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Thoaa too large to be entirely included In one exposure are filmed begkr.ning in the upper left hand corner, left to right and top to bottom, aa many frames aa required. The following diagrama illustrate the method: Lea cartae, planchaa, tableaux, etc., peuvent itre filmte i dea taux de rMuction diffirents. Lorsque le document est trop grand pour Atre reprodult en un seul cllchA, it est fllmA i partir da Tangle supArieur gauche, de gauche A droite, et de haut an baa, en prenant le nombre d'imagea nteeasaire. Lea diagrammes suivants liiustrent la mAthoda. 1 2 3 1 2 3 4 5 6 r:sT Sc^, w A SERIES OF CASES OF CALCULOUS OBSTRUCTION OF THE COMMON BILE DUCT, TREATED BY INCISION AND REMOVAL OF THE CALCULI. BY JAMES BELL, M.D., Professor of Clinical Surgery, McGill University, Surgeon to the Royal Vlctofia Hospital and Consulting Surgeon to the MontirM General Hospital. •s {Reprinted from the Montreal Medical Journal^ October, 1898,) * mmmtMi i' i' A SERIES OF CASES OF CALCULOUS OBSTRUCTION OF THE COMMON BILE DUCT. TREATED BY INCISION AND REMOVAL OF THE CALCULI' as James Bell, M.D., Professor of Clinical Surgery, McGill University, Surgeon to the Royal Victoria Hospital and Consulting Sti'-^^ecn to the Montreal General Hospital. It is safe to say that in no department of surgery has greater pro- gress been made in recent years than in the treatment of gall-stone disease by operation upon the gall-bladder and ducts. Lives are now saved and health restored by operations which are followed by a very low death rate, and which have this advantage over many other valuable surgical procedures, that they restore the health completely and leave the patient free from deformity or loss of function. The first successful cholecystotomy was done by Mr. Lawson Tait, in August, 1879, and the first attempt to remove stones from the com- mon duct was made, (also by Mr. Tait), by crushing in July, 1884.' Later Mr. Knowsley Thornton operated by breaking up the stones with a needle passed through the walls of the duct (" needling"), and forcing the fxagments out into the duodenum. The first successful choledochotomy was performed by Curvoisier in January, 1891.* To- day cholecystostomy is a common operation, frequently performed and generally with the most satisfactory results, and in ordinary cases the procedure is almost devoid of danger. Incision of the common duct for the removal of calculi, which has now almost entirely superseded the cruder operation of " crushing" and " needling," is, of course, a much more difficult and serious operation, and is generally called for > Read at the meeting of the Canadian Medical Association, Quebec, August, 1898. a Lancet, Vol. II., 1885. 3 A. W. M»7o Robeon Hunterian Lectures, 1897. in conditions of the patient which are much more unfavourable for operation. Nevertheless, the mortality rate is low, and the results in the successful cases are brilliant. I have purposely refrained from using in the title of this communication the uncouth and cumbrous terms by which these operations are described, (cholcdochotomy, chole- docholithotomy, {choledochoduodenotomy, choledochoduodenolitho- tomy, etc.), as no one of them could be properly used for all of the six cases which form the subject matter of the paper. Of these six cases five were females, each of whom had borne a large number of children. The ages of the patients ranged from 33 to 61 years. In two there was but a solitary stone, in three there were stones in the gall-bladder, as well as in the common duct, in four, there was obliter- ation of the cystic duct and a contracted gall-bladder, which contained no bile, and in two, a large stone was impacted in the ampulla of the duct within the duodenum, (diverticulum of Vater), and was removed through an incision in the duodenum (choledochoduodenotomy). There was but one death in the six cases, from pneumonia on the sixth day after operation, and one patient was submitted to a second operation upon the duct, five and one-half months after the first operation. Case I.^E. B., a gentleman, aet. 52, had his first attack of pain in the right side of the abdomen while travelling.by rail in the summer of 1892. It was severe, lasted all evening and was followed by jaun- dice, which passed ofl^in a day or two. Three similar attacks followed, one in three months, another in the winter of 1893, and the third in February, 1894, with intervals of good health. On the 25th of Jan- uary, 1895, the fifth attack began, more insidiously than any of the previous ones. From this time there were frequent attacks with per- sistent and steadily increasing jaundice, drowsiness, anorexia, itching of the skin, and loss of weight, from 225 lbs. to 140 lbs. in eleven months and a half, — Cfrom January 25th, 1895, till he came under my observation, January, 