BMJ (Clinical Research Edition)
668 MAY 15, 1920 AIR-WAY INFECTIONI. E THBm --v -I M~~~~~~~~~~~~~~~~~EDICAL JUR pressure inside the ducts. Kocher's incision was adopted; a vertical inoision had been used at the first operation. The gall bladder was very large, the common bile duct was distended, no stone could be felt at first, but later, on feeling the third part of the duodenum, 'a large'stone was felt evideintly at the end'of a very much elongated bile duct or pedunculated papilla. With some difficulty the pedunculated
... he pedunculated part of the duct was steadied with one hand while the stone was squeezed back into the duct with the other. In this way the need of opening the duodenum was avoided, and the stone then extracted from the first part of the common duct. In order to avoid recurrence, the ducts having been proved to be clear, the gall bladder was removed, and the common bile duct drained. The stone was the size of a filbert. The patient wrote on March 1st, 1920, stating that: " Since my second operation there has been no looseness of bowels, and the appetite became very moderate. The motions are always uniformly stained dark-brown with bile. Unless the gall bladder has some beneficial secretion of its own-I have only heard of mucus-I think we should be better without it." CASE II.-Cholecystostonmy: Cholecystectonmy: Choledochotonty. Mrs. J., aged 52 years, was a patient of Dr. Talfourd Jones. After sufferiug some twenty years from symptoms of gall stones with intermittent attacks of jaundice and colic, she had been operated upon by a woman surgeon in March, 1916. Cholecystostomy was then performed and several stones removed from the gall bladder. The attacks continued. The second operation was performed in January, 1917, by the same surgeon, who then removed the gall bladder. The attacks continued. The patient had a slight attack of jauindice while she was still in the hospital. On several occasions she has been deeply jauindiced, and has suffered very severe colic. She has been very reluctant to consider another operation, but slhe found life intolerable, and at last consented to see me. A vertical incision had been adopted at the former operation. She was admitted into Guy's Hospital in November, 1919. Kocber's incision. Six stones removed from the common bile duct, the stones serving as excellent guides to the dilated common bile duct, although the gall bladder had been previously removed. The patient made a good recovery, and has remained well since. It is probable that a larger and more suitable incision would have eniabled the surgeon to find and remove the stones from the common bile-duct at the first or second operation. CASE III.-Gall Stone in Neck of Gall Bladder: Cholecystectomny. Mrs. A., aged 45, patient of Dr. Phillips, Croydon. She had had three children, and is a very active woman who eats very little owing to indigestion. She has never had a bilious attack, but often has slight attacks of diarrhoea. On the evening of November 7th, 1915, she ate a piece of unripe pear. At 1 a.m. on November th she was seized witb violent abdobainal pain, and did not sleep again. She got up and went into another room and lay on a bed there, but could not sleep. She was sick a good many times. She then went downstairs and lay before the gas fire, as she was so very cold and in much Pain. She did not bring up anything but watery fluid, and later bile. Dr. Phillips saw her in the early morning, and thought she had intestinal colic due to the pear. The pulse and temperature were subnormal and she was cold. As she was very tender in the epigastrium, he wondered whether she had a perforated gastric ulcer, and got Dr. Male to see ber. Dr. Male found that the tenderness and pain were then lower down towards the appendix, and he suggested an operation for (?) acute appendicitis. I saw her at 4 p.m. on November 8th, and felt two swellings, which Dr. Male and Dr. Phillips had also felt, in the right flank. Dr. Phillips thought that they might be seybala or a piece of pear, and found that they were movable. After getting the abdomen thoroughly relaxed, I was able to make out that the swelling was of the same size, shape, and attachments as the gall bladder, but it was lying very far back and a little lower down and farther out than usual. As I felt it the patient was seized with nausea and vomiting, and the consistence of the swelling seemed to vary. Once it seemed to consist of one lump, and another time of two. At the operation this was explained, for I clearly felt the fundus and at times also the bend of the neck of the gall bladder. I diagnosed gall stones impacted in the cystic duct, and advised an immeliate operation, as the patient was so ill and woulA probably get worse. After some delay she was moved to a nurslng home. Operation. Dr. Male gave the anaesthetic (November 8th, 1915). The gall bladder having been more definitely made out under the anaesthetic, a Kocher incision was made. The gall bladder was found. It was considerably enlarged, uniiform in shape, and very oedematous. There was also some bloody fluid in the kidney pouch. A stone was felt impacted in the neck of the gall bladder. This was backed a good deal, but in view of the absence of stones in the common bile duct and the pendulous nature of the gall bladder, it was clearly safer to remove the latter, and this was done in the usual way, the raw area on the under surface of the liver being covered over with peritoneal flaps sewn with catgut. The abdominal wall was closed as usual, but a small tube was left at the inner anld upper angle of the wound. S3he made a good, rapid, and complete recovery, and is now well, four and a half years later.