Wright (forthcoming)
Wheelchair by Christopher R Smit
(forthcoming)
 ocean
STEVE MENTZ

Illustrations by Vanessa Daws

 BLOOMSBURY ACADEMIC
Bloomsbury Publishing Inc
1385 Broadway, New York, NY 10018, USA
50 Bedford Square, London, WC1B 3DP, UK

BLOOMSBURY, BLOOMSBURY ACADEMIC and the Diana logo are

trademarks of Bloomsbury Publishing Plc

First published in the United States of America 2020

Copyright © Steve Mentz, 2020

Illustrations © Vanessa Daws

Cover design: Alice Marwick

All rights reserved. No part of this publication may be reproduced or

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Library of Congress Cataloging-in-Publication Data

Names: Mentz, Steve, author.
Title: Ocean / Steve Mentz.
Description: New York, NY: Bloomsbury Academic, 2020. |
Series: Object lessons | Includes bibliographical references and index.
Identifiers: LCCN 2019037278 (print) | LCCN 2019037279 (ebook) | ISBN 9781501348631
(paperback) | ISBN 9781501348648 (epub) | ISBN 9781501348655 (pdf)
Subjects: LCSH: Ocean. Classification: LCC GC26 .M46 2020 (print) |
LCC GC26 (ebook) | DDC 333.91/64–dc23
LC record available at https://lccn.loc.gov/2019037278
LC ebook record available at https://lccn.loc.gov/2019037279

ISBN: PB: 978-1-5013-4863-1

ePDF: 978-1-5013-4865-5
eBook: 978-1-5013-4864-8

Series: Object Lessons

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for alinor, ian, and olivia
I realized that the sea itself must be the central character
whether I wished it or not.
RACHEL CARSON, UNDER THE SEA-WIND (1941)*

Shipmates, it is a two-stranded lesson.

HERMAN MELVILLE, MOBY-DICK,
OR THE WHALE (1851)

*
Excerpt from Under the Sea-Wind: 50th Anniversary Edition by Rachel L. Carson,
copyright 1941 by Rachel L. Carson. Copyright © renewed 1969 by Roger Christie.
Used by permission of Dutton, an imprint of Penguin Publishing Group, a division of
Penguin Random House LLC. All rights reserved. UK and Commonwealth: Reprinted
by permission of Francs Collin, Trustee.
CONTENTS

Deterritorializing Preface xv

1 Two Origins: Alien or Core? 1

2 Seafood before History 11

3 Myth I: Odysseus, Not Achilles 21

4 Wet Globalization I: The Premodern

Anthropocene 31

5 Sea Poetry I: Adamastor as Warning and

Gate 43

6 Sailors: A Technological History 55

7 Interlude: Port of New York 67

8 Sea Poetry II: The Sea in Emily Dickinson 77

9 Myth II: Queequeg and Other Mermaids 93

10 Wet Globalization II: Containers 105

11 Blue Environmentalism: Rachel Carson 115

12 Swimmers: Immersive Histories 127

Acknowledgments 139
Reading the Blue Humanities 141
Index 153

xii Contents
xiii
DETERRITORIALIZING
PREFACE

O
cean moistens our shared ground. The great waters
open up a dynamic environment, fluid, saline,
moving, and moved. Our bodies and imaginations
register the shift from familiar terra to alien oceanus. Watery
transformation deterritorializes. Radical French theorists
Gilles Deleuze and Felix Guattari describe deterritorialization
as a form of self-emancipation, “the movement by which
‘one’ leave[s] the territory.” Moving offshore reshapes our
vocabulary. The ocean needs new words. What happens
to “grounded” metaphors when everything solid becomes
liquid? Let’s start by swapping out the old terrestrial language
for saltwater terms.
To move offshore I offer seven words.

Word 1. Current (formerly field): For a long time

thinking has happened in fields, areas of expertise
imagined to be as stable and reliable as pastures. What
if instead we redescribe the adventures of thinking
 as currents, as rates of flow and change? Why not
emphasize movements and connections between or
through differences? Fields produce harvests but can lie
fallow. Currents flow. We need flow to know Ocean.
Word 2. Water (formerly ground): The thinking that
goes by the name “blue humanities” replaces ground,
land, and earth as dominant metaphors. Instead we
remember that the surface of Earth is mostly Ocean. Our
metaphors must float on water rather than resting on
ground. In an aqueous environment, nothing stays on
the surface forever.
Word 3. Flow (formerly progress): Rethinking
movement as flows and circuits rather than progress or
retreat can revivify intellectual communities. Thinking in
terms of cyclical flows rather than linear progress makes
historical narratives messier, more confusing, and less
familiar. These are good things.
Word 4. Ship (formerly state): The dissolving force
of oceanic history works against nationalism, though
at times it may also tend in the directions of global or
even imperial totality. Ships, as historians, philosophers,
and Hollywood movies have long shown, are symbolic
unities, heterotopias, and polyglot fantasy-spaces.
Perhaps it is time to imagine politics through ship-to-
ship encounters—trading, fighting, hailing, sighting—
rather than through the grounded metaphors of the
state?

xvi Deterritorializing Preface

 Word 5. Seascape (formerly landscape): This shift
seems simple enough as part of the offshore trajectory.
But is the “scape” still a problem? Is our language too
visual? Underwater creatures seldom rely very much on
sight.
Word 6. Distortion (formerly clarity): A basic feature
of any aqueous environments is visual distortion. Water
bends light. Water-thinking makes distortion a baseline
condition. Water’s tri-dimensionality sometimes orients
us on the buoyant top and at other times closer to the
irresistible bottom.
Word 7. Horizon (formerly horizon): Sailors and
oceanic historians spend a lot of time thinking about
horizons, seamarks, and landmarks. Early modern
European sailors heading into the Atlantic spent days
looking out for the unmistakable silhouette of Tenerife’s
volcano, which signaled impending arrival at the
Canary Islands, first stop on the transatlantic route. Can
horizon be a metaphor for futurity that spans green
pastures and blue seas? I imagine horizons as sites of
transition, like beaches or coastlines, and also as places
where perspectives merge. Horizons of ocean, horizons
of currents. These are places from which new things
become visible.

This seven-pack of deterritorializing terms can help us think

about the blue humanities and break up the Anthropocene.

Deterritorializing Preface xvii

The blue humanities name an ocean-infused way to reframe
our shared cultural history. Breaking up the Anthropocene
means reimagining the anthropogenic signatures of
today’s climactic disasters as a dynamic openings as well as
catastrophic ruptures.
These terms make a start. Use them, and we’ll change the
ocean.
I almost said, “Change the world.” But then I changed my
words.

xviii Deterritorializing Preface

xix
1 TWO ORIGINS:
ALIEN OR CORE?

Two stories herald Ocean’s arrival. In what used to be the

most common explanation of the blueness of our planet,
Alien water streaked through space on an icy comet that
splashed down onto barren rock. In a newer, alternative
explanation, Ocean was here all along, its waters stored
inside the planetary core of rocky material gathered together
billions of years ago when the planet formed. Water, the
element that fills up the ocean and makes life possible, either
dropped from the sky or oozed out from a solid center. It is
Alien, or it is Core. These rival possibilities establish Ocean
as an ambiguous thing from its prehistoric origins. It is an
object with two meanings, two origins, two stories.
The Alien story describes the radical intrusion of external
forces imposing themselves onto a stable, if lifeless, planetary
system. Think of that dry rock in the void, four-and-a-half
billion years ago, newly created and circling the sun. Onto
its jagged surface splashes the ice comet with its Alien cargo.
The newly arrived ice melts, spilling across our planet’s
surface and re-forming our earth as moist and ready for life.
So much depends upon this chance encounter in the void,
this Alien moisture from above. Space water, while not itself
living, creates the conditions without which life cannot begin.
In the Core story no sky-borne messenger appears from
on high. Water instead arrives with the rocks that accrete into
the planet on which we walk today. In this version of events,
the massive impacts and forces that facilitate planetary
creation conceal water inside the planet’s rocky core, from
which depths it seeps up to fill surface basins over geologic
time. Ocean need not descend from the sky, but instead the
great waters emerge, hidden, from the oldest rocks in our
planet’s history.
I don’t have the expertise to judge the scientific
controversy between these opposed stories, but I know why
the split matters. These are stories about the origin of Ocean
and the blueness of our planet. Without water, and without
a planetary temperature range that includes all three of its
physical phases—solid ice, liquid water, and gaseous water
vapor—life as we recognize it could not have developed on
earth. Ocean origins are birth stories. Did we come from the
sky or from under the ground? What does it mean that we
seem not to be able to choose? Are we Alien or Core?
The story of Ocean’s fall from the stars reinforces our
terrestrial alienation from the soup of life. We fear the ocean,
especially in its stormy moods. Sailors and swimmers know
that human bodies can’t go there to stay. Ocean surrounds
our dry homes as a place of risk, vulnerability, and weakness.

