VOLUME 18

NUMBER 5

Original Contributions

A FEW RECENT CASES ILLUSTRATING SOME PHASES OF GALL-BLADDER DISEASE.*

BY LOUIS FRANK, M. D.,

Professor of Abdominal Surgery and Gynecology, University of Louisville, Medical Department,

LOUISVILLE, KY.

CASE I.-ACUTE EMPYEMA OF GALL

BLADDER.

Patient, W. E. McG., age 37. Family History: Negative for tuberculosis, renal or cardiac disease.

Personal History: No gall-bladder trouble nor attacks of appendicitis pre

vious to present illness. Had typhoid

fever about three years ago; has had no trouble whatever since this attack of typhoid. Is actively engaged in work in the supply department of a railroad,

which necessitates rather strenuous labor and keeps him pretty busy.

Present Illness: Patient was seen by me on April 6, 1911, having been taken ill two days previously. Dr. Coleman. saw him shortly after his illness began. The trouble started with a sudden, acute, cramp-like pain in the upper abdomen, later becoming localized in the right iliac fossa just above McBurney's point, followed by nausea and vomiting. He vomited eight or nine times during the afternoon. At night, after a very light supper,

*Reported to the Medico-Chirurgical Society.

he again vomited, and Dr. Coleman saw him that night. The patient's leg was flexed upon the abdomen and he was unable to walk. Dr. Coleman made a diagnosis of appendicitis, and applied icepacks to the abdomen. I saw him the following afternoon and concurred in the diagnosis. At that time he had a temperature of 102 degrees F., and there was an area of exquisite tenderness over the right iliac fossa extending to a little above the umbilical line; there was no tenderness and no rigidity in the upper abdomen, all the symptoms being confined to the lower abdomen. I at once sent him to the infirmary, believing that immediate operation was indicated, and he was operated upon that same night.

Upon palpating the abdomen after administering the anesthetic, a mass could be detected, extending from the costal margin down below the umbilicus. We then believed that either the appendix was highly placed, or that we had to deal with a gall-bladder condition. Therefore. a high incision was made and we came at once upon a very much distended gallbladder, dark blue-and-red mottled-in fact it appeared to be of the color that usually precedes the death of the structure, with the intestines and omentum adherent to it. Everything was walled off, and the gall-bladder opened and drained of about eight ounces of pus mixed with a little bile and some mucus. A probe was passed into the cystic duct

and bile flowed back; no stones could be felt in the ducts, so a tube was placed in the gall-bladder and it was drained. The abdomen was also drained transperitoneally by a wick placed in the renal fossa. The duct walls were very much thickened, and the infection had almost completely cut off the circulation; there was no bleeding from the cut surfaces, though there was considerable hemorrhage from the mucous membranes of the gall-bladder. I believed that the gallbladder could be saved and, therefore (as has been my custom during the past few years), did not take it out. Length of time from incision to dressing, 65 min

utes.

This man went along and made a very nice recovery, except that the biliary fistula persisted for five or six weeks. A day or two after he had been allowed to get up (but while still in the infirmary), he had an attack of pneumonia. He recovered from that and was about ready to go home when he suffered a most virulent attack of tonsillitis, and about the time he recovered from that and was ready to go home again, scarlet fever developed in his home and he had to stay in the infirmary until three or four weeks ago. The fistula re-opened and he had. a discharge consisting of mucus alone. for a few days. This was due to cicatricial obstruction, but this has opened up and he has a permanently good result. He is back at work.

CASE II.-ACUTE EMPYEMA WITH RUPTURE OF THE GALL-BLADDER.

This case was one that I saw with Dr. Boggess.

Patient, Mr. V. G. Chief complaint, jaundice. There was nothing of note in his past history; he had not had typhoid fever. Age, 43; married, but no children; was formerly employed in a

brewery, but during the past several years has been engaged as a mechanic. Formerly used alcohol to excess, but during the past few years has drank very little.

Family History: Father died of carcinoma at age of thirty, mother died of pneumonia following asthma.

Present Illness: Began five months ago with dull aching pain in abdomen, accompanied by vomiting, which lasted for two or three days. After that he remained fairly well until January, 1911, when he began to suffer with severe pain in the abdomen which lasted about two weeks. Since that time he has had, daily, a dull, heavy, aching sensation in the abdomen, more marked in the median line, half way between the umbilicus and the costal margin, and in the area just. below the umbilicus. This pain was more or less constant, sometimes almost disappearing, but returning the next day. It seemed to bear no relation to eating. He has not vomited since the first attack. He continued to work very hard, night and day, until about four weeks ago when the pain became so severe that he was compelled to give up work and go to bed. He has had severe jaundice during the past few weeks. Has had no chills but some fever; the day I saw him his temperature was 102 degrees F. The jaundice grew less marked after a few days. and then increased again. He has lost about 50 pounds in weight during the past few weeks, but has not been eating much.

