Tubercular Joint Disease, Contraction of Arteries Probable Cause of Muscle Atrophy

Ventro-fixation of Meso-rectumin Case of Prolapsus Recti.

NOTE-July number was wrongly paged; it numbers 371 to 448,

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A FURTHER CONTRIBUTION TO THE SURGERY OF THE GALL DUCTS AND GALL BLADDER.

By J. F. W. Ross, M.D. TOR.,

Professor of Gynaecology and Abdominal Surgery, Woman's Medical College; Surgeon to St. John's Hospital, Toronto General Hospital, and St. Michael's Hospital.

THE CANADIAN PRACTITIONER for April, 1894, I recorded several cases of removal of gallstones. In various discussions I have expressed opinions that, in the light of riper experience, may be to some extent modified. The surgery of the gall bladder itself is fairly well established, but the surgery of the ducts is still in process of evolution. In a few years' time we will have the surgery of the gall ducts placed on a Sound basis; we will have eliminated errors and have accepted truths. The following are cases operated on since the publication of the former

article

Miss E. Operated on on the 22nd of March, 1894, for the removal of gallstones. (See plate, Fig. A.) The case was previously reported, and, at that time, it was stated that a fistulous opening still remained. The bile flowed when the patient was in the recumbent posture, and ceased flowing when she assumed the erect posture. Bile passed into the bowels, showing that the common duct was pervious. I decided that it was possible to close the fistula without establishing any anastomosis with the bowel. I considered that the intermittence in the flow was due to the fact that when in the erect posture the gall bladder drew down the common duct and influenced its valvular folds in such a way as to permit the onward flow of the bile into the duodenum. Without such evidence as this of the intermittence of the flow, it would have been dangerous to close the external fistulous opening.

On the 14th of January, 1895, ten months after the original operation, assisted by Dr. A. H. Wright, I opened the abdomen to the inner side of the old scar. The bowels were found firmly adherent around the adhesions of the gall bladder to the skin; they were peeled off until the gall bladder itself was freed. The gall bladder was firmly adherent to the edge of the liver. The opening into the gall bladder was enlarged, and the finger introduced to ascertain its condition and determine the presence or absence of another stone. There was no stone present. The opening into the gall bladder was now closed by two rows of suture of fine black silk thread; the continuous suture was used, and the two ends with which it was begun and ended were drawn through the external wound to assist in its subsequent removal. There was no further leakage of bile. Patient made an excellent recovery, and is now in perfect health.

This case demonstrates the fact that a leakage of bile may take place after cholecystotomy, when there is no obstruction in the common duct, and that such leakage may be terminated without resorting to the operation of cholecystenterostomy.

Mrs. C., æt. 29, referred by Dr. Hillary, of Aurora, married two years, one child seven months old. When six months' pregnant had a very severe attack of pain at the pit of the stomach; this lasted from two to three hours. Was not jaundiced. After the birth. of her child she suffered from another attack; then several attacks followed, each lasting from two to three hours. Was jaundiced on two or three occasions; with the jaundice the discharge from the bowels was light clay-colored and pasty, urine dark colored. Diagnosis of gallstones was made and operation advised. No mass could be felt.

Incision made in the usual inclined position on the right side, gall bladder drawn up into the incision, and, by pinching it together, several small gallstones could be felt. These were very small (see plate, Fig B),

not larger than the ordinary quarter-grain morphine pills; they were eight in number, and were removed. Gall bladder was short, barely reaching the incision. A drainage tube was inserted into its cavity. Patient made an excellent recovery, and, in a letter dated Dec. 9th, 1895, the husband says: "My wife is in fine health, and I am ever grateful to you."

Mrs. P., æt. 48, referred by Dr. Stuart, Newmarket, married twentyfour years, has three children. Complains of pain in the right side, often suffers from severe pain; suffered from the last attack three months ago, was at that time very tender to touch over the abdomen. The pains come on suddenly and without warning.

Never jaundiced.

On examination a lump to be felt below the edge of the liver. As the kidney could be felt on the same side, I decided that this was a distended gall bladder. Advised operation.

