« PreviousContinue »
symptoms, they can only be rationally the inflamed tube and a pathological treated by operation. Moreover, it is condition analogous to inflammation in true that a laparotomy per se for the re the Fallopian tubes and vermiform aplief of such conditions is attended with pendix. While a catarrhal cholangitis, less shock and danger than is a laparot- the inflammation limited to the mucous omy for other intra-peritoneal troubles, lining of the tubes, may be possible, as there will usually be very much less usually all the coats (the peritoneal inevisceration. This much in connection cluded) are involved. with the subject of cholelithiasis is prac We should also keep well in mind tically settled. The unsettled problem that while an obstruction in the cystic is to classify the various morbid condi- duct dams back the secretions of the tions ; to differentiate clinically between gall-bladder only, an obstruction in the them prior to an exploratory incision and common duct dams back the bile from to apply to their relief the most rational the liver as well as the mucus from the available surgical procedure. In this gall-bladder. Obstruction of the cystic we have a field for experimental pioneer induces dropsy of the gall-bladder, emwork, the cultivation of which offers pyema, chronic cystitis, inflammation rich reward.
of its coats, including the peritoneal inWhat are the morbid conditions call vestment, perforation or gangrene, and ing for surgical interference ? By al the local and constitutional symptoms most unanimity of opinion, and specifi- incident to such morbid conditions. cally, according to an enumeration of Obstruction in the common duct inProfessor W. Mayo Robson, operative duces inflammation of the duct, exteninterference is indicated and the earlier sion of that inflammation to the peritothe better
neal investment, local peritonitis, adhe(a) “In cases of repeated attacks of sions and perhaps ulceration and perforabiliary colic, apparently due to gall- tion, dilatation of the duct, decomposistones, which, not yielding to medical tion of the retained products within the treatment, are wearing out the patient's duct, and systemic poison as a consestrength.
quence. From the irritation alone re(b) In perforation from ulceration. flex disturbances are not infrequent,
(C) When there is suppuration in the while the chills, fever, sweats, etc., neighborhood of the gall-bladder set up make a septic cholangitis, simulate so by gall-stones.
closely malarial, bilious and other fe(d) In empyema of the gall-bladder, brile manifestations. There is no jaunwhich is usually accompanied by peri- dice in cystic duct obstruction. Varytonitis.
ing jaundice in common duct obstruction (c) In dropsy of the gall-bladder. from stone, persistent, unvarying jaun
In obstructive jaundice, when dice in obstruction from neoplasms, be. there is reason to think that the com- nign or malignant, pressing on the tube, mon duct is occluded by gall-stones." is the rule.
The study of the subject of chole Obstruction of the common duct, from lithiasis and its consequences will be whatever cause, if persistent enough, facilitated if we keep in mind the fact dams back the bile, induces cholenia that the gall-tract is a drain tract, and its consequences ; not the least sethrough which the bile from the liver rious of which is its effects upon the and the mucus from the gall-bladder blood. must pass unobstructed, to ensure good We should remember that stones in health. Obstruction means the dam the gall-bladder do not necessarily give ming back of the outflowing products, rise to trouble. It is estimated that ten dilatation of the ducts or gall-bladder, per cent. of adult males, twenty-five per irritation of the tracts, suppuration in cent. of adult females, and thirty-six the tracts, extension of the inflamma- per cent. of the insane have gall-stones, tion to the peritoneal investment of the and only from one to two per cent. have tracts, adhesions and matting around symptoms of the same. While this es.
timate of cases giving trouble is too indications to be met by operative intersmall it helps to sustain the well known ference. It goes without saying that fact that many gall-bladders are full of not every case of cholelithiasis demands stones which are doing no harm, but an operation. Gall-stones in great numthen again they may give trouble by ir- bers are found in the gall-bladder withritation, accumulation, infection and in out having induced symptoms of their flammatory changes, often of an intense presence, the patient continuing in good type. Each attack of inflammation of health. Under such circumstances there the gall-bladder due to stones therein, is no indication and no need for surgical and with no obstruction, causes more or aid. Only when symptoms incident to less thickening of its walls and subse- gall-stones are marked and continuous quent contraction of the bladder until are we justified in interfering surgically. finally nothing remains but a bound down This justification will not, however, be tube. Stones in the cystic duct, or wanting sooner or later if obstruction stenosis, induce changes in the gall from stone, stricture or morbid growth bladder and duct, septic, ulcerative or exists. Under such circumstances intergangrenous and colic, frequent and ex ference is imperative. The sooner the hausting. Stones in the common duct better, and this conclusion is fully susinduce urgent symptoms and call for tained by the good results which are prompt relief.