13th, 1896). Operation was performed on the 14th of January, 1896. There was much adhesion of the colon^ duodenum and omentum to the liver. The gall-bladder was contracted and crapty. A stone, about the size of a playing marble, was dis- covered impacted in the ampulla of the duct, within the duodenum. It was removed through an incision made along the line of the duct and obliquely across the duoden\im at its posterior border — choledocho- duodenotomy. The wound in the duodenum was closed by fine silk sutures, two or three carried through all the coats of the bowel, and then a double I'ow of Lembert sutures. A rubber drainage tube was carried down to the bottom of the cavity and surrounded by iodoform gauze packing, There was no escape of bile or duodenal contents, 8 and the patient made an excellent recovery. Within a few weeks he had regained the SO lbs. which he had lost in the year preceding the t)peration, and he is still, I believe, in the enjoyment of perfect health. Case II. — Mrs. S., set. 56, the ^mother of a large family, was ad- mitted to the Royal Victoria Hospital on the 16th February, 1897, deeply jaundiced and complaining of pain and tenderness in the epi- gastrium. A long series of attacks of crampy pain in the epigastrium (evidently biliary colic) had begun about twenty years prior to her admission to hospital and had continued for ten years with consider- able frequency and steadily increasing severity. At the end of ten years a large, painful, tender tumour developed in the epigastrium, and she was confined to bed with chills, flushes, pain and weakness, (acute cholecystitis ?) At the end of six months, the tumour began to diminish in size and gradually disappeared altogether, and at the same time she became deeply jaundiced. The .jaundice lasted about six months. She remained fairly well then for four or five years, with the exception of frequent " weak turns." Then she had typhoid fever, after which she remained well again until one year before coming under observation, when the pain returned with swelling of the limbs, high-coloured urine, and general malaise, which lasted six weeks. Two months before admission, she was again seized with pain in the epigastrium. The attacks were fi'equeut and severe, the urine became high-coloured and jaundice developed. Two weeks before admission the jaundice became very marked ai \d steadily in- creased. She had also been losing flesh rapidly duriiig the last two months. On admission there was extreme jaundice, with bile stained urine and colourless stools. The liver was not enlarged but there was a tender point midway between the xiphoid cartilage and the umbilicus and just to the right of the middle line. There was great prostration which was attributed to cholsemia. This patient was operated upon on the 23rd of February. On opening the abdomen there was much adhesion of the omentum to the lower surface of the liver. The gall-bladder was contracted and contained twelve small facetted stones which were removed with the finger through an incision made into the least prominent part. There was no bile. Two smallish stones were removed in fragments through an incision on the dilated common duct and a large one, about the size of a marble, which lay in the ampulla of the duct, within the duodenum was pushed back- wards and removed through the same incision. The aggregate weight of the fifteen stones was 3.1 grammes. The incision in the common duct was closed by sutures as in the previous case, but it was found impossible to either completely close the wound in the gall-bladder or bring it up to the parietal peritoneum. There was considerable e^^cape of bile from the incision in the duct during the operation owing to the difficulty of dislodging the large stone from the ampulla of the duct. The bile was carefully mopped out and a large drainage tube carried down to the border of the cavity, and well-packed round with iodoform gauze. There was u moderate escape of bile from the tube, and the patient seemed to do fairly well for four days, when she developed a right-sided pueumonia and died on the first of March, six days after operation. There wa.s no autopsy, but during the six days following operation there was neither abdominal pain nor distension nor any symptom to indicate local disturbance. This patient was cholsemic, weak and miserable at the time of operation and took ether badly, having the air passages full of mucus throughout, and to this I am inclined to attribute the pnt'umonia which was the cause of death. Case III. — Mrs. C, Ji't. 47, the mother of 11 children, the youngest six years of age, was admitted to the lloyal Victoria Ho.''pital on the 13th of August, 1897, deeply jaundiced and complaining of pain just to the right of the epigastrium. She had had her first attack of biliary colic in 1881, and