Two Cases of Cholecystotomy

1897 Boston Medical and Surgical Journal  
ecchymosis marking the track of the bullet. Discharged well in 18 days. Case II. A boy, fifteen years old, was shot oue and one-half hours before entrance, from a point four feet distant; the weapon was a revolver of 22-calibre. Pulse 100, respiration 24, temperature 100.4°. A circular wound, 3£ inches above the pubes and slightly to the left of the median line. Although the peritoneal cavity had been perforated, there was no gaseous or fecal extravasation nor hemorrhage. Laparotomy. Inspection
more » ... arotomy. Inspection of the intestine revealed two double perforations of the ilium, which were closed with fine silk sutures. At another point the peritoneal covering of the intestine had been lacerated by the forcible embedding of a small piece of cloth and metal. These were cautiously removed without disclosing an opening into the gvA, and the wound was closed by Lembert stitches of fine silk. There had been no hemorrhage or extravasation of intestinal contents into the peritoneal cavity. The bullet was not found. Recover}' uneventful. The bowels moved from the third day. There was no wound of exit, but the x-ray showed the location of the bullet deeply imbedded at the right of the sacrum, proving that it had crossed the pelvis. Case III. A boy, sixteen years old, entered the hospital on the following day, oue hour after accidentally discharging a pistol of 32-calibre while withdrawing it with his right hand from an abdominal belt. Pulse 100, temperature 100°, respiration 16. A circular wound, with blackeued edges that would admit the end of a lead-pencil, was found on the left side of the abdomen, two inches from and a little above the anterior superior spinous process of the ilium. The clothing over the wound was blackened and charred. After sterilizing the wound, a probe was entered and passed obliquely downward for two inches to the ilium. This track was laid open, and found to reach the peritoneum without perforating it. The direction of the bullet continued through a perforation of the bone, aud was lost in the muscular structures outside of the hip. A counter-opening was made and the wound dressed. Bowels moved after the third day. The bullet was subsequently discovered by the x-ray at the inner side of the great trochanter about an inch below the surface, whence it was removed, its course having described nearly a half-circle. Recovery and discharge from the hospital at the end of five weeks. age forty-seven, had been a patient of mine for over a year preceding her first attack of biliary colic, February 7, 1896. Her symptoms from the first had suggested cholelithiasis ; but as jaundice had never appeared, no positive diagnosis had been made. This first attack of colic, however, left no doubt as to the nature of her malady. I be pain was intense, and the fever and pulse charts showed a high degree of inflammation of the biliary passageseven to the extent of suppuration, it was feared at the time. For five days the temperature ranged from 100°to 104°, aud the pulse from 100 to 130. After three weeks' prostration she was able to be about again, but an exquisitely tender spot in the right hypochondriac region continued to harass her from this time forth. No jaundice occurred at any time. On May 24th she had another attack, similar in character, and confining her to her bed for a month. Through the summer she lived in constant dread of another prostration, and constantly embarrassed in her work by.the sharp stabbing pain in the right side that ensued upon any active exertion. As there was no improvement in her coudition, and as she was almost incapacitated from attending to her duties as housewife, she readily consented to undergoing the operation of cbolecystotomy, preferring its risks to her constant suffering. September 12th was finally agreed upon, and after two days' preparation of the patient the operation was begun upou an improvised table set up in the " front room " of the farmhouse where she lived. She was etherized ; her shoulders were raised upon an inclined plane of about 35°, and attached by straps passing under the arms. A vertical incision, four inches long, was made in the right linea semilunaris, just under the ribs, through one aud a half inches of subcutaneous fat. The enlarged left lobe of the liver aud the iuterlobar notch were revealed. The hand was then introduced in search of the gall-bladder, and a hard mass, the size of an egg, was found eight inches below and to the right of the wound. Adhesions were mauv. but were gradually separated by the fingers, and the mass was drawn up to the incision. It proved to be the gall-bladder, with apparently but one large stone enclosed. After careful walling off with gauze about the gall-bladder, it was incised. The walls were vascular and one-eighth of an inch in thickness, but healthy appearing. The stone was revealed ; it was the size of a pigeon's egg, symmetrically ovoid, with two facets (weight 260 grains). The gall-bladder was almost entirely filled by it. The ducts were then palpated, aud other stones located in the cystic duct. These were firmly imbedded and enveloped, about the size of chestnuts. Gradually these were loosened by deep manipulation, "milking" them back into the gallbladder, and with considerable difficulty, owing to the fat abdominal wall aud large liver. The first stone was crushed, the second extracted entire (weight 26 grains). A sound was then passed without obstruction the full length of the cystic and common ducts. Hepatic duct seemed clear. Nothing further made out. The bile now began to well up freely into the gall-bladder, but was restrained by gauze packing uutil a continuous catgut suture was placed through the muscular coat of the viscus, finally closing in the whole gall-bladder incision. Then a close continuous suture of fine silk was taken through the peritoneal coat, folding in and burying the catgut suture. The gall-bladder gradually became distended with bile, and as no leakage was observed and the seam appeared to be tight and safe, the whole was dropped back into the abdomen. A wick of iodoform gauze aud a rubber drainage-tube were then carried down to the proximity of the gall-bladder, aud the abdominal wound was closed, leaving only the small opening at the lower angle for the exit of the tube and wick. Large absorbent dressing applied. Patient in good condition. Pulse 112 aud irregular; dropped to 100 and regular in two hours after enema of hot coffee and brandy. September 13th. Temperature 100.8°, pulse 96. Passed a good night ; slept six hours. The dressing was soaked with bloody serum. No trace of bile. Fresh dressing and pad.
doi:10.1056/nejm189710071371504 fatcat:k5ltmpw6jvasbiepe3gax2wq44