2 OCEAN
We live near the waters, we employ them, and we love them.
But they are not our home.
Unless they are. The Core story, championed by
astrophysicist Lindy Elkins-Tanton among others, locates
water inside our earth from the start. A leader in space
exploration and primary investigator for the planned
NASA mission to the metal asteroid Psyche in 2022,
Elkins-Tanton has studied the chemical composition of
water in asteroids and on earth, and has demonstrated
through computer simulations that water can endure
the process of planet formation. She describes herself as
having become an “evangelist” for “planets getting their
water through their common formation processes, and not
by later chance.” Perhaps, she speculates, more interstellar
planets than just ours have formed with watery cores that
could support life.
Is our ocean Alien or part of our essential Core?
The interlaced stories of how humans have imagined
and interacted with the ocean over time show that both
contrasting narratives speak lasting truths. Ocean defines
our inhospitable home, but even that oxymoron doesn’t quite
capture the tension and urgency, dependence and fear, in the
human-sea relationship. Humans share some evolutionary
characteristics with aquatic mammals, including a layer of
subcutaneous fat and relative hairlessness. The controversial
“aquatic ape hypothesis,” in which a crucial phase in the
evolution of homo sapiens may have occurred in an oceanic
or terraqueous environment, remains unverifiable, but it

TWO ORIGINS: ALIEN OR CORE? 3

speaks to an “oceanic feeling” that many of us recognize,
even if we don’t know where it comes from. Herman Melville
wasn’t an evolutionary biologist or NASA scientist, but the
opening chapter of Moby-Dick knows what people love:
“They must get just as nigh the water as they possibly can
without falling in.” Poised on the sea’s edge, we balance
between kinship with and alienation from the watery part of
the world. Ocean insinuates its salty fingers into that division
and wedges meaning out of both the longing that draws us to
the great waters and the fear that drives us away.
I feel both feelings. Every day I walk down the street to a
crescent-moon of gritty sand that bears the unoriginal name
of “Short Beach.” I look out past a pair of rocky headlands onto
Long Island Sound. On clear days I glimpse the North Shore
of Long Island, about twenty-five miles distant. Sheltered
from northeast-churning hurricanes by the massive glacial
moraine of the island, my bay in Connecticut is a relatively
calm body of water. But like all saltwater inlets it flows into
the encircling currents of the World Ocean. Every day in
summer and fall, I throw myself into the water’s gray-green
embrace and think about what it means to put my singular
body into the biggest object in the world. It’s disorienting and
pleasurable and helps me think. According to Diana Nyad,
the only person to have swum the hundred miles between
Cuba and the United States without a shark cage, swimming
creates sensory deprivation and a particular form of physical
meditation. Every day I churn sentences through my mind to
the rhythm of crawl-stroke arms.

4 OCEAN
 Many of the phrases in the Ocean that is this book found
me in those salty waters. The meanings of Alien environment
and the waters of our Core never strike me more palpably
than when I’m swimming, head down, ears and nose clogged,
minimally aware. I’m a mismatched terrestrial creature partly
at ease in the water, relying on repeated movements of arms
and legs to keep me moving and on the surface. I’m also a
fleshy bag of water, matching my fluid center to my aquatic
surroundings. Both things, always.
What follows elaborates the two stories of the object
Ocean. Duality in fact becomes this book’s organizing
principle; almost everything appears twice. Two accounts
describe the planetary origins of seawater. Two myths
explain the place of Ocean in Western cultural history.
Two poetic voyages engage maritime verse. Two phases of
oceanic globalization structure the last half-millennium of
human history. Two images of laboring bodies, sailors and
swimmers, opposingly define human intimacy with Oceanic
forces. Two individual swimmers splash through the final
chapter on two different sides of the Atlantic. Throughout,
this Ocean splashes between the two ways I encounter the
great waters, through writing and thinking on the one hand
and direct immersion on the other. It’s an intellectual project
and also a physical practice.
There will be recognizable currents underflowing these
pairs of objects and ideas. A tension between solitary
swimmers and collectivizing ships will surface throughout.
Multiple developments in ocean history will shape this telling,

TWO ORIGINS: ALIEN OR CORE? 5

from the dependence of prehistorical communities on the
ocean’s bounty for sustenance, to sudden bursts of maritime
expansion in antiquity and early modernity, to the ambivalent
industrial turning-away from the ocean that framed late-
twentieth-century Western culture. Oceanic feelings in
religious rituals, myths, and psychoanalytic accounts will
guide the narrative. Awareness of the controlling force of the
“blue ecology” of the ocean, home to roughly 90 percent of
our planet’s biosphere, will organize my speculations about
global warming, ocean acidification, and the ways the ocean
floods the center of today’s environmental crisis. All these
currents reveal Alien and Core influences that flow around
us. Human bodies barely touch and only partially know the
ocean, even as its waters structure our historical, political,
and personal lives.
In what is probably the most influential book written in
English about the ocean in the twentieth century, The Sea
Around Us (1951), Rachel Carson places “that great mother
of life, the sea” at the core of the human story. But she also
recognizes that when humans touch the great waters, as “in
the course of a long ocean voyage,” the insights that swim
into our imaginations reflect alienation: the sailor “knows
the truth that his world is a water world, a planet dominated
by its covering mantle of ocean, in which the continents are
but transient intrusions of land above the surface of the all-
encircling sea.” Few sea-writers speak with Carson’s particular
combination of poetic fervor and scientific exactitude. Her
responsiveness to both experience and emotion remains

6 OCEAN
my polar ideal. One way to describe this book might be
an effort to juxtapose Carson’s precision with Herman
Melville’s obsessions, but there will be time enough to hurl
harpoons after several other deep-diving whales. A different
theoretical and historical complement to Carson’s material
sea appears in the “socially constructed” ocean of geographer
Philip Steinberg, who charts the changing political, legal, and
economic frames through which humans have understood
the ocean. Steinberg writes a complex social history that
unfurls the classical Greek geographer Strabo’s notion that
humans are “amphibious,” intimately connected to both land
and sea. Bringing together the contrasting strains of Carson’s
positivism, Melville’s mania, and Steinberg’s critical theory
makes this book intellectually amphibious as well.
These models of ocean thinking do not exhaust even
the water’s undulating surface, to say nothing of its violet-
black depths. Carson’s history, Melville’s epic, and Steinberg’s
theory map out entwined planes, but the ocean’s verticality
plunges down into hidden ways of thinking, including
histories of change and human suffering. Another guiding
star, to whose work I’ll return often, is Martiniquan poet and
philosopher Édouard Glissant, who envisions the sea as a
site of human crimes and imagined retribution. For Glissant,
the essential point of origin is neither Alien arrival nor Core
secretion, but instead the drowned human bodies of the
Middle Passage whose remains sediment the Atlantic floor.
Glissant imagines “the entire ocean, the entire sea gently
collapsing in the end into the pleasures of sand, make[s]

TWO ORIGINS: ALIEN OR CORE? 7

one vast beginning, but a beginning whose time is marked
by those balls and chains gone green.” Sunken bodies and
rusting chains present a more painful and intimate origin
story than comets and planetary accretion. Can a small book
have a whale’s throat to swallow all these stories whole?
The singularity behind these currents of history and
thought is Ocean as object, vast, moving, vibrant, imagined,
and ungraspable collective.
Let’s dive in.

