CHOLECYSTOTOMY AND CHOLEDOCHOTOMY; SEC ONDARY CHOLECYSTECTOMY AND OPERATION FOR LIVER ABSCESS AFTER RESECTION OF RIBS AND RETROPLEURAL PROCEDURE.
DR. F. LANGE presented a man, forty-four years of age, otherwise healthy, who began to suffer from gastric disturbances fourteen years ago. One year later, attacks of severe pain, prin cipally in the region of the scapula; and small of back, would occur, lasting from half an hour to a day. About twelve years ago had dysentery. In October, 1898, jaundice set in with quick emaciation after an unusually severe attack of pain.
January 3, 1899, laparotomy. Incision parallel to free border of ribs. Gall-bladder emptied of gall, mucopurulent material, and some stones. Choledochotomy. Much of a soft, chalky, brownish concretion removed, a great deal of which was shovelled out of the hepatic ducts by a blunt curette. Papilla vateri free. In rear wall of duodenum over vertebral column circumscribed resistance could be felt, probably an old cicatrix. Common duct closed by suture. Gall-bladder inverted about the edges of the wound and drained. Suture of peritoneum. Tight tamponade of abdominal walls on account of free oozing.
For more than one week after the operation oozing from the drainage tube in the gall-bladder continued. Purulent mucus and a great quantity of small particles of soft concretion were admixed with the bile. This, however, gradually ceased, and about eight weeks after the operation the fistulous opening closed, though repeatedly attacks of colicky pain, evidently due to stag nation and retention, now occurred. The constipation with occa sional visible contraction of the expanded ascending colon was all the time troublesome. Evidently the action of the gut was hampered by adhesions about the region of the gall-bladder. On March 4 the patient was discharged healed and in convalescing condition. Very soon, however, pain set in again, with rise of temperature and chill. On March II pain very severe. Tem perature on following day io5.6° F. Three days later a small stone about the size of a pea was discharged with the stools. Pa tient felt transiently relieved. After about ten days again rise of temperature and occasional pain in right shoulder. No icterus. Stools of normal color. April 2, 1899, readmission, with temper ature of over Io3°.
April 3, gall-bladder and large ducts exposed. Many adhe sions broken. Common duct dilated but apparently not ob structed. Gall-bladder was then removed. Cystic duct closed by suture near its insertion into common duct. The gall-bladder was removed because repeatedly retention of much purulent ma terial had taken place in it, and the fistula had reopened.
Convexity of liver freed from adhesions and explored by touch. A resistant area could be felt about five inches distant from free border. Its puncture with aspirator-needle yielded thick pus.
Abdominal incision supplemented by a transverse one, and about seven to eight centimetres of the next three rib cartilages, including some of their bony portion, resected. Periosteum and perichondrium peculiarly adherent and tedious to be lifted off.
Pleura diaphragmata stripped from the muscular layer of diaphragm and pushed upward. Incision through diaphragm over seat of abscess. Edges of this wound united to liver sur face by suture. Abscess incised by actual cautery. It was about the size of a small hen's egg. Tamponade without suture. Oper ation had lasted very long and patient was much exhausted and collapsed ; he, however, rallied under saline infusions, hypoder mic injections of camphor, etc.
For several weeks feverish condition continued. Gradually, however, the patient improved, and on the 27th of May the enormous wound was closed with the exception of a small fistula, and patient was discharged.
In August, 1899, he went to Carlsbad, spent the winter of 1899 and i9oo in favorable climates, mostly on the border of the Geneva Lake, and he went again to Carlsbad in June, 19oo.
His condition is now quite satisfactory. He has his original weight, attends to his business, and feels strong and healthy. Jaundice has never recurred. Inclination to being constipated still exists, and from time to time patient will have over the lower part of his chest a somewhat painfully oppressive feeling, which, however, soon passes away. The difference in weight between the extreme degree of emaciation and his present weight is more than seventy pounds. He had at one time come down 112 pounds.
Dr. Lange thought this case was of interest for the follow ing reasons: ( 1 ) The morbid tendency to oozing caused by the cholemic condition of the blood, though alarming after the first operation, and usually and justly also, after his personal experience, regarded as a most serious complication, was gradually overcome with the cessation of stagnation of bile.
(2) The liver abscess seems to have been the only one, an uncommon thing in cases where its formation is due to gall stone disease and cholangeitis.
