Cases of Cholecystotomy

GEORGE W. GAY
1892 Boston Medical and Surgical Journal  
Mrs. O, aged thirty, was under Dr. Clement's care for about two months before she entered the City Hospital. Her symptoms were : severe pain, jaundice, obstinate vomiting, emaciation, debility, tenderness over the gall-bladder (but no distinct tumor), faeces claycolored, and urine dark brown, evidently due to bilepiginents. A judicious trial of the usual remedies had tailed to give any permanent relief. The day after entering the hospital the gall-bladder was opened by an oblique incision four
more » ... ique incision four inches long, au inch below the ribs, and commencing about an inch to the right of the median line. The lower edge of the liver projected an inch below the ribs. The gallbladder was readily found. It was not distended, and on being caught in a loop of silk and opened, was found to contain only a drachm or two of thick bile. No calculus could be detected by the finger outside the duct, nor by a long probe passed into it. After irrigating the cavity of the gall-bladder with warm water, a small stone was easily detected with the probe and removed. It was broken by tho forceps during tho extraction, but was estimated to be about the size of a large pea. The gall-bladder was stitched to the abdominal walls, and tho wound closed around the drainage-tube in the usual way. The convalescence was uneventful. Jaundice was a good deal diminished in two weeks, and bile was apparent iu the stools. In four weeks the discharge from the wound was very slight, and the skin was about normal. She was up about the ward iu a short time, and was discharged nearly well in seven weeks. At the end of three mouths the patient is well. The wound is entirely healed, and she is iu her usual health. It should bo stated that this patient had previously undergone laparotomy for tho removal of " pus-tubes." s Mrs. G., also a patient of Dr. Clement's, aged fiftynine, was seen in consultation in July, 1891. The present attack was of nine months' duration, and was the fourth in as many years. The usual symptoms were present, to wit: jaundice, vomiting, pain, exhaustion, loss of appetite, high-colored urine, palo faeces, and some emaciation. Being a very fat woman, no tumor nor area of dulness could be determined. Operation July 5th. A vortical incision five inches long through \ury thick walls was carried down to the liver. Firm and extensive adhesions existed everywhere. In separating them with the linger below the liver, a profuse haemorrhage was brought on, which threatened to terminate her life upou the table. Nothing could be seeu on account of the free bleeding, and no gall-bladder nor foreign body could be felt iu the mass of fat omontum and adhesions. As the patient was failing the operation was reluctantly abandoned. The wound was packed with baked gauze, and covered with a large mass of the same material. Stimulants were freely given. She rallied somewhat for a few days, but never sufficiently to justify further efforts to find tho gall-bladder and the obstruction. A low muttering delirium set iu, and the patient died at the end of ten days. An autopsy revealed the presence of a calculus, about the size of a hazel-nut, in the common duct. In the few cases of cholecystotomy that 1 have seen, the gall-bladder has not been distended, even though the jaundice has been most profound from the presence of gall-stones. On the contrary, in the case of a young lady upon whom 1 performed this operation several years ago, no stone was found, nor had she ever had jaundice. Yet the gall bladder was enormously distended by about three pints of thick bile. She recovered, and remains well at the present time. In oue case of gall-stones, which was under my care many years ago, the ulcération extended in various directions. Calculi not only came through the opening in the skin, but several were coughed up. At the autopsy the gall-bladder was found to be entirely obliterated. October 17, 1891, I was asked by Dr. Edwards, of North Chelmsford, to do an operation for abscess of the liver. The patient, F. M., a man aged thirty, was just recovering from a moderately severe attack of typhoid fever, when Dr. Edwards, his attending physician, discovered upon the right side a tumor, with distinct fluctuation, extending from the free border of the ribs to tho median line, and a short distance below the umbilicus, and nearly to tho pelvis on tho right. Dr. Edwards aspirated, and drew olf about one quart of pus. Two weeks later, when 1 saw the patient, the tumor had regained its former size ; the abdominal walls were evenly distended over it; there was no place showing any tendency of the abscess to point. An incision, three inches long and about two inches to the right of the median line and below the border of the ribs, was made. A large quantity of pus, about one quart, was discharged. The enormously enlarged liver was so completely adherent to the abdominal parietes that no precautions to prevent an escape of pus into the abdominal cavity were necessary. The abscess cavity was thoroughly irrigated, and a glass drainage-tube inserted. The patient made an excellent recovery. A second case of liver-abscess I saw December 7, 1891. Mr. M., of Lowell, aged sixty, had had during the past ten years several attacks of icterus, which had speedily cleared up. He had never sulfered from biliary colic. Previous to December 7th, he had, for two weeks, severe and continuous pain in the right shoulder. At the time 1 saw him his skin was but slightly tinged with bile. A large, fluctuating tumor occupied the upper and right side of the abdomen, extending nearly to the pelvis. As in the preceding case, a long incision was made and about three quarts of pus escaped. The abscess cavity was thoroughly drained; but a large amount of pus continued to discharge, and the patient died of exhaustion, February 27th. I am uucertaiu whether death was due to the continued formation of pus or to the extensive destruction of liver-tissue that had occurred. Iu this case, too, the abscess wall was so closely attached to the abdominal as to preveut any escape of pus withiu the cavity of the abdomen.
doi:10.1056/nejm189204281261706 fatcat:ob3w4zpwh5ctpclmexujjtjvzq