8 OCEAN
9
2 SEAFOOD BEFORE
HISTORY

Humans live near water. Water frightens us and lures us into

danger, but we never want to be too far from it. Not all the
ways in which the words “ocean view” have become the most
valuable phrase in the vocabulary of twenty-first-century
real estate have deep historical roots—locating fragile and
expensive beach houses on barrier islands constitutes a
distinctively twentieth-century foolhardiness—but human
settlement patterns have always oriented themselves around
access to bodies of water. Today, roughly 80 percent of the
human population lives within 60 miles of a coast, including
freshwater coasts. Freshwater supports agriculture, health,
and religious ritual, but saltwater nourishes the imagination.
We’ve needed the sea since prehistory. The bitter waters
provide food and transportation. They serve as boundaries
and sacred sites. Despite the symbolic appeal of deserts and
mountains, there is no human history without the sea.
Theories abound about evolutionary turning points, but
the exploitation of marine and tidal resources has a claim
to serve as a major inflection point in the 200,000-year
story of homo sapiens. As maritime historian John Gillis
argues in The Human Shore (2012), the earliest evidence
of human settlement, at Pinnacle Point, South Africa,
suggests that access to maritime resources, including fatty
acids in fish and shellfish, helped support an increase in
brain development before humans first left Africa 50,000
years ago. Armed with larger brains, homo sapiens went on
to settle the globe, displacing other early species of genus
homo such as the Neanderthals, and hunting megafauna
largely to extinction. Gillis summarizes recent work by
archaeologists, anthropologists, and neurochemists to claim
that “it was only when humankind reached the sea that the
brain could evolve to its present human dimensions.” What
Gillis calls humankind’s “journey to the shore” started in
the African savannah where our species first appeared, but
the evolutionary changes wrought by the rich foods of tidal
ecotones drove crucial brain developments. Only dolphins
and other marine mammals, who have direct access to
marine foods, match the brain-to-body ratio of homo sapiens.
The big brains of humans, which Gillis describes as “our
distinguishing trait,” may have formed first through contact
with the sea. The sea was certainly not the only factor in the
evolutionary path that forged homo sapiens, but proximity
to its bounty may have been crucial in the development of
modern humans.
This coastal theory of brain development presents a
nutritional and cultural reinvention of the “aquatic ape”

12 OCEAN
hypothesis. First proposed by Alistair Hardy in 1960 and
expanded by feminist scholar Elaine Morgan in the 1970s
and 1980s, the hypothesis that humans evolved at least
partially in an aqueous environment remains controversial.
The timescale needed for substantial evolutionary changes
in species development seems not to be met by the coastal
environments for which we have prehistoric evidence of
human settlement. The expansion of multiple species of
genus homo around the world also mitigates against the
strongly Darwinian argument that Hardy and Morgan put
forward in their different ways. But the theory that early
humans relied on coastal subsistence for many millennia
before and during the global expansion of homo sapiens
remains actively under exploration by scholars of prehistory
and evolutionary biology.
Early histories of human culture often center around
either the development of agriculture in the Fertile Crescent
around 12,000 years ago, or the 20,000-40,000-year-old
Paleolithic cave paintings found from Europe to Indonesia.
Both these origin stories discount the amphibious tale
that Gillis relates in which “shores were humankind’s first
Eden.” With the exception of rare sites such as Pinnacle
Point, much of the archaeological evidence of early human
coastal dwellings likely sits under 250–300 feet of sea-level
rise since the end of the last ice age, roughly 12,000 years
ago. If the theory of coastal settlement and changes in brain
development around 50,000 years ago is correct, evidence of
this amphibious explosion of human physical and cultural

SEAFOOD BEFORE HISTORY 13

evolution mostly lies on the floors of coastal seas. The
movement of homo sapiens out of Africa to settle the Fertile
Crescent, Asia, Europe and Australia, and the Americas
would not have meant abandoning the sea but rather moving
along what archaeologists term the “the Kelp Highway”
into new coastal ecotones that were ripe for amphibious
gathering. When the land bridge connected Siberia to Alaska,
early human groups appear to have followed the shoreline
into the Americas, harvesting shellfish as they went. The
hunting of large mammals that would lead to the extinction
of mammoths and many other species may be considered a
supplement to this coastal foraging, or perhaps a survival skill
developed by humans in areas such as central Europe that
lacked sufficient coastal resources for a growing population.
Considering the seacoast as preagricultural Eden means
displacing the pastoral garden from the center of our cultural
imagination. The Hebrew scriptures, written during the so-
called Axial Age when large-scale agricultural civilizations
were developing religious traditions throughout Asia
and the Near East, exclude the sea from Paradise. Ocean
voyaging signaled divine punishment for Noah and Jonah,
and laboring in fields represented both the punishment for
disobeying God’s command in Eden and also the return to
the land after the Flood waters receded. In the Christian
Book of Revelation, the post-apocalyptic arrival of “a new
heaven and a new earth” comes through universal drying-
out of ocean water: “there will be no more sea” (Rev 21:1).
As the cultural geographer Christopher Connery has noted,

14 OCEAN
the turn against the sea in Revelation parallels a common
Near Eastern mythic structure in which a male god of the
earth defeats a female divine embodiment of the ocean. The
feminist Christian theologian Catherine Keller has suggested
that the text of Genesis, in which God’s spirit moves “over the
surface of the deep” (Gen 1:1), indicates the nascent presence
of tehomic or oceanic divinity. Joining Keller’s theology to
Gillis’ prehistory, we might speculate that the ancient divinity
seen fitfully and fearfully in the great waters echoes our
species’ ancient connection to coastal ecotones. Agricultural
civilizations, in this reading, turned their collective backs on
the sea.
But in the pre-apocalyptic world of human history, the
sea has always been alien but never absent. Even in prehistory,
sea travel and maritime exchange, as well as river-based
trade, were essential to human thriving. Archeologist Barry
Cunliffe argues that Europe’s geographical position facing
Atlantic, Mediterranean, and Black Sea coastlines, “between
the oceans,” structured its cultural and physical expansions
over the past 11,000 years. Human proximity to the sea has
also underwritten water’s symbolic presence in religion
and artistic cultures. The religious meanings of the ocean
include profundity as well as hostility. In Hebrew scriptures,
when Jonah descends into the whale’s belly, he encounters
the divine truths that the Psalmist believes that sailors
also see: “They that go down to the sea in ships, that do
business in great waters; / These see the works of the Lord,
and his wonders in the deep” (Psalm 107). Contemporary

SEAFOOD BEFORE HISTORY 15

scientist and activist Wallace J. Nichols’ notion of “blue
mind” suggests ways in which the human fascination with
the sea undergirds medical sciences, psychology, and water
sports. Thinking more broadly about the religious meanings
attributed to the sea in many cultures, historian of religion
Kimberly Patton explores the sea as a vehicle for purification
on both individual and global levels. Taking her mantra from
Euripides, “The sea can wash away all evils of humankind”
(Iphigenia at Tauris), Patton sees the modern history of
the ocean as a painful overlap between “the exigencies
of religious purity and human habits of waste disposal.”
As industrial waste has fouled the great waters and the
oceans have acidified due to their uptake of carbon, ancient
beliefs about the sea’s infinite vastness collide with tangible
evidence of degradation. Patton describes a “paradox . . . in
contemporary attitudes toward the sea that strangely mingle
awestruck love with relentless abuse.” Both the love and the
abuse ring true—but neither can extend itself forever.
The sea-love that Wallace Nichols finds in California
surf culture echoes the sea-harvesting that supported early
populations of coastal homo sapiens 50,000 years ago. In both
cases an alien environment supports and lures. Through
direct and indirect contact with the sea, its resources, its
coasts, and its physical being, humans have always defined
themselves in dialogue with alien and inhospitable waters.
The “blue mind” evangelism that Nichols trumpets—sea-
bathing for him is both medicine and therapy, as it also
was for the early-nineteenth-century doctors who treated

16 OCEAN
supposedly “hysterical” women with forced cold-water
dunking—bridges the gap between Ocean/Blue and Human/
Mind. Nichols believes in Ocean as a biological, historical,
and evolutionary source to which we can return. The key task
today for sea-thinkers like him, Patton, and environmentalist
Carl Safina is to learn to see the sea. The alien ocean must
come fully into view. To create what Safina calls a “sea ethic,”
a marine companion to Aldo Leopold’s famous “land ethic,”
requires imaginative engagements with alien spaces. “The sea
demands a reckoning,” says Kimberly Patton. Blue reckoning
requires that we look back into the human past as well as
forward into the ocean’s perilous present and future.
The ancient humans who followed the Kelp Highway
out of Africa around the globe were unlikely to have been
superheroic swimmers along the lines of Lynne Cox or
Michael Phelps. As coastal foragers and denizens of the
fertile ecotone where sea meets land, they may well have
been more routinely aquatic that their urban and agricultural
descendants, but even the “aquatic ape” hypothesis does not
claim that early humans were marine mammals. Rather,
the particular qualities of early human societies, from
brain size to tool-making, appear to have co-evolved with
the watery part of what Herman Melville trumpets as “this
terraqueous globe.” The past century has seen a massive turn,
especially among wealthy Westerners, toward blue water
as a marker of aesthetic value and a site of recreation. In
Nichols’ estimation, globally “more than 500 million people
choose water-based recreation as a means of exercise, escape,