Upon examination this man presented. a well-defined mass in the upper abdomen. I made a probable diagnosis of peri-cholecystitis, with stones obstructing the common duct, and sent him to the infirmary. He had been seen by another doctor, who had, I believe, made diagnosis of cirrhosis and told him that he

did not require an operation. However, he went to the infirmary and we operated upon him the next day through a right rectus incision, beginning at the costal margin. The omentum was found to be adherent to the liver, gall-bladder and adjacent viscera. The liver was very dark, mottled, and enlarged. As soon as the omentum was separated from the edge of the liver, we went directly into the gall-bladder, which was open at the fundus and adherent to the under surface of the liver, at the lower margin, and from which escaped probably an ounce of pus mixed with bile and dark grumous material. The adhesions were very extensive. Pancreas not enlarged. This man was in very bad shape. No stones could be felt through the adhesions, but as these were not separated completely, examination in this respect was unsatisfactory. A tube was introduced into the gall-bladder and drainage was established in the renal fossa and also the lesser peritoneal cavity. A coffer-dam was placed in the infected area and the abdomen closed up. Length of time from incision to dressing, 32 minutes.

The discharge of bile continued for eight or ten days and then ceased. He still has a fistula from which there is a discharge of mucus mixed with pusabout an ounce in twenty-four hours. I think this man also has a cicatricial stenosis. The discharge of bile would indicate that the bile passages were unobstructed at the time of operation with subsequent contraction and cicatricial stenosis taking place in the infected area as the infectious material was absorbed.

I stopped in to see this man the other day, at which time all the dressings had been taken off, the tube had been removed and he was having no pain and was apparently completely well. When

he left the infirmary he weighed 140 pounds; he now weighs 195 pounds.

CASE III.-CHRONIC CHOLECYSTITIS. This was a case of chronic infection of gall-bladder, which I have seen three or four times in the course of the past two years. This patient, Mrs. M. K. B., had all the classical symptoms of gall-stones, and I sent her to the infirmary and opened the gall-bladder. No stones were found, but the gall-bladder itself was distended, and contained a dark, turbid, tenacious fluid, mixed with bile. The mucosa had the appearance characteristic of infection in this region. There were enlarged glands at the neck of the gall-bladder and also along the common duct. The head of the pancreas was not enlarged. A tube was sutured into the gall-bladder and brought out through the lower angle of the incision, and the wound closed about it. The patient made a nice recovery, all her pain disappeared, and at this time she is at least symptomatically well. Length of time from incision to dressing, 34 minutes.

CASE IV.-CHOLELITHIASIS-ACUTE

CHOLECYSTITIS.

Patient, Mrs. P. T. Chief complaint, soreness in upper right quadrant of abdomen. She came to me with a diagnosis of appendicitis, having been brought here. from the country after having suffered two or three attacks. She had a temperature of 103, and the abdomen was distended. I felt reasonably sure that I could detect a mass in the upper abdomen, and made diagnosis, before operation, of cholecystitis, probably with gall

stones.

She was operated upon through an upper right rectus incision, extending six inches from the costal margin, and sixtyeight stones were removed. No bile was

discharged. She had been sick for a week before I saw her. I had Dr. Davis see her and examine the stomach contents, which revealed nothing abnormal. The gall-bladder was very greatly thickened and no bile was discharged. I could not get a probe down into the duct. Length of time from incision to dressing, 56 minutes. I did not feel justified in keeping her on the table any longer, as she was more or less septic. Therefore, after about 50 minutes had elapsed, I deemed it best to close up the abdomen and if she proved to have an obstruction, to advise a second operation for the purpose of opening up the cystic duct. However, on the fifth or sixth day after the operation she began to discharge bile profusely. She stayed in the infirmary two weeks. As soon as the discharge became free of bacteria, the tube was taken out and the wound closed. She has completely recovered.

CASE V.-CHOLELITHIASIS-ACUTE CYSTIC

DUCT OBSTRUCTION WITH EMPYEMA.

Mrs. H., age 52. Referred by Drs. Boggess and Melton. I had seen this woman a number of times previously, having treated her, twenty years ago, for Reynaud's disease, from which she lost three toes. I also treated her for tertiary syphilis a number of years ago. Dr. Frazier and myself operated on her son for perirenal abscess, and also curetted some bone, tuberculosis in character. He finally went out west and died of tuberculosis.

