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Cholecystostomy for Obstruction of the Cystic Duct Dr Henry R Wharton

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CHOLECYSTOSTOMY FOR OBSTRUCTION OF THE CYSTIC DUCT.

DR. HENRY R. WHARTON presented a woman, aged fifty three years, who was admitted to the Presbyterian Hospital, January 23, with the history that for some years she had suffered with indigestion and intermittent attacks of jaundice, paroxysmal pain, chills and fever, which symptoms persisted, varying in severity, up to the time of her admission to the hospital. Upon examination it was found that she was much emaciated, weighing only sixty-seven pounds, and was deeply jaundiced ; the abdomen was moderately distended, and palpation showed that the liver dulness extended downward beyond the umbilicus.

. The patient was etherized and an incision made, and the gall-bladder was exposed with some difficulty, as it was very much contracted, being not over three inches in length and three-fourths of an inch in diameter, and as it was overlaid by the hypertrophied liver. When it was exposed and palpated it was found to contain several stones. It was also adherent to the surrounding tissues. As it was found impossible to bring the gall-bladder up to the surface of the wound and suture it to the tissues of the abdominal wall, the intestines were carefully packed away from the bladder with sterilized gauze, which was held in place with retractors, so that a free exposure of the gall-bladder was obtained. The gall bladder was then opened and several stones were removed, and at the upper part of the organ a large-sized stone was found, a por tion of which was impacted in the cystic duct, the remaining por tion protruding into the gall-bladder. This was removed with some difficulty. As it was found impossible to bring the edges of the gall-bladder up and suture them to the abdominal walls, the gauze packing was allowed to remain, anu a large rubber drainage tube was introduced to the bottom of the wound, and the ends of the wound were closed with silkworm-gut sutures.

After the operation there was profuse discharge of bile from the wound, and the patient suffered from more or less persistent vomiting; the abdomen became markedly distended, the bowels remained constipated, and the patient presented decided symp toms of intestinal obstruction. The gauze packing was removed on the third day, and after this the symptoms of intestinal obstruc tion rapidly subsided, and the patient's condition became markedly improved. Bile continued to escape freely from the wound for several weeks, the patient's health improved, and at the end of four weeks the wound was firmly healed, and the passages showed that the bile was escaping by its normal route.

The patient was discharged from the hospital, April 14, in good condition. Examination of the patient, November 26, shows that she is well nourished, is in good condition, and weighs too pounds.

A COMPOUND FRACTURE OF THE RIGHT TIBIA AND FIBULA GREAT CONTUSION OF THE LEG AND THIGH COMPLICATED FRACTURE OF THE CONDYLE OF THE LEFT FEMUR.

DR. WHARTON presented a man, aged twenty-five years, who was admitted to the Presbyterian Hospital on the night of May 25, 19oo, having been injured by being caught between cars in a freight wreck. On examination it was found that he had sustained a compound fracture of the tibia and fibula of the right leg, with great contusion of the soft parts, and an injury of the right knee and a contusion of the right arm. When seen by the reporter, about twelve hours after the injury, he found a compound frac ture of both bones of the leg in the middle third, and the knee was held in partial flexion and could not be extended. The leg and thigh were greatly swollen and tense, and the vitality of the soft parts seemed threatened.

The patient was anwsthetized, and free incisions were made at several points through the skin and deep fascia to relieve the tension, which were followed by the escape of a large amount of dark blood and serum. An examination of the injured knee showed that full extension of the leg was impossible, by reason of a fracture of the internal condyle of the femur, which appeared to be displaced downward into the joint, which caused locking of the joints in attempts at extension. As the vitality of the tissues of the leg and thigh seemed doubtful, and as attempts to reduce the fragment by manipulation were unavailing, it was decided at the time to postpone any operative treatment to reduce the fracture of the internal condyle. The compound fracture of the bones of the leg was dressed with a copious sterilized gauze dressing, and moulded binder's-board splints were applied to the leg and thigh to fix the fragments. A skiagraph was taken of the knee, and it was found that a mass of bone was wedged into the knee-joint. Three weeks after the injury, as the vitality of the tissues of the leg seemed assured, the patient was etherized, an incision was made over the inner portion of the knee-joint, and the seat of fracture of the internal condyle was exposed. It was then found that the internal condyle of the femur had been separated from the shaft of the bone, and had been so turned that the fractured surface of the bone was presenting in the joint, and the articular surface was turned towards the fractured surface of the femur. The fragment was carefully removed, a large drainage tube was passed into the joint, the ligamentous structures were brought together by chromicized catgut sutures, and the wound was closed by sutures. The fragment removed consisted of a large portion of the internal condyle of the femur, and represented a mass of bone two and one-half inches in length and one and one-half inches in width. After the removal of the fragment the leg could be placed in the extended position without difficulty. The limb was then held in the extended position and a plaster-of-Paris dressing was applied to the foot, leg, and thigh.

The patient did well after the operation. The drainage tube was removed on the fourth day by trapping the plaster bandage, and the bandage was not removed for a month. The patient was discharged from the hospital on July 29, a little more than two months from his admission, walking with crutches, and at this time there was some motion at the knee-joint. The patient was again examined on November 12, and it was then found that he was able to walk with a cane and had regained a very fair range of motion in the knee-joint.

leg, patient, found, fracture, wound, removed and condyle