SEAFOOD BEFORE HISTORY 17

challenge, relaxation, excitement, and play”—a number that
he notes would be much higher if it added the millions
more who use water in religious rituals. John Gillis argues
that, as twenty-first-century human populations become
less tied to agricultural labor, the terrestrial myth of Eden
as a landlocked garden not only “misrepresent[s] our past
but now, when for the first time more humans live in cities
than on the land, it is wholly misleading about our future.”
The nutritional value of seafood before history stimulated
early human brains and sounds a blue echo that is now
pinging in our ears. To follow surf culture into the waves
might not simply be acceding to another California trend.
Instead, engaging with the blue makes visible the alien
environment that has splashed alongside human physical
and cultural evolution throughout history. As Amitav
Ghosh observes in The Great Derangement (2016), the great
urban centers founded during the colonial age of maritime
empires, including New York, Mumbai, Miami, Singapore,
and Sydney, cluster at the seacoast, where they are vulnerable
to rising sea levels and storm surge. Responding from these
cities to today’s environmental conditions requires that we
re-engage with the sea in our lives, our politics, our cultures,
and our urban planning.
Many historians who consider the role of land and
sea across the long span of human history have described
sudden turns toward or away from the sea. The example of
Ming China’s destruction of its massive oceangoing fleet in
1525, not long after the voyages of Zeng He had traversed the

18 OCEAN
Indian Ocean to the east coast of Africa, represents a specific
and radical shift of the sort that historical thinkers are eager
to find. The Nazi jurist Carl Schmitt, in his meta-historical
volume Land and Sea (1954), interprets world history as a
series of “spatial revolutions.” For Schmitt, writing in the
early 1950s as the postwar European and global order was
coming into shape, the most important spatial revolution
in human history was the oceanic turn of the European
powers after Columbus, which he calls “the first complete
space revolution on a planetary scale.” Similarly, but from
the poetic left, Charles Olson claims in Call Me Ishmael
(1947) that Melville’s turn toward the Pacific represents the
“third and final Odyssey” and that “America completes her
West only on the coast of Asia.” These and other visions
of maritime empires surge far away from small groups of
prehistoric humans gathering shellfish and kelp in tidal pools.
But they share with French philosopher Gaston Bachelard
the conviction that “the true eye of the earth is water.” The
ocean in these polyglot intellectual currents represents blue
Core and Alien heart. Humans live near the ocean, play in it
and pray in it, and live off its ecological bounty. But we never
comprehend it.

SEAFOOD BEFORE HISTORY 19

3 MYTH I: ODYSSEUS,
NOT ACHILLES

The man weeps, staring out at the waves and longing for
home.
The godlike boy rages and clogs the river with the
corpses of his enemies.
Which hero is our hero?
The philosopher Michel Serres observes that when Achilles
fights against the river in Book 21 of Homer’s Iliad, the struggle
allegorizes human violence against Nature. The superhuman
warrior, as a byproduct of his assault on his Trojan rival
Hector, fills the water with blood, mud, and corpses. The
river-god Scamander splashes to his own defense, and the
inhuman waters threaten even the mightiest of the Achaeans.
The battle that ensues matches man against god, mortal body
against flowing current. Christopher Logue’s twenty-first
century free translation captures the scene’s violence:

    Picking his knees up, Achilles, now

Punting aside a deadman, now swimming a stroke or two,
 Remembered God’s best word and struck
Like a mad thing at the river. He beat it
With the palm of his free hand, sliced at it,
At the whorled ligaments of water, yes, sliced at them,
Ah!—

Can the warrior slice water? Will River defeat the hero?
Perhaps the ability to injure the landscape is the epic hero’s
primal talent, the end point of his godlike excess and lust for
victory. To the extent that murderous and doomed Achilles
sits at the center of Western heroism, this episode, as Serres
emphasizes, captures the hostility between Man and Nature.
River is not quite Ocean, but Achilles’ struggle against
Scamander represents a basic environmental hostility.
Alien fluid threatens the human hero. Water may be able to
drown his singular body, even this godlike man, “best of the
Achaeans”:

        And the water’s diamond head

Shut over Achilles, locked round his waist
Film after film of sopping froth, then
Heaved him sideways up while multitudinous crests
Blubbed around his face, blocking his nostrils with the
blood
He shed an hour before.

The translator’s adjective “multitudinous” echoes Macbeth’s

description of “multitudinous seas,” giving the English

22 OCEAN
passage about the river an oceanic flavor. Scamander’s
water tastes salt from Achilles’ blood, as well as the blood
of the innumerable Trojan corpses damming up its current.
Violence, including the divine rage against Troy that
undergirds Achilles’ quest for Hector, reds the clear stream.
As Serres shows, this side-battle that distracts the hero in the
war for Troy represents the human destruction of nonhuman
environs that has fouled the waters of our blue planet from
antiquity through today. Homer’s solution to the impasse,
put into operation by “Hera, Heaven’s queen,” counters
Scamander’s water with divine fire. Hephaestus burns back
the raging waters so that the field clears for Greeks to butcher
Trojans. Chastened, the river-god returns to his course:
“between his echoing banks / Scamander / Rushed gentled
over his accustomed way.” In the war epic, killing humans
remains the central focus. Achilles’ tussle with Scamander
represents a side-turning in the battle for Troy. But the heroic
image that the warrior creates, in which the need for victory
overrides any environmental destruction it creates, has long-
term resonance, up to and including the present day. What is
global warming but a planet-sized battle waged by humanity
against the world-girdling river, Oceanus?
Odysseus fights alongside Achilles at Troy, but his crafty
heroism engages with fluid environments very differently.
Tears, not rage, frame his encounter with Ocean. The
Odyssey opens by describing “the man” with the famously
untranslatable epithet polytropos—trickster, a man of many
turns and tropes, “a complicated man,” in Emily Wilson’s

MYTH I: ODYSSEUS, NOT ACHILLES 23

recent version. When the epic picks up Odysseus’ story, he
sits facing the ocean, weeping his inability to perform the
bloody combat into which Achilles heedlessly plunges. The
goddess Calypso tries but cannot comfort him:

She found him on the shore. His eyes were always

tearful: he wept sweet life away, in longing
to go back home . . . [/]
      By day he sat
Out on the rocky beach, in tears and grief,
Staring in heartbreak at the fruitless sea.

The complicated man longs in sadness for the alien element.

At this point, he’s a sailor not a fighter. The sea engages
Odysseus more directly than the river does Achilles. In the
Iliad, the godlike warrior’s struggle against the water distracts
him from his mad rush toward Hector. But in the less direct
turnings of the Odyssey, the ocean presents itself as both
barrier and road. The man must sail through waves and
shipwreck into them. “Let this come too,” he tells Calypso
when she releases him to sail home.
The hero of craft not wrath builds his own boat, with the
goddess’s help, but the shipwreck that follows requires not just
skill and strength but also his ability to orchestrate multiple
forces in an aquatic environment. The craft he fashions with
Calypso’s help splits under the force of Poseidon’s storm.
Unwilling to abandon even its fragments, he at first refuses
the advice of the sea nymph Ino, who instructs him “With just

24 OCEAN
Another random document with
no related content on Scribd:
duodenum, and I once saw a long one in the appendix. Cancer in
this neighborhood is also a not infrequent exciting cause in
producing acute cholangitis.
Symptoms.—There is usually a history of spasmodic pain covering
a considerable period, and then of such an attack followed by chill
and fever, with more or less jaundice, which may persist for some
time. Such attacks as these become more severe and more
frequent; the gall-bladder enlarges if it contain no stone, or contracts
if calculi be present. This association was especially noted by
Courvoisier, who formulated a statement to this effect, often absurdly
known as his “law.” Later the entire liver or its right lobe may enlarge,
while patients complain of tenderness over the gall-bladder, as well
as of loss of appetite and flesh, and those vague symptoms included
in the term “dyspepsia.”
Such a condition may possibly subside in time, but is more likely to
be followed by acute trouble of one of the types already described. In
the matter of diagnosis it may be distinguished from malaria,
especially in districts where malaria prevails by absence of relief
from quinine, and the results of a carefully completed examination,
combined with the fact that in the former it is usually the gall-bladder
which is enlarged, and in the latter the spleen. When the condition
has proceeded to its suppurative form the occurrence of still more
significant symptoms and signs should lead to prompt operation.
Treatment.—In the acute infections and affections, both of the
gall-bladder and of the duct, operative intervention is
imperative. The more acute the case the more urgent the indication.
Free evacuation and drainage are the indications to be met, and as
early and completely as possible. These cases call for
cholecystostomy, often for choledochotomy, with drainage of both
gall-bladder and duct, and perhaps of the peritoneal cavity, while
possibly even posterior drainage may be indicated. So true is this
that the back should be as carefully prepared for operation as the
abdomen, in order that no time be lost during the operation, should
one decide on the wisdom of a posterior counteropening. Of course
much will depend upon the patient’s condition at the moment and
what it may appear he can endure. By free opening of the gall-
bladder evacuation of its septic contents and removal of calculi are
secured, if present, while the ducts are permitted to empty
themselves and free flow outward of all septic material is invited and
permitted, pressure is relieved, the tumor is disposed of, respiration
allowed to become normal, and no small load removed from the
kidneys; and the chronic pancreatitis which so often accompanies
many of these cases is allowed to subside by virtue of the other relief
thus afforded.