daily accumulating. The dangers of cholelithiasis and its What are the operations applicable to consequences as grouped are:
the relief of gall-tract troubles? Prom(a) “That repeated attacks may and inent among the operative procedures not infrequently do exhaust the patient. which are now and have been in vogue Cases are on record in which the ex for the past ten years are cholecystotomy, treme vomiting and prolonged suffering cholecystostomy, cholecystectomy, choof one attack has terminated fatally. lecystenterostomy, and choledochotomy.
(6) Fatal cholemia, with its strong Of these the operations upon which most hemorrhagic tendency, both post- and interest is being centered, the comparaante-operative.
tive value of which is, to some extent, a (C) Distension of the gall-bladder un. matter of dispute, are choledochotomy til it enlarges sufficiently, in some cases, and cholecystenterostomy. Cholecysto reach to the pelvis, pressure effects in tenterostomy was an advance of no small cident thereto, and local and general proportions over cholecystostomy. The effects from the decomposition of its re technique of this operation, as now pertained products - i. e., empyema and formed, is so simple, where the gallcystitis."
bladder is not too much contracted ; its If we recall its rich lymphatic supply, immediate effects so strikingly we will readily understand the rapidly good, its execution attended with so occurring and serious systemic poison in little danger, that it was heralded as suppuration about the gall-tract. Mr. almost an ideal operation. Where the Tait and others have found stones in obstruction is in the cystic duct, when hepatic abscesses. It is easy to under the damage is due to retention of the stand that a stone formed and retained secretions of the gall-bladder, drainage in the hepatic duct may induce an irri- into the duodenum is a great improvetation and afford a suitable environment ment over drainage through an incision for the morbific effect of the common in the abdominal parieties. When the bacillus of the colon and other pathoge- obstruction is in the common duct, by nic germs. It is held by others, how. cholecystenterostomy the current of bile ever, that gall-stones are invariably is turned through the cystic duct and formed in the gall-bladder, as a result gall-bladder into the duodenum and its of the inspissation and sluggish flow of usefulness to the animal economy is not bile at that point.
lost, as is the case where it escapes by What operation shall be done, and means of a cholecystostomy. By it how it shall be done, depends upon the drainage of the suppurating gall-tract is
secured and systemic poison - i. e., nal canal. But a continued evolution cholemia and septicemia--are prevented. of the subject of the surgical treatment Its ease of execution, its minimum death of gall-tract diseases demonstrates to rate, and its immediate effects for good, the satisfaction of many, whose opinions mark it as an advance of large propor merit our regard, that cholecystenterostions. Nature pointed the surgeon to tomy is not an ideal operation. It has this way of draining the suppurating a limited scope of application, and is area around the gall-tract by not infre- only indicated for irremediable stenosis quently forming adhesions between the of the duct or where the impacted stone gall-bladder and duodenum and empty or obstruction, of whatever nature, caning the suppurating cavity into the in not be removed. The ideal operation testine. For years various operators contemplates restoring the gall-tract to have essayed to imitate nature by trying its natural state, reëstablishing it as to establish a gall-bladder and duodenal a drainage tract. This is accomplished anastomosis by sutures ; but not until by removing the obstruction — the cause the advent of that ingenious product of of the morbid changes -- which, in a American invention — the Murphy But majority of cases, is an impacted stone. ton – was the technique of cholecysten- The operation of choledochotomy — i.e., terostomy so simplified and so com incising the duct, removing the stone, pletely shorn of danger as to inake it safe immediate suturing of the duct, and almost in the hands of the novice. drainage, as a precaution -- is the ideal
Dr. Murphy enumerates the indica- operation. tions for cholecystenterostomy as follows: For a time surgeons hesitated to incise
1. “In all cases where it is desirable and suture the duct for fear of leakage to drain the gall-bidder.
