■:^^^. IMAGE EVALUATION TEST TARGET (MT-3) % 1.0 1.1 Iff Kii 12.2 us Li i2.0 I Lis III u ,j4 < 6" ^ VV^ ? Photographic Sciences Corporation 33 WIST MAIN STRUT wnSTIi.N.Y. MSIO (71«) •73-4503 rF^%^ CIHM/ICMH Microfiche Series. CIHIVI/ICMH Collection de microfiches. Canadian Institute for Historical Microreproductions / Institut Canadian da microraproductions historiquas Tuchnical and Bibliographic Notaa/Notaa tachniquas at bibliographiquaa Tha Instituta haa attamptad to obtain tha baat original copy availabia for filming. Faaturaa of thia copy which may ba bibliographically uniqua. which may altar any of tha imagaa in tha raproduction, or which may significantly changa tha usual mathod of filming, ara thackad balow. r*~] Colourad covars/ 1^1 Couvartura da coulaur I I Covars damagad/ D D D D Couvartura andommagia Covars rastorad and/or laminatad/ Couvartura rastauria at/ou palliculte r~1 Covar titia miaaing/ titra da couvartura manqua r~~\ Colourad mapa/ Cartas gAographiquaa wt coulaur Colourad inic (i.a. othar than blua or biacic)/ Encra da coulaur (i.a. autra qua blaua ou noiral rn Colourad platas and/or illuatratlona/ Planchas at/ou illustrations an coulaur Bound with othar matarial/ Ralii avac d'autraa documants Tight binding may cauaa shadows or distortion along intarior margin/ Laraliura sarria paut causar da i'ombra ou da la diatorsion la long da la marga intiriaura Bianit laavas addad during rastoration may appaar within tha taxt. Whanavar possibla. thasa hava baan omittad from filming/ II sa paut qua cartainaa iMgaa blanchas ajoutiaa lors d'una raatauration apparaiaaant dans la taxta. mais. lorsqua cala 4tait possibla. cas pagaa n'ont paa *t« filmAaa. Additional commants:/ Commantairas suppl4mantairas; L'Instltut a microfilmA la maillaur axemplaira qu'il lui a iti possibla da sa procurer. Las details da cat axamplaira qui sont paut-Atra uniquas du point da vua bibliographiqua. qui pauvant modifier una imaga raproduita, ou qui pauvant axigar una modification dans ia mithoda normala da fiimage sont indiquAs ci-daasous. r~~1 Colourad pagas/ D This itam is filmed at tha reduction ratio chaclced below/ Ce document est filmA au taux da rMuction indiquA ci-dassous. Pagaa da coulaur Pagaa damaged/ Pagas endommagAas Pagas restored and/oi Pagas restaurAas at/ou palliculAes r~n Pagaa damaged/ I — I Pages restored and/or laminated/ Pagas discoloured, stained or foxed/ Peges dAcolorAes, tachatAes ou piquAes □ Pages detached/ Pagas dAtachias QShowthrough/ Transparence □ Quality of print varies/ QualitA inAgaia da i'impression □ Inductee supplementary material/ Comprand du matAriel supplAmentaira □ Only edition available/ Saula Adition disponible Pages wholly or psrtiaily obscured by errata slips, tissues, etc., have been refilmed to ensure the best possible image/ Lee pagaa totalement ou partiellement obscurcies par un feuiliet d'errata. una pelure, etc., ont AtA fiimAes A nouveau da faqon A obtenir ia mailleure imaga possibla. 10X 14X 1SX 22X 2tX 30X 12X itx aox a«x 28X 32X Th« copy filmed hw has lM«n r«produe«d thanks to ths gsnsrosity of: Mfldical Library McGill Uniranity Montreal Tho imagos sppoaring hora ara ttw baat quality poaaibia conaldaring tha condition and tagibiilty of tha original copy and in icaaping with tha filming eontraet spacifieationa. L'axampiaira fiimA f ut raproduit grica k la ginAroaitA da: Madical Library McGill Univanity Montraal Las imagaa suhrantaa ont 4ti raproduitaa avac la plua grand soin. eompta tanu da la condition at da la nattat* da l'axampiaira fiimA. at w% eonformiti avac laa conditiona du contrat da fllmaga. Original copiaa in printad papar covars ara filmad beginning with tha front covar and andlng on tha laat paga with a printad or illuatratad impraa- sion, or tha bacic covar whan appropriate. All othar original copiaa ara filmad baginning on tha first paga with a printad or Illuatratad impraa- slon, and andlng on tha laat paga with a printau or Illuatratad impraaaion. Laa axampialraa originaux dont la couvartura it papiar aat ImprimAa sont fllmte an comman^nt par la pramiar plat at an tarminant aoit par la damMra paga qui compona una amprainta dimpraaaion ou dllluatration. soit par la tacond plat, salon la eas. Toua laa autras exampialraa originaux sont film4a an comman9ant par la pramlAra paja qui comporta una amprainta dimpraaaion ou d'lHuatration at an tarminant par la damMra paga qui comporta una taiia amprainta. Tha laat racordad frama on aaeh mierofleha shall contain tha symbol *-^ (moaning "CON- TINUEO"). or tha symbol ▼ (moaning "END"), whichavar appilaa. Un daa symbolaa suivants apparattra