ULCERATIONS AND PERFORATIONS OF THE BILIARY

PASSAGES.
These may occur anywhere along the biliary tract, and vary as
between the superficial and the perforating, the former being
sometimes multiple, the latter solitary. Of these lesions cholelithiasis
is the most common cause, while typhoid and cancer should be
ranked next. They are all of pathological import, because of their
possible sequels, i. e., not merely perforations with fistulas, but
possible strictures or hemorrhages, or peritonitis with sepsis. When
ulceration is extensive a previous local difficulty may be supposed,
with more or less adhesions, but as the trouble becomes more
serious the local excitement will extend to the peritoneum, at least
that of the area involved. In fact most cases of gallstone disease are
accompanied by more or less peritonitis, and adhesions which are
protective, although they may cause other troubles as well, such as
dilatation of the stomach from displacement of the pylorus.
Hemorrhage is not a frequent event, for thrombosis usually precedes
erosion. Some degree of sapremia or septicemia will be present in
nearly all cases.
Stricture of the ducts is the most common result, especially of the
cystic duct. If this occur and the mucous membrane be still active the
gall-bladder will become distended with pus or mucus, or both.
These are the cases which perhaps give the best results after ideal
cholecystectomy.
Perforation is a constant possibility whose menace cannot be
estimated, but which is always actual, the great danger depending
on the virulence of the extruded material and the consequences of
delay in operating. Although healthy bile is but slightly toxic, these
cases do not furnish it, and one may always look for consequences
of infection. Nevertheless if diagnosis be made sufficiently early to
bring about immediate operation prognosis is good. Occasionally
during such an operation there will be found a gallstone endeavoring
to extrude itself, but not yet completely escaped. It might be, in rare
instances, possible to utilize the opening which it has partially made
for subsequent drainage purposes.
It is not advisable to permit patients with distended gall-bladders to
go unoperated, even in the absence of serious symptoms, because
the risk of operation is small and that of rupture is large.
Acute intestinal obstruction due to gallstones will usually, but not
invariably, involve the upper intestinal tract. It may be due to the
actual occlusion of a large stone which has escaped from the gall-
bladder or duct, or it may be caused by volvulus due to intense colic
accompanying peristaltic effort, or it may depend upon adhesions
after a local peritonitis due to previous disease of the gall-bladder or
to stricture following ulceration; or again it may be purely paralytic,
and in this way result from a local peritonitis. Impaction of a biliary
concretion may happen at any point, but most often at the ileocecal
valve, where the intestinal tube is narrowest. The size of the stone is
not the only consideration. Obstruction depends perhaps as much
upon spasm above and below as upon any local disturbance that its
presence may have caused. Biliary concretions may enlarge as they
pass downward, growing by accretion of calcareous and of fecal
matter. The larger the calculus the more likely it is to obstruct the
upper intestine. The majority of these calculi have escaped from the
gall-bladder by a previous process of ulceration, and usually into the
duodenum, rarely into the colon.
Symptoms.—Symptoms of this condition, thus produced, will
obviously be those of acute obstruction from any
cause, the most marked features being severe pain and early
frequent vomiting. Bile may be raised in quantities because of the
biliary fistula so near the stone, and from which it is supposed to
have escaped. The higher the exciting cause the more violent the
symptoms and the less the distention of the abdomen by gas. A
significant history may help in assigning the cause for the evident
obstruction.
 Treatment.—Since more than half of these cases treated
expectantly die without relief early operation is to be
urged. It should always be preceded by lavage in order that the
stomach may be thoroughly emptied. When a stone has been
exposed within the intestine it is advisable to open the bowel a little
below where it rests, so as to make the division at a point where the
chances of repair are not compromised by previous excitement. In
severe cases a temporary enterostomy may be made, but this
should of necessity be high. The volvulus may be relieved by
untwisting the kink or by an anastomosis. Obstruction due to
adhesions will require separation of these adhesions, with perhaps
an anastomosis.