of bile. Experience shows it to be safe 2. In all cases of perforation into the and curative in the full sense of the abdominal cavity where the duct must word. Curative, in that, not only is be obliterated by the reparative process. drainage secured, but the cause of the
3. In all cases of cholelithiasis where morbid condition, the stone - is reobstruction of duct is present, or where moved. As long as the stone remains the reflex disturbances of digestion are in the duct it is an irritant, and inflammarked.
mation, catarrhal or septic, and reflex 4. In all cases of cholecystitis, either gastric disturbances will continue. Chowith or without gall-stones.
lecystenterostomy does not remove the 5. In all profusely discharging biliary stone impacted in the duct, and this is fistulae, either following operations or the weak point which limits its applicaas a sequelae of pathological changes in tion. Cholodochotomy is safe. The gall-tract.”
mortality of incising and suturing the It will be seen that Dr. Murphy finds duct is less than eighteen per cent. in cholecystenterostomy by means of It is true that it is not always an easy his anastomosis button a means for the matter to find the duct and stone, and relief of a large portion of the morbid sometimes it is impossible either to loconditions incident to cholelithiasis. cate the stone or remove it after it is His contra-indications for its use are located, or to bring the bound-down mainly a too much contracted gall-blad duct into position to suture it; but an der to get the button in, where the ad. improved technique is rendering this a hesions are so extensive that we cannot less formidable objection to cholodochotget the duodenum up to the gall-bladder omy. Dr. Elliott of Boston finds great without risk of kinking it and inducing advantage in placing the patient in a reintestinal obstruction. Dr. Murphy him versed Trendelenburg position, and also self and many operators, especially in urges that the sutures to close the inci. this country, have furnished us with sion in the duct be passed before the example proof of the usefulness of this posed stone is removed. Some authors operation, which makes a new short claim that a cholecystostomy should route from the gall-tract to the intesti- be done in connection with incision and
suture of the duct, if we have an exist terostomy, with Murphy button, while ing empyema of the gall-bladder or sup it only relieves the consequences and purating cholangitis, for the better does not remove the cause, has saved drainage of the suppurating tract; but, and will continue to save lives, espeothers contend, if we remove the oh.
cially by tiding over desperate cases too struction in the tubes, that sufficient feeble from sepsis and cholemia to stand and curative drainage will go on through a prolonged operation. the natural tract without additional aid. In many of its details the technique While many are better satisfied to drain of the operation of choledochotomy is with gauze the area of the sutured duct
still imperfect, but, in spite of this, it is for a short time, still others, however, an ideal operation in its conception, and do not fear the leakage of bile and do a mortality of less than eighteen per not hesitate to close at once the abdo cent, is wonderfully encouraging as to
results. In this as in other fields of abAn objection urged against cholecyst dominal surgery the point should be enterostomy is the danger of infection of urged that fatalities are not due to the the gall-tract by the bacillus coli com operation, but to the want of its early munis and infection of the liver ; but, execution. While it is often impossible admitting this possible danger incident to make the diagnosis of cholelithiasis to establishing a short route for infection and its consequences, or utterly imposfrom the duodenum to the liver, it is of sible, in many instances, to differentiate small consequence compared to the good one morbid condition from the other, it resulting from free drainage in cases of is fair to assume choledochotomy will empyema and cystitis of the gall-bladder be more than ever an ideal operation from stenosis of cystic duct, or in cases when we can diagnose gall-tract disof cholangitis and cholemia from com eases before long existing cholangitis mon duct obstruction which cannot be and local peritonitis has bound down removed.