from that er, perfectly well. Cask IV. — Mrs. C, nt. 61, a stout wuman. the mother of 14 chil- dren, was admitted to the Royal Victoria Uoapital on the 13th of October, 1H97, deeply Jaundiced, and with two large carbuncles on the rijBfht Hide of the abdomen, on a line with the umbilicus. Her symp- toms had be^un in the winter of 1894, after a fall, in which she struck her rijfht side against the edge of a barn door. Periodic attacks of pain ami tenderne.ss in the right epigastrium occurred about twice in the year, but they were not accompanied by jaundice. Until August 10th, 1897, when the last attack began. This was attended with severe and continued pain, constant vomiting and a sense of fulness about the stomach, and jaundice, which grew gradually deeper and deeper until she came to hospital. The carbuncles were tirst attended to, on the 14th of October, and on the 4th of November, the abdomen was opened. The liver was enlarged, the gall-bladder was shrunken and contained live calculi, but no bile. The cystic duct was obliter- ated and the common duct was dilated and contained a fairly large stone which could be moved back and forth along the duct. The stone was removed through an incision in the middle third of the duct and the incision sutured in the usual way. This stone was facetted, as were the five others removed from the shrunken gall- bladder. The aggregate weight of the stones was 4.7 grammes. The cavity was drained by a tube passed down to the incision in the common duct, and surrounded by iodoform gauze packing. This patient made an uneventful recovery and was discharged on the 20th of December, with the wound perfectly healed. [Within the past ten days I have heard of the patient through her son. His report is as follows : For some time after going home she remained quite well but in January she began to complain of pain in the abdomen. On the 7 th of May, she became detinitely insane with delusions on the subject of religion, etc. At no time has she had any jaundice, her color is good, and the stools and urine are normal.] Case V. — Mrs. K., set. 49, the mother of 12 children, the youngest born 14 years ago, was admitted to the Royal Victoria Hospital on the 5th of February, 1898, with a history of two month's illness. On the 8th of December, 1897, she was seized with moderately severe pain in the epigastrium, which prevented her from straightening her- seH! up. This was soon followed by jaundice. The jaundice persisted and the attacks recurred about twice a week until she came to hospi- tal. She had lost a good deal of flesh and had been chilly and feverish. On axlmission she was deeply jaundiced ; the stools were colorless and d the urine very dark. Operation was performed on the lOtli of Feb- ruary. The duodenum was tirndy adherent to the contracted gall- bladder and was wounded in separating them. The wound was closed by silk sutures— first through the whole thickness of the bowel and then a double row of Lembert sutures. A large stone weighing 3.25 grammes was found in the common duct which was much dilated- It was freely movable in the duct and was removed through a longi- tudinal incision which was sutured with fine silk in the usual way. A drainage tube was inserted and surrounded by iodoform gauze packing. The dressings next morning showed evidence of the escape of bile, and again on the following morning. From this time there was more or less escape of bile into the dressing forfour or five weeks- In the meantime the jaundice had entirely disappeared and the stools and urine were normal in color and appearance, and the wound was almost completely healed. On the 24th of April, it was noticed that the skin was slightly yellow again, (.^n the 6th of May, she had a severe attack of pain with increase in the jaundice. From this time on she developed symptoms of obstruction in the common duct an«l the abdomen was re-opened on the 21st of July, by an incision al»out an inch inside of the previous one. The duct was easily reaehed, although the duodenum was again wounded in separating it from the under surface of the liver. The wound was immediately closed by sutures as before. A movable stone was found in the common duct and removed through a longitudinal incision, which was closed by sutures of fine silk as in the previous operation. This stone weighed .5 grammes. There was nothing in the appearance of the duct to indicate that it had been previously opened or otherwise interfered with. The cavity was drained and packed as in the previous opera- tion. There was some escape of bile the following morning. This soon ceased, however, and in four days the urine and stools were nor- mal and the yellowness had almost entirely disappeared from the skin and conjunctivee. This patient continues to make excellent progress towards recovery. This second operation was