CHOLELITHIASIS, GALLSTONE OR BILIARY COLIC, BILIARY

CALCULI.
There is so much which may be said about the formation of
gallstones and the troubles which they may produce that it is
necessary here to epitomize as much as possible and to refer mainly
to the surgical features of this condition. Gallstones are of all sizes,
from the most minute to that of a hen’s egg, are present in numbers
varying from a single calculus to thousands of calculi, are found
commonly in the gall-bladder, in the cystic duct, or in the common
duct, but occasionally are met with just escaping into the duodenum,
through the duodenal ampulla, or in the smaller ducts of the liver or
the main hepatic duct (Fig. 627). In at least 99 per cent. of cases
they will be seen in one of the locations first mentioned.
Pages might be devoted to a discussion of the reasons for their
formation. That cholesterin, their principal component, should more
readily deposit in such a way as to produce these calculi, and more
often in some individuals than in others, is hard to explain, but may
be held to be largely due to its formation in excess in certain
individuals and to concentration of those fluids which hold it in
solution. Increase of cholesterin seems to be connected with catarrh
of the membrane which produces it, and thus stagnation of bile may
predispose. That bacteria have much to do with biliary calculi is now
conceded, and a history of typhoid is obtainable in many cases. It
has been shown Fig. 627
experimentally that
aseptic foreign bodies
introduced into the
gall-bladder remain
indefinitely without
becoming covered
with precipitate, while
virulent organisms set
up disturbance, and
only the attenuated or
moderately infectious
organisms produce
calculi, and usually
then only when some
trifling foreign body is
introduced at the
same time. It will thus
be seen that a nidus
may be afforded by a
clump of epithelial
cells or débris.
It is not at present
so much a question of
what organisms are
at fault, although they
are usually the colon
and typhoid bacilli
and the ordinary
pyogenic organism. It
has been shown, Gallstone presenting at the ampulla of Vater, i. e.,
moreover, that in endeavoring to escape into duodenum. (Pantaloni.)
typhoid fever the gall-
bladder is often invaded, and that the typhoid bacilli may live there
indefinitely, and that they tend to clump or agglutinate themselves in
a very suggestive way into trifling masses which may serve as
minute foreign bodies. Thus each predisposing factor reacts upon
the other, and by a vicious circle either an acute lesion may be
established or calculi may be formed in varying numbers.
Gallstones have been found in the newborn, but are relatively
infrequent below the age of twenty-five, and are most common in the
later years of life. The condition is by four to one more frequent in
women than in men. The only predisposing habit seems to be such
lack of exercise as gives no expulsive movement to the gall-bladder
by action of the abdominal muscles. They are more common in the
gouty and in those predisposed to uric-acid diathesis, while
abundance of nitrogen seems rather protective. Biliary calculi have
never been found in the wild carnivora.
McArthur has formulated the following conclusions of interest in
this connection:
1. Not all gallstones originate within the gall-bladder.
2. The origin of a cholesterin stone is probably the gall-
bladder, with subsequent accretion, either in passing
through, or in the duct, where it may have lodged.
3. Bilirubin calcium is the principal constituent of the smaller
intrahepatic duct stones.
4. Calculi in immense numbers may exist for months in the
ducts without producing serious symptoms.
5. Under these circumstances the surgeon need not reproach
himself if there be recurrence of symptoms after common
duct drainage.
Biliary calculi are serious menaces to a patient’s welfare, not alone
because of the obstructive symptoms which they may produce, but
because of the acute or chronic conditions to which they indirectly
give rise. These have been in some degree already mentioned. Thus
cholecystitis and cholangitis of all degrees of severity, from the
milder chronic forms to the phlegmonous and fulminating varieties,
may be at least associated with the presence of such calculi and
seem to be to a greater or less extent due to their presence. Around
such foci of excitement there will always occur local peritonitis, which
will result in adhesions, and the consequent tenderness with referred
as well as local pains to which it necessarily gives origin. The viscera
suffer not only in this direct way, but functional disturbances are
produced, and are usually covered under those vague terms
“dyspepsia” and “indigestion” with which patients crudely describe
their discomforts, and under which physicians too often conceal their
failure to appreciate the actual condition.
Furthermore there is always a possibility of cirrhosis resulting,
because of distention of the hepatic ducts and backing up of the
hepatic secretion. Thus the liver becomes larger and more dense, is
colored green, its edges become more rounded, this occurring
especially in the right lobe, or at least attracting more attention in that
location because more easily recognized from without. Again the
more acute inflammatory conditions sometimes cause paralytic ileus,
or at least paralysis of the lower bowel, and thus lead to conditions
almost identical with, and difficult to distinguish from acute intestinal
obstruction.
Of equally great and growing importance is the fact that, according
to Schroeder, some 14 per cent. of gallstone sufferers develop
cancer, the presence of these irritating foreign bodies in the biliary
passages having much the same relation to cancer of the liver as
does the existence of previous ulcer to cancer of the stomach.
Symptoms.—There is scarcely any morbid condition which is at
one time characterized by such significant symptoms
and at another by none at all as cholelithiasis. In rehearsing the list
of the ordinary symptoms produced by the conditions exceptions
should be made, for no matter how complete the list something may
be omitted which has been noted in some particular case.
Gallstones confined within the gall-bladder proper may produce
few or no symptoms, this being particularly true so long as the ducts
are free and there are no persistent consequences of previous acute
trouble. A stone may grow in the gall-bladder to a large size and
cause little or no distress until it begins to work its way by the
ulcerative process. Doubtless small concretions pass with little or no
disturbance, or only that which would be considered a “temporary
dyspepsia.”
When, however, gallstones produce symptoms these usually
include more or less paroxysmal pain, occurring unprovoked and at
irregular intervals, referred not alone to the upper abdomen, but
radiating to the rest of the trunk, as well as in the direction of the
right shoulder-blade. (The shoulder pains of biliary and renal lesions
are due to the connection of the pneumogastric nerves with the
ordinary sensory nerves above, and below with the sympathetic
ganglia.) Attacks of pain are usually followed by nausea and
vomiting, and if extremely severe by more or less depression and
collapse. At times there will be a sensation as of distention in the
region of the gall-bladder. Tumor in this location may or may not be
present, and jaundice is an uncertain symptom, not occurring unless
the ducts are occluded. The stomach so far sympathizes that
digestion is at least temporarily disordered. In proportion as
angiocholitis is produced by the passage of calculi we may meet with
more or less septic features. The pain produced is uncertain in
severity and duration, and is often relieved by the relaxation which
may accompany or follow vomiting. After subsidence of severe pain
there remains a dull ache for several days, lasting perhaps until
another acute paroxysm. These pains are sometimes referred to the
left side and over the stomach, in which cases it will usually be found
that the gall-bladder is adherent to the stomach, while when the pain
is felt in the right side of the thorax it is usually because there are
numerous adhesions between the lower surface of the liver and the
viscera below it. Such pain may even simulate angina pectoris or
may involve the genitocrural distribution. In fact it may be referred to
almost any part of the body.
Vomiting which is at first paroxysmal and colicky may become
persistent, continuous, and even dangerous. It is essentially an
expression of pneumogastric irritation. The vomited matter may
contain bile or even, by retrostalsis, fecal matter. The depression
which at first occurs may merge into complete collapse; it may even
be fatal. It will necessarily be more marked when the paroxysms are
more frequent.
A significant feature in nearly every case is muscle rigidity,
especially of the upper abdominal muscles on the right side, but not
necessarily confined to these. This muscle spasm is a symptom
common to many serious conditions and is not of itself indicative. It
simply implies a serious condition within. Tumor or enlargement in
the region of the gall-bladder may be met with, but are by no means
constant. These may become more pronounced with each attack,
being reduced between times because of the escape of bile between
paroxysms. It is a valuable symptom when noted, but no importance
should be attached to its absence.
The presence of gallstones in the stools is, of course, indicative,
but most valuable time is often wasted when waiting for their
discovery. Moreover, a number of hours, or even days, may elapse,
the time depending on the activity of peristalsis, between the escape
of calculi into the duodenum and their appearance in the stools. A
convenient way to search for them is to let the stool be stirred with a
1 per cent. solution of formalin and then strained through a sieve
which has about sixteen meshes to the inch. The question of the
wisdom of operation can practically always be decided without
reference to the appearance of calculi. In this way the surgeon may
feel that his diagnosis is corroborated by it, but in no sense
weakened without it.
Jaundice is always a significant sign when present, but is absent
in at least four-fifths of cases which nevertheless should be
subjected to operation. Its occurrence is a matter of interest along
with the previous history of the case. It is, however, of great value if it
were noted in connection with the first pains or cramps. In chronic
obstruction by stone in the common duct it is important to determine
the intensity of the jaundice, since this may indicate whether we deal
with calculous disease or obstruction from tumor. In chronic
obstruction by stone the color changes are less marked, and often
clear up entirely, while when produced by tumor they become
gradually more intensified.
Deep and persistent jaundice is suggestive of malignant disease.
The degree of cholemia rather predisposes these patients to
hemorrhage or persistent oozing during operation. Jaundice
gradually deepening with each attack of pain is also very suggestive.
Such attacks, coming on with symptoms like those of malaria, chill,
sweating, and pyrexia, are extremely suggestive and always call for
surgical intervention, i. e., drainage. In brief it may be said that
jaundice, with enlargement of the gall-bladder, is at least suggestive
of cancer, while a history of gallstone colic, without much
enlargement of the gall-bladder, is indicative of stone in the common
duct. Although this statement is probably true for the majority of
cases there are occasionally marked exceptions to it, as, for
instance, when a gall-bladder is distended with hundreds or even
thousands of small calculi, or to such an extent that it may form even
a pear-shaped tumor hanging down within the abdomen.
In addition to these features thus rehearsed there might be made
a long list of possible “extras,” by which the original condition is
complicated and made to appear in unusual aspect or even life
endangering. Such a list would include nearly every imaginable
lesion of the upper abdomen. Suffice it to say that the liver, stomach,
and the pancreas especially may suffer, while other viscera and the
larger veins, with the surrounding tissue, may any or all of them
become involved.
Diagnosis.—Diagnosis has to be made mainly from non-calculous
obstruction; from the acute gastric conditions, ulcer,
etc.; from renal colic; from the acute or subacute pancreatic
affections, duodenal ulcers, renal lesions, localized peritonitis from
some other cause; from cancer, lead colic, angina pectoris,
pneumonia, pleurisy, and even hysteria. Not so rarely pneumonia
and pleurisy begin with pains which are referred to the upper
abdomen and are suggestive of gallstone disease, while they
seriously perplex the medical attendant. Much stress is to be laid on
the first location of the pain, especially if this be in the direction of the
right shoulder, and upon concomitant vomiting and jaundice, if
present, as well as on the location of the greatest tenderness and
muscle rigidity. Recurrence of more or less similar attacks is also
suggestive. Diaphragmatic pleurisy may cause pain, referred
especially along the esophagus, and intensified during the act of
swallowing or vomiting. Affections of the appendix and gall-bladder
may co-exist, as well as be easily mistaken one for the other. The
former is so true that when operating for one condition it is always
advisable to explore in regard to the other. When the appendix is
placed high, especially behind the colon, confusion may confound.
Biliary colic is usually free from the associated ordinary symptoms
which are so often met with in renal colic, while in the latter the urine
will contain no bile pigment and the pain will usually be referred to
the external genitals. In lead colic the characteristic line upon the
gums and the habitual constipation which always accompany it will
be suggestive. When the stomach is at fault and the pylorus
obstructed this viscus will usually be dilated, and the vomit is of a
different character, while, at the same time, actual stomach
movements may or may not be made visible. With gastric or
duodenal ulcer pain it is more regular and associated with food
taking after a definite interval, longer in the latter case.
Chronic pancreatitis is so often associated with cholelithiasis that it
is impossible to disassociate their symptoms, but the referred pain is
rather midscapular or even on the left side. It will be particularly
suggested by rapid loss of flesh. In acute pancreatitis the symptoms
are usually more excessive, the distention earlier and greater.
Cancer of these various organs does not commence with pain, but
has a more gradual, distinctive downward course, with cachexia.
These are some of the considerations which may aid in differential
diagnosis.
The detection of bile pigment in the urine and blood will have
corroborative value.[63]
[63] Hanel has shown that a small capillary tube filled with blood, sealed
at both ends, may afford a convenient corroborative test. After standing for
a few hours in a vertical position its separated serum can be examined
against the light. Normal serum is colorless, while even a trace of bile
pigment will give it a distinctive yellow tint.
Baudouin’s test for the urine will be the most satisfactory in the matter of
precision and simplicity. If two or three drops of a ¹⁄₂ per cent. solution of
fuchsin be dropped into urine containing bile it immediately develops a fine
orange tint, in marked contrast with its own red. No other coloring matter in
the urine gives this reaction; which is very delicate. (Mayo Robson.) Methyl
blue and methyl violet each give a reddish tint; Loeffler’s blue solution gives
a green tint which vanishes on heating, to reappear on cooling. There are
numerous other tests, but these are the simplest and most satisfactory.