the duct, matted the parts in its neighCholedochotomy and cholecystotomy borhood, and poisoned the system by are, unquestionably, ideal operations septic or cholemic infection. where they can be done. Cholecysten
REMOVAL OF A PIECE OF PYLORIC allowed to run in. The occurrence of Mucous MEMBRANE BY THE STOMACH- vomiting while the tube is in the TUBE.- Ebstein (American Journal Med- stomach necessitates special caution. ical Science) reports a case in which this accident happened, the fragment being SEMINAL EMISSIONS.— Potassium brofound in the fenestrum of the tube. mide, says the Philadelphia Polyclinic, The case was one of chronic peritonitis the popular remedy, is often unsatisfacwith strictures and dilatations of the tory ; sometimes it even aggravates the duodenum. Death occurred from septic condition, perhaps deepens the despondperitonitis four days after a laparotomy. ency that commonly accompanies this Neither loss of tissue nor cicatrix could condition. A number of physicians be found in the stomach. Ebstein have given up the alkaline bromides, thinks this accident much more frequent preferring hyoscine, administering zón than is usually believed. Position and of a grain at bed-time. The effect is size of the stomach, and, as in the case nearly always favorable, and frequently reported, adhesion with neighboring or affords permanent relief. If hyoscyagans, favor the occurrence. The author mine is employed instead of hyoscine, it advises distention before passing the is important to stop short of the point sound in order to be able to form an where the physiologic effect of the drug idea of the extent and configuration of is manifested.
is manifested. One advantage is, either the stomach. The sound must be suffi hyoscine or hysocyamine properly adciently thin ; must not be removed too ministered can be continued for months rapidly, but slowly, and while water is without appreciable ill-effects.
VAGINAL SECTION AND DRAINAGE FOR PELVIC ABSCESS.
WITH REPORT OF CASES.
By T. J. Watktns, M. D.,
at St. Luke's, Lakeside, and Provident Hospitals, Chicago. Pus in the Fallopian tube, ovary or “I last saw Mrs. S. some three months pelvic cellular tissue will be considered
ago. She was in perfect health, and a pelvic abscess.
has had no return of the pelvic trouble." The object of this paper is to advocate Mrs. S. 0. was admitted to St Luke's vaginal section and drainage for excep- Hospital in January, 1895, suffering tional cases of pelvic abscess. Most of severely from disease of the left tube the literature on the treatment of pelvic and ovary, which were adherent in abscess through the vagina appeared be- Douglas' cul-de-sac. The uterus was fore the pathology of this condition was retroverted. Her temperature was norwell understood and before aseptic sur mal. Vaginal section revealed a small gery was practiced, and is therefore of abscess between the ovary and the poslittle practical value. Many gynecolo
Many gynecolo- terior vaginal wall, which was evacuated gists, among them our esteemed Presi and the sac thoroughly cleansed. The dent (" Treatment of Pelvic Abscesses separation of the adhesions about the by Laparatomy," Chicago Medical Re. ovary and thickened tube was followed corder, May, 1894, p. 295), advocate ab by restoration of the uterus to its normal dominal section in all cases of pelvic ab position and elevation of the left uterine
Dr. Clement Cleveland recently appendage. The right uterine appendread a paper on “ The Treatment of Pel. age was normal. The wound was packed vic Abscess by Vaginal Puncture and
Recovery from the operaDrainage" (New York Journal of Gyne- tion was satisfactory, and the uterus cology and Obstetrics, June, 1894, p. 652), and appendages remained in normal in which he demonstrated that the opera position.
position. Recent examination shows tion was a valuable procedure in selected some thickening to the left of the uterus, cases.
which does not occasion any special disA brief report of a few cases of pelvic tress. The operation was made for exabscess which I have treated by vaginal ploration. The ovary and tube did not section and drainage will, I think, facil appear to be so diseased as to indicate itate the presentation of the subject. excision.
Mrs. S. was referred to me by Dr. Mrs. S., aged 28, patient of Dr. Joseph A. W. Bigelow in May, 1893. Exami Trenchard, had a large abscess which nation showed an abscess filling the en filled the pelvis, pushed the vagina fortire pelvis, pushing the uterus and va ward, and extended to the perineum. gina forward, and extending above the The abscess had occasionally discharged brim of the pelvis on one side. The ab through the rectum. The patient was scess was of long standing and the pa emaciated, temperature 100° to 103°, tient feeble and emaciated from sepsis. pulse rapid and weak. In February, Vaginal section was performed with 1894, I made vaginal section, irrigation irrigation and drainage. About one and drainage. The abscess contained pint of pus was evacuated ; operation ex- about one pint of offensive pus and tra-peritoneal. The patient made a rapid liquid feces. The patient made a rapid and complete recovery. The drainage and uninterrupted recovery and the tubes were removed in about four weeks. drainage tubes were removed about four Dr. Bigelow reported on April 11, 1895 : weeks after the operation. At this time