Operation on Oct. 30th, 1895, at St. John's Hospital, assisted by Dr. Davidson. Made an incision along the edge of the costal cartilage on the right side in the usual position.

Found the gall bladder adherent to the liver, and enlarged and thickened. Removed thirty-five stones from the gall bladder and one stone from the cystic duct (see plate, Fig. C). The stone impacted in the cystic duct was firmly fixed, and, owing to the length of the gall bladder, it was very difficult to remove it. By steadying the duct with the stone in it with the fingers of the left hand, and by the use of the scoop passed into the gall bladder, it was finally dislodged. It showed evidence of having been in this position for some time, as it was eroded on its surface. Gall bladder drained. Gall bladder was full of pus. Patient made an uninterrupted recovery, and returned home in good health.

Mrs. S., at. 6. Mother of three children, last one born twenty five years ago. Four years ago had an attack of severe pain and vomiting, followed by jaundice. The jaundice continued for two weeks. Eleven months ago she suffered again from severe pain and sickness of the stomach; chills and fever came on. Pains of a spasmodic nature recurred once a week; stools became pasty and clay-colored at times. Has now suffered from continuous jaundice for two months with high-colored urine and clay-colored motions; has lost weight, suffered from bleeding at the nose, and suffers intensely from irritation of the skin. An indefinite mass to be felt under the edge of the liver. Diagnosed distended gall bladder ; obstruction of the common bile duct by stone. Advised operation. I decided, owing to the condition of the patient, to drain the gall bladder and relieve the jaundice at the first operation, and, on a subsequent occasion, to return and remove the obstruction. The patient's health was such that no prolonged operation could be thought of, and, owing to the Intense and long-continued jaundice, hemorrhage would necessarily be an element of danger.

On November 6, 1895, at the Toronto General Hospital Pavilion, assisted by Dr. Temple, I performed cholecystotomy, and removed one large gallstone (see plate, Fig. D) from the mouth of the cystic duct. The bleeding was troublesome, and the operation performed with as much despatch as possible. The patient recovered, jaundice disappeared, and her health became greatly improved. Bleeding at the nose and

irritation of the skin ceased, but the stools remained clay-colored.

On the 14th of December, 1895, or six weeks after, I made another incision just below the scar of the first one, and opened the abdomen. The omentum was found firmly adherent to the surface of the liver; this was peeled off, and the liver surface bled freely. The duodenum was found adherent to the under surface of the liver, and, after a good deal of difficulty, was separated. Stomach and ducdenum were now drawn out on to the abdomen, and a stone was found impacted in the common duct, and the common duct was found lodged in a bed of adhesions. These were separated to a sufficient extent to permit the fingers of the left hand to raise it. A small bladed knife was then inserted after the passage of a purse-string suture around the portion of the duct it was intended to open. The opening was enlarged by stretching with a pair of forceps. A small scoop was then inserted and the stone removed. The stone was broken down and removed in pieces, so as to avoid the necessity of a larger incision. The purse-string suture was now tied, the orifice closed, superficial sutures placed to further insure the complete closure of the opening in the duct. The stomach and omentum were replaced in the abdomen and the wound clo: ed. A drainage tube was placed in the undisturbed and adherent gall bladder to allow of the ready outward flow of bile and minimize the dai ger of extravasation of this fluid into the peritoneal cavity. The operation was an extremely difficult one, as it was necessary to work so far up under the liver. Operation consumed one hour and fifty five minutes.

As the bile did not flow freely from the tube after the first twentyfour hours, the tube was removed for fear that it might be blocked; it was found open from end to end. For the first few days the bile alternated in its flow, at times escaping through the opening of the gall bladder, and at other times apparently flowing on through the now pervious common duct into the duodenum. The first motion from the bowels still remained clay-colored. They then became streaked with bile, and the bile then passed through without any obstruction.

made a excellent recovery.

There are several questions that arise in the mind of an operator. First, in the presence of profound jaundice, should we proceed to perform what is a difficult and prolonged operation-the removal of a stone