Treatment.—The general subject of cholelithiasis and its

associated lesions constitutes an important topic in the
so-called “border-land” between medicine and surgery, where views
and advice regarding prognosis and treatment will depend on the
experience and the training of the medical attendant. Surgeons now
recognize, and physicians are being gradually converted to their
view, that gallstone disease is essentially a surgical disease, i. e.,
one to be combated by surgical intervention. While it is not to be
gainsaid that many patients live and die with gallstones who are
never conscious of their presence, and while others who have had
serious attacks live to die of some other disease, nevertheless the
general statement may be boldly made and easily defended, that
when the disease is well marked and when patients suffer more or
less constantly from it the only successful method of treatment is the
surgical, and that, in other words, operation offers the only prospect
of permanent relief. Regarding its associated dangers it may be said
that danger comes from delay rather than from operation, and that
here, as with many other conditions, patients often wait too long,
partly from lack of proper advice, partly from timidity, and that a
septic and moribund patient, allowed to become so for lack of earlier
application of the resources of surgery, is a reflection on the one who
waits rather than on the surgeon, who, endeavoring to save, still
unfortunately loses his patient.
This is not the place to discuss non-operative measures—i. e.,
medicinal and dietetic treatment—valuable as they may be in certain
cases. Most of the drugs which are supposed to be effective in their
power of solution of gallstones or of facilitating their escape are
disappointing, and at best are vague and uncertain in their action.
The hydrotherapeutic treatment, such as carried out, for instance, at
Carlsbad, will do good in many cases, especially for those who have
been indulgent in their appetites and careless in their habits. Cases
of any description not too far advanced would be benefited by a
careful regimen of this character, but that Carlsbad or any other
waters will certainly cure cholelithiasis is now absolutely disproved.
As a preparation for operation a sojourn at some such place may be
advised; as a substitute for it, never. Large doses of glycerin (50 to
150 Cc.) often temporarily relieve the pain of biliary colic.
In general, then, it may be said that cases which give a history of
recurring attacks of biliary colic, with or without recurrent jaundice,
and with those varied concomitant symptoms which are usually
grouped under the term “indigestion,” in which there is definite
tenderness over the region of the gall-bladder, with or without muscle
spasm, and with the other referred pains so often present in this
condition, should be regarded as legitimately surgical, where
operation is more than justifiable and usually decidedly advisable,
even too often imperative. The same is true of those cases of
distended gall-bladder with obstruction of the duct where perhaps no
calculi are present, but where the patient suffers in much the same
way as though they were present. Biliary drainage is equally called
for, and the presence or absence of calculi is but a minor feature
upon which too much stress should not be laid nor too much
disappointment expressed if they be not found.
Many cases of chronic cholelithiasis have become more or less
toxemic, as well as cholemic. It is a well-recognized fact that
cholemic patients are more likely to cause inconvenience to the
surgeon from free hemorrhage or persistent oozing, because of the
slowness with which coagulation of their blood takes place. When
time is afforded for preparation it is of great value in these cases to
administer calcium chloride, of which several doses may be given
each day, in considerable water, the former varying in amount from 1
to 2 Gm. When time suffices, too, it is always of value to prepare
these patients for the operation by measures already discussed,
improving their elimination, reducing the degree of their toxemia, and
fortifying their circulatory systems by well-known measures. The
value of such preparation is perhaps more apparent in such
instances than in most others. On the other hand, many cases
calling for operation are almost as imperative as those of acute
appendicitis, where every hour’s delay is to the disadvantage of the
individual. The operations which are practised upon the biliary tract
will all be discussed together in a section by themselves.

TUMORS OF THE GALL-BLADDER.

This expression refers rather to actual neoplasms of the gall-
bladder itself than to distention of the sac by which an intra-
abdominal tumor may be formed. The latter subject may be
dismissed with the mere statement that the gall-bladder may become
distended with bile, with mucus, with pus, with concretions, or with
the products of such disease as echinococcus, actinomycosis, etc. In
this way it may be so much enlarged as to be easily felt through the
abdominal walls or to be even mistaken for other conditions. In the
latter case it may have to be differentiated between such a condition
and a movable right kidney, a tumor of the kidney itself or of its
capsule, as well as from tumors of the stomach, especially the
pylorus, of the liver, or of the intestine and from the enlargement of
the right lobe which often accompanies cholelithiasis, or from fecal
impaction. It would be best to abstain from the use of the aspirating
needle in these cases, as more harm might be done by the escape
into the abdomen of deleterious fluid than would be atoned for by the
information which the procedure would afford. Even when the
abdomen is open the gall-bladder should rarely be punctured in this
manner, unless one is prepared at the same time to open it and
drain. In other words, there is less risk about a small exploratory
incision than in puncture.
Nearly all varieties of malignant and many of benign tumors have
been reported as occurring in this location. It will be sufficient in this
place, however, to say that cancer of the gall-bladder, which, of
course, may extend in various directions, is by no means an
uncommon affection, and is usually a complication of gallstones. In
fact, it may be doubted whether primary cancer of the gall-bladder
ever occurs in the absence of such a source of irritation. These
cancers vary in type between the round-cell and the squamous, most
of them, however, being of the former character. Although Musser
has put the percentage at 65 and Zenker as high as 85 of instances
where gallstones are found within cancerous gall-bladders, it does
not follow that the above statement may not be true regarding their
almost universal association and causal relation, for any gall-bladder
found empty at a given time may at some other time have contained
a calculus. This frequent association is justly among the valid
arguments which surgeons may now use in making a plea for earlier
operation, and for making it a more standard procedure.
Cancer may be suspected in cases of progressive and
unintermittent jaundice, especially when there can be felt in the
region of the gall-bladder a distinct tumor or an enlargement of the
liver. Pain is a frequent but by no means a constant or reliable
symptom. As the disease spreads the adjoining textures will become
matted together, and a low grade of local peritonitis may still further
cement them into a mass which will occupy a considerable portion of
the upper part of the abdomen.
 But few cancers of the gall-bladder which are so apparent as to be
recognized without exploration can be considered as still amenable
to surgery, which for them can hold out but little prospect save
perhaps a temporary relief by biliary drainage. It is the cases in their
earlier stages, when the condition is made out by exploration, and by
it alone, which still afford prospects of more or less permanent relief.
The very impossibility of detecting the condition in these earlier
stages without exploration affords one of the strongest arguments for
such a procedure in every vague case of the kind. That cases of this
character are not necessarily hopeless is instanced by an
experience of my own, where on opening the abdomen of a large
and fleshy woman I found a distinctly cancerous gall-bladder
containing two large calculi, and removed the entire mass, with a
considerable portion of the surrounding hepatic tissue, the removal
being effected with the actual cautery. At present date of writing,
nearly six years after the operation, the patient is apparently
perfectly well and doing her own housework.