much easier than the first, and except at the lowermost part of the wound the operation field was entirely cut off from the general peritoneal cavity by adhesions. Case VI. — Mrs. " aet. 33, the mother of six children, was admitted to the Royal Victo i Hospital on the 6th of May, 1898, suffering from jaundice and recurring attacks of pain in the right hypochron- drium. Her first symptoms, of this kind, had occurred two years previously. In three months more she had a series of mild attacks and then remained well for a year, when she had another severe I If attack. TIiIh wan in June, 1897. Slio waR again free from attacks of pain until four weeks prior to admission, when she began to have a series of attacks accompanied by jaundice which varied in intensity, from time to time, but never disappeared. The temperature ranged from 98° F. to 101° F., the liver was slightly enlarged a*^.*' its lower border was palpable, and there was a trace of albumen in the urine. Operation was performed on the 12th of May. On opening the abdo- men the colon and stomach were adherent to the liver, but tlie gall- bladder and ducts were exposed without much difficulty. The gall- bladder was distended and tense and the common duct much dilated. A stone was found firmly impacted in the ampulla, within the duo denum. It was removed through an incision over the end of the duct into the duodenum, which was immediately closed by silk sutures, first through all the tissues, and then a double row of Lembert sutures. This stone was facetted. The base of the distended gall-bladder was next aspirated and three ounces of greyish thick pus withdrawn which gave sterile cultures. Six facetted stones were removed from the gall- bladder and one from the cystic duct — eight in all, weighing 7.3 grammes. The cystic duct was obliterated beyond the impacted stone. The gall-bladder was attached to the peritoneum and a drainage tube inserted into it. A strip of iodoform gauze was passed down along the upder surface of the gall-bladder and cystic duct, to the line of incision in the duodenum, at tlie end of the common duct. The remainder of the abdominal wound was closed. The patient made an excellent recovery and was discharged (juite well on the 5th of July. In estimating the value of a surgical procedure, we have to consider : (1) The conditions which call for r)peration and the prognosis in these conditions, under other methods of treatment, or no treatment at all. (2) The gravity of the operative pnxsedure in itself, and (3) the results which we may reasonably expect to attain by operation ? (1) Tke conditions calling for operation. — In jaundice due to me- chanical obstruction by a stone, or by .several stones in the common bile duct, there is but one ground for hope, outside of operation, and that is the expulsion of the stone by natural methods, or its escape into a neigh- Ixjuring viscus, (stomach or colon), by adhesion and ulceration. Medi- cinal treatment is useless and nothing short of direct interference can avail to remove the stones. If the obstruction persists, cholaemia sooner or later proves fatal, (directly or indirectly), or perforation and escape of contents into the general peritoneal cavity occurs and sets up a fatal peritonitis, or cancer develops as a result of the long con- tinued irritation of the passages and carries ofi" the patient. The only question then would seem to be, how , long one should wait in obstructive jaundice before resorting to operation ? This is a motet difficult question to decide, because on the one hand We cannot fix any period at which we can say that tlie possibilities of nature have been exhausted, and on the other, it is obviou^^ly undesirable to allow patients to suffer unnecessarily t<>r weok^ or months before a/ffording the relief which must sooner or later be given. In general tentne, it may be said that no rule can be laid down and each case must be taken upon its own merits. On this point I have had, in my own experience, one very instructive demonstration. [A yoUDg wonittB, aged '28 years, had her flrst attack ot bllidry colic on the l«rt of April, 1897. Repeated attacks followed, and on the 22nd of June she became Jaan- diced. The jaundice persisted and attacks of pain, gradually increasing in severity, occurred at short intervals until the day after her admission to the hospital (Atip^st 19th, 1897), when they ceased altogether. I operated on the 25th August, only to find distinctive evidence that the stone had passed through the duct.] (2) The gravity of the operation. — The operation, although often difficult, is not a serious one, as is shown by statistics, and no doubt the death rate, in this as in all the newer operative procedures, will be much reduced in the future. The nurrher of choledochotomies heretofore reported is too limited to furnish statistics of