(3) The procedure for successfully approaching the abscess aggravated, no doubt, the operation, but allowed of safely dealing with the abscess.
(4) In this like in several others, he had observed that cholangeitis has gradually disappeared. Such cases may go on with slight feverish actions for many months, and gradually heal. Nay, he was inclined to assume that small abscesses in the gall system may be discharged through the gall-ducts and spontaneous recovery take place. Carlsbad seems to act well on such cases.
DR. A. J. McCosH said that in connection with this subject of cholecystotomv and cholecystectomy, he wished to mention the operation devised by Dr. William J. Mayo. The speaker said he had done Mayo's, operation three times, and had in two of the cases found it exceedingly satisfactory. In both the mucous membrane of the gall-bladder could be peeled off very easily, but in the third case it was brittle, and could be removed in small pieces only by forceps, so he abandoned the operation and extir pated the gall-bladder.
DR. WILLIAM J. MAYO, of Rochester, Minnesota, said that in nine cases of stricture of the cystic duct he has been able to remove the mucous membrane down to the point where the ob struction existed, and in that way was able to get rid of the col lection of mucus. In five cases he was compelled to remove the whole gall-bladder, as it was impossible to get the mucous mem brane out. It sometimes can be peeled off very readily, and this obviates the risk and danger that accompany removal of the gall bladder.
DR. B. F. CURTIS said the method of procedure employed by Dr. Lange in his case was of considerable interest. In a somewhat similar case which came under his observation some years ago, the speaker said he resected a rib, exposed the pleura, sutured a circular area of the latter to the diaphragm so as to close off the pleural cavity, and then cut through the diaphragm ; after shutting off the peritoneal cavity with a strip of gauze placed circularly around the wound between the liver and dia phragm, he evacuated the abscess. Dr. Lange was able to sim plify this method by pushing up the pleural fold.
The preferable line of the abdominal incision in these gall bladder cases is another point worthy of discussion. Many have raised objections to the oblique incision along the edge of the ribs on account of the danger of injury to the upper muscular nerves resulting subsequently from hernia, but in Dr. Lilienthal's where this incision was made, there are no signs of a hernia, nor are there any in Dr. Lange's in spite of his second incision.
DR. LILIENTHAL said the operation of cholecystectomy bore a certain analogy to that of appendicitis ; just as in certain cases of appendicitis it is impossible to get the organ out entire without spending a great deal of time and running much unnecessary risk, while it can be readily eviscerated, so it is in operating on the gall-bladder. If the gall-bladder comes out easily, it should be removed ; if there is difficulty about its removal, other meth ods, such as the evisceration of its mucous membrane, must be resorted to.
As to the incision, Dr. Lilienthal said he did not make his incision along the free border of the ribs. It is made at a slight angle, but almost parallel with the border of the rectus ; the rectus is then drawn inward towards the median line after the manner suggested by Dr. Weir in appendicitis, making the in cision through the upper parts transversely. Then, if necessary, the rectus is partially cut in its upper portion. The speaker said he had resorted to this method in quite a number of cases without a resulting hernia.
DR. WILLY MEYER said that in a number of cases of gall bladder disease which had come under his care he had not experi enced any special trouble in cutting out the gall-bladder, no matter how large it was. In those cases where it is adherent to the liver tissue the danger of haemorrhage can be obviated, to a great ex tent at least, by using the Paquelin cautery. One must, of course, avoid entering the liver tissue.
As regards the choice of an incision, Dr. Meyer said he pre ferred to make it parallel with the border of the ribs. This has never resulted in a hernia, so far as he knew. It is better to make this incision and push the belly of the rectus muscle inward, then dividing transverse fascia and peritoneum in the direction of the cut according to Weir's method, than to make the entrance through the rectus muscle in the direction of its fibres.
DR. F. KAMMERER referred to one case of subphrenic ab scess which he opened after resetting some of the costal carti lages and ribs, pushing up the pleura and perforating the dia phragm. In this case the pleural cavity contained quite a quantity of serous fluid, which gave rise to some doubt as to diagnosis, one physician getting clear serous fluid and the other pus on puncture. At the operation the lower border of the pleura was easily recognized and pushed away for an inch or so, with out opening it. Where such a procedure is possible, it is cer tainly preferable to opening the pleura and risking an infection of its cavity.