sur la damiAra imago da chaqua microficha. salon la caa: la symbolo -«> signifia "A SUIVRE". la symbols ▼ signifia "nN". Maps, plataa, charts, ate., may be filmed at different reduction ratioa. Thoae too large to be entirely included in one expoeure are filmed beginning in the upper left hand comer, left to right and top to bottom, aa many fra m ee aa required. The following diagrama illuatrate the method: Lee cartee. planchee, tableeux, aw., peuvent itre fiimde A dee taux do rAduction diff Arenta. Loraque la document eet trap grand pour Atre reproduit en un soul cllehA, il aat filmA A partir da I'angle supArieur gauche, do gauche A droite. et do haut mt boa. an prenent le nombre dtmegoe nAceeaaire. I.as diagrammes suivanta INuatrent la mAtlwde. 1 2 « 3 1 2 3 4 8 6 Mf!"-- (i-7. ,\ A CASE OF CHOLECYSTENTEROSTOMY PERFORMED WITH MURPHY'S BUTTON; DEATH FBlOM HAEMORRHAGE ON FOURTH DAY. By FRANCIS J. SHEPHERD, M.D., CM., OF MONTREAL, SURGEON TO THE MONTREAL GENERAL HOSPITAL; PROFESSOR OF ANATOMY AND LECTURER ON OPERATIVE SURGERY IN MCGILL UNIVERSITY. OWING to the fact that we only read of the successful cases in which Murphy's button has been used, it seems to me fitting that the following fatal case from a hitherto not much noticed cause should be placed on record. The button was made by J. J. Ryan, of Chicago, and was a No. i of the series. Mrs. J. F., aged thirty-six years, came to me in August, 1894, complaining of jaundice and a swelling in right side of abdomen. She gave the following history : In January, 1893, had a severe attack of fever, which was fol- lowed by jaundice and a very uncomfortable feeling along the right side of the abdomen. Later this feeling developed into a severe pain. After lasting four months the jaundice disappeared entirely. During the winter of 1894 she again had pains in the right side of the abdomen but no jaundice. These pains were described as of a gnawing character. In June, 1894, was troubled with indigestion, nausea, and vomiting, continuous high temperature, and with pains in right side of the abdomen. In July of this year first noticed a lump in right hypochondriac region and a continuous soreness, which was relieved by hot applications. The lump itself was freely movable and not at all tender to the touch. This lump has been continually increasing in size. On examination patient was found to be deeply jaundiced, much emaciated, and on examining her abdomen a large pyriform swelling was felt on the right side, continuous with the liver and extending down below the umbilicus. It was elastic and freely movable, and FRANCIS J. SHEPHERD. was dull on percussion, the dull note being continuous with the liver dulness. Having decided that the tumor was an enlarged gall-bladder, operation was recommended and agreed to. She was admitted into the Montreal General Hospital, and operation was performed August 30. Incision over tumor, which was, as diagnosed, a distended gall- bladder. This was incised, and nearly a pint of bile evacuated, with some very small gall-stones. The obstruction in the common duct was then sought for, and a hard lump found the size of a small almond near the entrance of the duct into the duodenum, and some lumps higher up, which it was supposed might be enlarged glands. The lump near the pancreas was thought might be the obstructing stone ; so padded forceps were used to break it up, without result. It was then decided to sew the gall-bladder to the skin incision and insert a drain. The case progressed well, all the bile, of course, coming through the tube. The patient soon got an appetite, gained flesh, and lost her yellow color. She went home September 29, with the bile still flowing from the wound. It was suggested that at some future time a cholecystenterostomy might be performed if the bile fistula did not close. The stools were slightly colored. In three months, November 28, she returned, saying she had never felt better in her life, and she looked strong and robust, having gained considerably in weight since she left the hospital. Her bowels had been irregular, in fact inclined to diarrhoea. She said she was tired of having a continual discharge of bile, and desired the opera- tion I had mentioned to her when she left the hospital in September. I agreed to perform a cholecystenterostomy, and decided to make use of a Murphy button. Operation December 3, 1894, assisted by Dr. Armstrong. An incision was made inside the first one, and the bladder was seen attached to the abdominal wall. On examining the site of the lump previously felt, one came down on a large mass, the size of