any special value, but Mr. A. W. Mayo Robson' gives the death rate, as calculated from three series of collected cases, as well as from his own individual cases and those of two or three other surgeons, as ranging from 16 per cent, to 37.8 per cent. In my own cases, (seven operations upon six patients), there was only one death, from pneumonia on the sixth day after operation. The dangers are, shock, from undue prolonga- tion of the operation, peritoneal infection by the contents of the bile passages and haemorrhage. Wounds of viscera in separating adhesions are accidents common to all abdominal operations. It is believed by many surgeons that long continued jaundice predisposes to hsemorr- liage by altering the composition of the blood. My limited personal experience in these cases and others in which I have removed the stones by other means than through incision of the duct, has not confirmed this observation. Method of operating. — The methods of different operators differ only in unimportant details. My operations have been carried out in the following manner : A vertical incision is made in the abdominal wall from the costal margin over the centre of the rectus muscle, down to about the umbilicus. The fibres of the muscle are separated and the peritoneum opened. Through this wound the parts are explored and the conditions determined as far as possible. A second incision is then made from the upper end of the first one along the costal ' Diseases of the gall-bladdc^r and bile duct. margin towards the ensiform cartilage, for one inch, or perhaps two inches. There is generally much adhesion of omentum, colon, duodenum or stomach to the under surface of the liver, and the separation of these adhesions is in most cases the most important and difficult part of the operation. The large thin-walled vessels of the omentum are easly torn and may give rise to very troublesome hsemor- rhage and greatly prolong and complicate the operation. It is at this point, too, that the hollow viscera are likely to be wounded. When these adhesi ns are separated there is no difficulty in discover- ing the dilated common bile duct at the bottom of the cavity, extend- ing obliquely inwards from the gall-bladder, (which is usually shrunken and contracted), to the head of the pancreas. It is, of course, indis- tinguishably bound up in cellular tissue with the portal vein and hepatic artery, — the whole appearing as a rounded rope-like mass, usually about two inches in length. The field of operation is now limited to a cavity, bounded internally by the stomach and duodenum, below by the colon, above by the liver and externally by the right lobe of the liver and the parietes of the abdomen ; and with a few sterilized gauze pads the general peritoneal cavity is completely cut off. With the first two fingers of the left hand, under the rope-like mass above referred to, and the thumb apposed anteriorly the duct, which lies in front, can be explored from end to end and any stone easily detected. The stone is then made to project against the anterior wall of the duct by the fiugers beneath, and the thumb compresses the duct on its proximal side to prevent the gush of bile which follows the relief of the obstruction. A longitudinal incision is made in the duct and the stone or stones evacuated. I generally retain the fingers and thumb in this position until I have passed three or four, or more, silk sutures through the edges of the incision, which are tied by my assistant. I can then relax my hold upon the duct and insert a number of Lenibert sutures, carefully approximating the peritoneal surfaces. In this way neither bile nor blooJ escapes. A drainage tube is passed down to the bottom of the cavity near the line of suture and surrounded by a tubular packing of iodoform gauze to ensure the safety of the peritoneal cavity in case of the sutures in the duct giving way. It is sometimes said that it is unnecessary to close the wound in the duct, but the great gush of pent up bile which always escapes though the incision, if allowed to do so, leads me to think that closure of the wound is, at least, a wise precaution. I also look upon provision for drainage as a wise precaution — if not a neces- sary one, for in spite of the greatest care there may be some escape of bile from the wound in the duct; which may, as pointed out by 10 Kiedel, be temporarily pbstructed by blood clot after operation. In three of my cases there was some escape of bile a few days after operation, and I am of the opinion that to depend upon the suture of the duct with so much confidence as to close the abdominal wound completely would surely lead, sometimes at least, to disaster. Finally, the vertical portion of the abdominal wound is closed by sutures and the drainage tube brought out through the obliquely transverse portion. 1 A iBSHfiB