OPERATIONS UPON THE GALL-BLADDER AND BILIARY

PASSAGES.
The small area included under the above title has been made the
field for a variety of operations, dignified with formidable names, the
entire list of which might be made quite long. In order to simplify their
arrangement and illustrate their purposes they may be referred to as
(1) operations upon the gall-bladder proper; (2) those upon the
ducts; and (3) the more complicated operations upon one or both of
these in connection with some other part of the intestinal tract; or, to
catalogue them somewhat definitely, the operations upon the gall-
bladder include cholecystotomy, cholecystostomy, and
cholecystectomy, according as the surgeon opens the gall-bladder
and closes it, makes a more or less permanent opening, or
completely removes it. Again, upon the ducts he may make
cholangiotomy or cholangiostomy, or, using their practically
equivalent synonyms, choledochotomy or choledochostomy, these
terms referring to operations upon the cystic and the common ducts;
while when similar procedures are applied to the hepatic duct they
have been spoken of as hepaticotomy and hepaticostomy.
Cholecystenterostomy refers to an anastomosis between the gall-
bladder and the upper bowel, while when this is effected between
the common duct and the bowel it is referred to as
choledochenterostomy. When a stone lies partly in the common duct
and partly within the wall of the duodenum, and it becomes
necessary to incise the latter, it may be spoken of as duodenotomy.
The operation of merely crushing biliary calculi, hoping that the
fragments will be passed on with the flow of bile, and spoken of as
cholelithotrity, is now almost abandoned, and the term has historical
rather than present value.
To even attempt to epitomize directions for these various
operations into space available here would be impossible, for large
volumes have been devoted to this subject alone. The main thing for
the student and the junior practitioner is to appreciate the indications
for their performance, at which he should certainly have assisted
before attempting to perform them himself. General directions,
however, may be given as follows, the usual preparations having
been made both of the patient and the environment: A woman who
has borne children and who has, in consequence, relaxed abdominal
walls, makes a more favorable subject for operation than a muscular
man whose abdominal muscles cannot be relaxed until a profound
degree of anesthesia has been obtained. In many instances
exposure is made better by placing a sandbag behind the region of
the liver, especially on the side to be operated, by which the costal
angle is more outlined and the parts pushed forward.
A preliminary incision should be made of, say, three inches in
length, and is best placed a little to the inner side of the outer border
of the rectus, whose fibers are separated and its tendinous
intersection divided. This incision may be extended upward and
curved toward the middle line, as recommended by Bevan, or
downward, as the exigencies of the case may require. The beginner
especially should provide himself with sufficient space for
manipulation. The posterior sheath of the rectus and the peritoneum
are best divided together. Sufficient opening being thus made, a
finger may be inserted for the purpose of exploration. In the
presence of adhesions, and especially in acute cases in which pus is
likely to be present, this should be done with great caution. When no
adhesions are present gauze pads may be inserted and so disposed
as to permit exposure to view of the lower surfaces of the liver. The
operator should be prepared for any and all conditions—one of
dense adhesions or their complete absence, as well as for cobweb-
like adhesions which surround foci of infected exudate or of pus. The
more reason he may have for suspecting the presence of pus the
more carefully should the region be walled off with protective gauze.
Adhesions are most likely to form between the omentum and the
colon, in front and below, and with the stomach, duodenum, and
colon below and behind. Those who have had experience with
abdominal operations will appreciate whether these adhesions are
recent and likely to cover purulent foci, or old, and will proceed
accordingly. Occasionally tissues will be so matted that even an
experienced operator will scarcely be able to differentiate them.
The endeavor should be, if possible, to expose the gall-bladder
itself, both to touch and sight, in order that after orientation
concerning its actual condition its duct may be followed into the
common duct, and this into the intestine. This is sometimes an
exceedingly easy matter, and again impossible. The presence or
absence of pus will of itself indicate what should be done. When, for
instance, the gall-bladder is found black or partly gangrenous the
surgeon will content himself with doing the least possible amount of
separating, endeavoring rather to provide the widest outlet for
drainage. It might be better to make simply a small opening and
permit the escape of fetid débris, and to postpone until a later day
further attempt to remove the calculus, which presumably has
produced the difficulty. Local indications, then, should be considered
along with the general condition of the patient.
The lower surface of the liver will afford the guide to the location of
the gall-bladder, and when the latter is nearly obliterated its
discovery sometimes taxes the resources of the surgeon. When not
contracted it is usually easily exposed, and so far freed that it may
be even drawn up into the wound. After having thus isolated and
perhaps secured it, it must be decided by further exploration how it
shall be treated. It is of great importance to liberate the ducts from
surrounding adhesions.
 Cholecystotomy.—Cholecystotomy, sometimes fallaciously
spoken of as ideal, consists in simply opening
the gall-bladder, emptying it of calculi or other contents through a
small incision, and closing this by sutures. The operation is ideal in
but one way, but conditions which permit it rarely justify it, for any
gall-bladder so diseased as to call for operation needs either
removal or drainage.
Cholecystostomy.—Cholecystostomy includes provision for
drainage over a considerable length of time. A
distended gall-bladder which permits of easy manipulation and
isolation may be sufficiently long and large to justify uniting its
surface to the peritoneum and deep margins of the wound, in such a
way as to permit discharge of its contents through the latter. The old
method was to unite it to the skin. This should never be done, as
fistulas thus resulting are more likely to be permanent. If the gall-
bladder be thus affixed to the parietal peritoneum the better way is to
insert a drain, its arrangement being left somewhat to the choice of
the operator. For my own part I prefer a rubber tube, not too flexible,
inserted two or three inches into the gall-bladder, through a small
opening closed around it, with invaginated edges, by a purse-string
suture of chromic gut, by which it is intended to prevent leakage into
the abdominal cavity. By another suture of common gut the tube may
be so fixed as to avoid danger of being lost in either direction. If the
gall-bladder be sufficiently long to permit additional fixation to the
depths of the abdominal wound the operation is made still more
ideal; but in the case of a short and contracted cavity the tube may
be left to follow it into the abdominal recesses. Within forty-eight
hours the exudate which has been thrown out around it will have
become sufficiently organized and well ordered to form a canal in
which the tube shall rest, and which shall serve later as a conduit to
conduct bile to the surface after removal of the tube itself. Into such
a tube, after the application of the dressings, may be conducted
another more flexible tube, whose upper end shall connect with a
receptacle of some kind, which may later be a bottle held within the
dressing, to receive the discharge, and thus avoid soiling.
This operation has been done occasionally in two sittings, the gall-
bladder being brought into the upper part of the wound and fastened
to the peritoneum by sutures, which should not perforate its walls, as
that leakage would occur which the method is intended to avoid.
After waiting a day or two for adhesions to form the cavity is then
opened with a knife or scissors and drainage thus accomplished.
This method has been practically abandoned, for the reason that it
permits no digital exploration by combined manipulation.
Cholecystectomy.—Cholecystectomy includes the removal of the
whole or the greater part of the gall-bladder. It
has already been stated that this is a reservoir, convenient and
advantageous, but not needed in a way, and not essential to life. It
figures as a superfluous organ, then, similar to the appendix, and
there is no reason why, when diseased and troublesome, it should
not be extirpated. Its removal will sometimes be a matter of choice,
and at other times a necessity. The former is the case when the
surrounding conditions lend themselves to its dissection from the
lower surface of the liver without too much violence to other tissues;
the latter when it is involved in malignant processes or when its
interior is seriously infected. An incomplete method of treating the
gall-bladder under the latter circumstances might include the
scraping or removal of its thickened mucosa, without removing the
entire thickness of its structure. In this case, however, drainage
would be required. That the gall-bladder may be completely
separated and thus isolated, with comfort and speed, requires that
its wall be sufficiently strong to stand the ordinary manipulation. This
may not be true of the perfectly normal gall-bladder, but in such case
no one would think of removing it, whereas the cyst, which is
diseased sufficiently to justify removal, will usually permit of the
necessary manipulation. Even if somewhat torn in the process the
procedure may be effected without much added difficulty. This
procedure consists essentially in separation of the overlying
peritoneum and enucleation of the gall-bladder from its bed or the
depression in the liver in which it lies, which, as already indicated,
may be narrow or wide and deep. Actual separation from liver tissue
will be followed by oozing and at least two or three vessels in the
surrounding structures and at the neck of the gall-bladder will require
to be secured. Removal should not be attempted in cases which do
not permit of it, but may be practised in those cases not too infected,
when after emptying the sac (full of calculi, for instance) it can still be
established with the probe that the common duct is patulous. These
are ideal cases for such complete work. The gall-bladder having thus
been isolated down to its cystic termination, the surgeon proceeds
much as though it were the appendix, by firmly ligating the duct with
chromic gut, guarding against escape of contents while it is divided
on the distal side of the ligature thus applied. The stump of the duct
is then cauterized with pure carbolic, after which oozing is checked
by tamponing for a few moments. It then is often possible to bring
together the peritoneum beneath the torn liver surface and almost
completely cover it anew. The liver tissue will bear a ligature or
suture not too tightly drawn. If the case have been one otherwise
surgically clean, and the operation properly conducted, the
abdominal wound may be closed without drainage. If, however,
doubt be felt a small cigarette or a tubular drain may be placed, to be
left not more than thirty-six hours. Every infected gall-bladder, if not
removed, should be thoroughly cleansed, its interior being mopped
with gauze, preferably with the addition of hydrogen dioxide. An
important step, next to attention to the gall-bladder proper, is to
demonstrate the patency of the ducts. This is done by gently passing
a probe, which should be bent to suit the case, along the duct and
into the intestine. This, of course, cannot be done if calculi are
discovered by manipulation, neither can it always be done when
calculi are not present. Gallstones in the duct can usually be
distinguished by the fingers with which the exploration is made, and
failure to thus pass a probe may be brought about by stricture rather
than by calculous obstruction. The importance of this determination
will be seen in removing the gall-bladder, as to remove it in an
obstructed case is to leave no outlet for bile except into the
abdominal cavity, whereas to fail to drain such a case is to plainly
neglect to meet the indication.