one's fist, which apparently involved the head of the pancreas and duodenum. Being now certain that the case was one of malignant disease, and that all measures for relief could only be temporary, it was decided to unite the gall-bladder with the colon instead of the duodenum, as being easier and more rapid and quite as beneficial. The button was introduced without very much difficulty, the purse-string suture being CHOLECYSTENTEROSTOMY WITH MURPHY'S BUTTON. first inserted. Owing to the thickness of the gall-bladder there was some puckering, and the parts did not come together without con- siderable pressure on the button. At one point in the colon where the button could be seen easily through the bowel, a few Lembert sutures were placed. It was decided not to close the fistulous opening which had existed during the past three months, as it was fe?t this would close of itself after free communication was established between the gall-bladder and bowel. On dropping back the bowel and gall- bladder with the button, there was no pulling or tension, and the parts seemed to be in accurate apposition and to lie comfortably. The wound was closed with layers of buried sutures. The patient went on well for four days, felt bright, and was cheerful ; no sickness, no abdominal distress, and good pulse. There was also no bile discharging from the fistulous opening. On the morning of the fourth day some blood was noticed oozing through the dressings. This seemed to come from the fistula leading to the gall-bladder and also from the abdominal wound. The blood was bright red, and on squeezing the abdomen gently a huge clot was forced out of the gall-bladder. This was carefully packed with iodoform gauze, and the abdominal wound examined and some stitches removed. Here was also found a blood-clot, but on its removal no further haemorrhage was apparent. The same evening my house surgeon called me up, saying my patient was again bleeding freely from the wound. On reaching the hospital I found her much blanched, sighing, and almost pulseless. Blood was rapidly oozing from the fistulous opening and wound. It was decided to reopen the wound and arrest the haemorrhage if pos- sible. On opening the ab'omen a large clot was found about the seat of the anastomosis, r d the gall-bladder was distended with blood-clot. There were foi nd no signs of sepsjs, the peritoneal cavity being perfectly normal. On examination of the button anas- tomosis the origin of the haemorrhage was at once found. The button had cut through the thick and friable gall-bladder and could be easily seen. The haemorrhage came entirely from the gall-bladder. To remove the button the tissues of bowel and bladder had to be in- cised and the button unscrewed. Feeling that it would be useless to reinsert the button, it was decided to sew up the incisions in the gall- bladder and colon, and to allow things to remain as they were before operation. The wound in the colon was closed easily enough, but that in the gall-bladder, owing to the friability of the structure, with 4 FRANCIS J. SHEPHERD. greater difficulty. The abdominal wound was closed and dressings applied. By this time the patient was in a very weak condition with the pulse hardly perceptible; so an intravenous injection of saline solution was given with good effect, increasing the volume of the pulse and reducing it to 140. Next morning patient was going on very well, but towards mid- day another oozing of blood took place, and she gradually sank and died that evening. Only a partial post-mortem could be obtained, but it was found that the obstruction to the common duct was due to carcinoma of the head of the pancreas. Near the duodenum were numerous glands enlarged and infiltrated. The gall-bladder was full of bile-stained blood-clot, and there was a large clot in the lesser sac. Since the above was written I have read Dr. Murphy's paper,' in which he says that the operation of cholecystenter- ostomy in malignant disease is very unsatisfactory, as several deaths occurred in eight operations, none, so far as I can make out, from haemorrhage, though it is well known that the tendency to haemorrhage in those suffering from carcinoma is very great. Dr. Murphy also says that now, when he finds a large car- cinoma of the pancreas, duct, or neck of the gall-bladder, he abandons the operation. No doubt before long we will find out the limits of the application of the button. Its use ought cer- tainly to be avoided in cases of obstruction due to malignant disease. ' ' Philadelphia Medicpl News, February 9, 1895. ,» al ce :y It. ir- he lUt ir- int