This woman gave a history of typhoid and pneumonia 13 years ago. I was called to see her some years ago, but found that she had some heart lesion and referred her to Dr. Boggess. I had not seen her since, until the present attack, at which time she had been ill about three days, with vomiting and pain in the abdomen. In two days the pain became localized

radiation.

over the gall-bladder; no Pulse irregular; temperature 102 degrees F. She had a large mass in the gall-bladder region, and I recognized that we had to deal with an acute obstruction of the cystic duct, with pus in the gallbladder. She was sent to the infirmary and operated upon the next morning, icepacks having been kept upon her abdomen since her arrival at the infirmary.

Upon incision, a large tumor was exposed, covered by omentum, the colon being adherent below, as well as the duodenum. This was all free and walled off, the gall-bladder tapped with a trocar, and about four ounces of bile-stained, purulent fluid withdrawn. The gall-bladder had flakes of fibrin adherent to it all over the outside, and inside the mucosa looked very much like what we used to call a pyogenic membrane. Upon palpation, a stone could be detected in the cystic duct, near the gall-bladder, and this was forced back and removed. Inspection of the gall-bladder shows the interior to be reddish-blue in color. Length of time from incision to dressing, 40 minutes.

This woman stayed in the infirmary about two weeks. A tube was stitched in the gall-bladder, and this was removed in twelve days. She discharged sixteen ounces of bile the first twenty-four hours. At first there was a lot of flocculi in it, and it was very turbid; afterwards it cleared up, and on the twelfth day after the operation the tube was taken out. She is now perfectly well.

CASE VI.-CHOLELITHIASIS, DIAGNOSED AS GASTRIC ULCER.

Case seen on January 5, 1911. I had seen this woman some five years ago, just at the end of what was believed to have been an attack of acute appendicitis, and removed the appendix, which was acutely inflamed. My records show that the

gall-bladder was palpated at that time, but nothing was found. However, it appears from the subsequent history of the case that this may have been error. This woman went along without any trouble until about two years ago. She had not had typhoid fever or any other illness during the interval. At that time she began to suffer with stomach complaint. She was a patient of Dr. Hancock, of Jeffersonville, who sent her to me with the statement that she could not eat with comfort. I examined her and telephoned Dr. Hancock that I thought she had gallstones, and advised that the abdomen be re-opened. This was not accepted, however, and she went along, at times having no trouble, and again complaining a great deal. Dr. Hancock washed out her stomach repeatedly, and put her on treatment with rest in bed, which was followed by apparent relief, but after she had been up for a while the discomfort returned. Several months ago she vomited some blood, and she was again referred to me. I examined her again, and came to the conclusion, in view of her past history, that my previous diagnosis was an error, and that she must have an ulcer of the stomach or duodenum. I sent her to the infirmary where Dr. Davis made the gastric analysis and agreed in the diagnosis.

Last August she vomited some blood, and soon afterwards she again vomited blood. Her stomach had been washed out very often since that time, and there had been no active bleeding. Her appetite was sometimes not good, but at times it was insatiable. She suffered with headache over the eyes and in the lower part of the head. She did not sleep well on account of the pain, and in the morning her abdomen was always sore. She was very nervous and had lost twenty pounds in weight; she had not been eating very much. Possibly her worst

symptoms had been since last August. With this history, I believed that we had to deal with a gastric ulcer, and advised that she be operated upon, which was again refused. She returned about two weeks ago and I insisted upon operation, which she then accepted and was sent to the infirmary.

When I opened the abdomen, pretty high up, the first thing I came upon was the gall-bladder filled with stones. (Dr. Lucas had seen this woman and also believed that she had an ulcer of the stomach, but I do not know whether or not he made gastric analysis.)

One hundred and thirty-eight stones were removed. One of them was very large, and was impacted lightly in the cystic duct. The site of the appendix was inspected; there were no adhesions. I then brought out the stomach and inspected it, and found it free of scars, as was also the duodenum and pylorus. The walls of the gall-bladder were apparently not thickened. A rubber tube was stitched into the gall-bladder and brought out through a stab-wound, and the abdomen closed. Length of time from incision to dressing, 32 minutes.

This woman is now (9 days after the operation) sitting up in bed.

CASE VII.-CHOLELITHIASIS-ACUTE

CYSTIC DUCT OBSTRUCTION.

These are three stones which were removed from Mrs. A. E., age 75, whom I saw in consultation with Dr. F. W. Koehler. This patient has been a sufferer from chronic bronchitis, and has had pneumonia several times, having been more or less an invalid and very frail for a number of years. Ten days before I saw her she began to suffer with a severe colicky pain in the abdomen, followed by nausea, her temperature ranging from 99 to 101 de