ACUTE CHOLECYSTITIS COMPLICATING TYPHOID FEVER.
Dr. Neilsonreported the case of a man, aged forty-two years, who, on the evening of May 14, the fifty-eighth day after admission with typhoid fever which had pursued a mild course, but had relapsed, and was then apparently proceeding to convalescence, complained of a sharp pain, which he located in the epigastric region, and which, he said, followed immediately after he had reached to a small table, close by the right side of his bed, for a glass of water. At the time when he complained first of this pain, the temperature was F., the pulse 82, the res piration 20. The bowels had been freely moved that day, and the tongue was clean. The pain was considerably relieved by simple measures (soda mint, etc.). The next day, however, the pain was still present, although not severe, being referred to the same region, and there was no change in the pulse or temperature. By the morning of the following day the pain was somewhat more marked, the temperature was ioo°, the pulse 96, respiration 24. Examination of the abdomen again failed to elicit any marked tenderness in any part of it. Through the day the pain continued, tending to be paroxysmal, and being referred, but quite indefi nitely, to the right hypochondriac region, although the patient also complained of it at times in the lower portion of the abdomen. The evening temperature was the pulse-rate had increased to 104, and the respiration was the same as in the morning.
The next morning, May 17, the patient vomited what was evidently bile ; the temperature rose to the pulse to 120, and the respiration to 28. The abdomen was slightly tympanitic, pain in the region before described persisted, and was intense at times, and on palpation he found some tenderness close to the costal border, in the region of the gall-bladder. There was nausea at intervals, and eructations, and considerable flatus passed by the bowel. The condition of the patient grew worse through the day, his temperature in the afternoon rising to and the pulse to 13o, with poor volume. Pain was more severe and vomiting again occurred in the evening. The general condition was far from promising ; nausea was unrelieved by treatment, and, besides that, hiccough was added to the already distressing state.
Early the following morning a chill occurred, and after that there was vomiting again. The temperature was then 103°, and by eight o'clock it was 104°. Examination of the abdomen re vealed its condition to be as on the day previous,—slight disten tion, some tenderness in the region of the gall-bladder, but not of a marked degree. There was, in addition, some muscular rigidity in the right upper quadrant, and some elastic resistance near the costal margin at the ninth and tenth ribs could be de tected. There was hyperleucocytosis, the count being 12,35o. The patient was in a condition of extreme anxiety and depression, and although the outlook was not promising,—the temperature at noon being and the pulse 136,—operation was advised and agreed to. Immediately, as soon as the necessary preparations could be made, the abdomen was opened.
On opening the peritoneum, the gall-bladder, the surface of which was dark-red and dull in appearance, presented in the wound. It was distended, and on breaking away numerous light and recent adhesions which had formed between it and the sur rounding viscera—especially the transverse colon—it was found to be markedly lengthened upward and inward. When the gall bladder was incised, there first flowed out a thin, watery mucus, then bile and mucus, and last of all a fluid more viscid and un mistakably pus. The walls of the gall-bladder were thickened, soft, and friable, and were deeply congested, bleeding easily when punctured and incised.
Evacuation having been accomplished, fresh iodoform gauze was substituted for that first packed around the gall-bladder, a rubber drainage tube inserted into the latter, and the margins of the opening made in the fundus were secured by silk stitches to the parietal peritoneum at the upper angle of the wound, which latter was, for the remainder of its extent, closed with silxworm gut sutures. A copious dressing of sterile gauze was applied.
The patient bore the operation well, and was none the worse for the ether, which was most carefully given. There was little, if any, shock. The temperature fell to F., and three hours later to accompanied, however, by a fall in the pulse-rate from 138 to 124. By six in the evening the tempera ture rose again, reaching but after that it slowly fell, remaining for the greater part of the next forty-eight hours between 99° to ioo°, the respiration ranging from 20 to 26, and the pulse from 122 to 140.
The patient experienced but little relief from the operation, —none besides freedom from the severe pain which he previously had. Hiccough and nausea, particularly the former, were most obstinate and became very distressing. The abdomen was not tender, save, of course, in the region of the wound, nor was it markedly distended ; but the accumulation of gas in the intestines was an annoying feature. The bowels were moved with difficulty by means of calomel and enemata.
The patient got but little rest on account of the persistent hiccough, which yielded but for short intervals to varying medi cation. Vomiting occurred several times, but the patient was able, for a considerable number of hours, to take small amounts of liquid nourishment. Rectal alimentation was, of course, re sorted to in addition. From the wound there was a free discharge of bile, requiring many gauze pads to absorb it, besides the gentle changing of the dressing.
On the afternoon of May 20, the beginning of the third day after the operation, the patient vomited freely, and his condition became emphatically worse. Tympanitis increased, hiccough be came more violent and constant, nausea more persistent, the temperature rose to F., the pulse grew weaker, although no more frequent, and a low delirium developed. In short, the picture of septic peritonitis was complete. Death occurred at 4.3o on the following morning.
Dr. Gibbonremarked that about a year ago he operated for empyema of the gall-bladder following typhoid fever. It was a young girl who had been in the wards of the Pennsylvania Hospital, suffering from a typical attack of typhoid fever. She had been at home for about ten days when she returned to the hospital, saying that she had been taken sick with a pain under her right costal border, and her mother the day before discovered a tumor in this position. She had some fever. The tumor was very easily outlined in the gall-bladder region, and there was very little rigidity of the abdominal muscles at the time. There was no general distention, but the symptoms were acute ; the woman had fever, and the operation seemed to be urgent. When the abdomen was opened the gall-bladder came into view very much distended, and there was at first a copious discharge of mucus and then pus. This girl got well without any trouble. The sinus closed entirely. He looked up her history in the medical ward afterwards and found that several times during her typhoid fever she complained of pain in the region of the gall-bladder. Once or twice at night she was given morphine for this pain. Each time it went away, and the pain complained of on readmis sion was, the patient said, in the position and of the same char acter as that which she had when ill with typhoid fever.
Dr. Harts remarked that as a rule the operation for chole cystitis immediately following typhoid fever is not a favorable operation, as the patient's condition necessarily is always very much below par. He had had an opportunity to operate on two cases of cholecystitis following typhoid fever, but in both of these instances the patient had quite thoroughly recovered from the typhoidal attack, and consequently was well able to withstand the result of the surgical operation. Both of these cases did per fectly well and made very satisfactory recoveries. Attention had been called to the fact that the first fluid to escape from the gall bladder of Dr. Neilson's case was serous in nature. His ex perience is that that is nearly always the case in these conditions. The first fluid is usually serous in character, then sometimes serum stained with bile, and then, lastly, the pus is usually found down at the bottom of the gall-bladder, often accompanied with masses of calculi which it surrounds. This condition of affairs, of course, is entirely dependent on the effect of gravitation, and of course the relative positions will be influenced by the position the patient has assumed prior to the operation.