CHOLECYSTOTOMY, WITH LIGATURE OF THE CYSTIC DUCT.
Zielewicz (Centralblatt f. Chirurgie, No. 13, 1888,) proposes in addition to the so-called “ideal” method of Spencer Wells, that of suturing the gall bladder to the abdominal wound, to ligate the cystic duct, in order to insure the patient against the return of the biliary lithiasis. The only case in which he has tried it was one in which an attempt was being made to perform cholecystectomy, but the adhesions between the gall bladder and liver were so dense and unyielding as to render the removal impossible, on account of severe hæmorrhage. He therefore passed two ligatures around the cystic duct and divided the latter between them. The gall bladder was then fastened to the abdominal wound, incised and emptied of its contained calculus and biliary secretion. The patient made a good recovery, a fistula remaining, of which the writer says, that “after a time it was almost closed.”
The author claims for this operation the following advantages: 1st. Rapid healing without a resulting fistula. The gall bladder is practically removed from the organism. With appropriate after treatment, its secretion soon ceases, and it becomes obliterated. 2d. The operation is simple and less dangerous than cholecystectomy, and gives the same results.
In contrasting this operation with cholecystotomy, it may be said that the latter simply aims at removing the existing calculi, and makes no provision against the recurrence of the same. Where the “natural” method of Bernay is adopted, and the gall bladder dropped back into the abdominal cavity after suturing the incision made in its walls for the removal of its contents, in case of a recurrence of the disease, the entire operation must be repeated. In the “ideal” method of Spencer Wells, only an incision need be made, in such an emergency, at the site of the first operation. Troublesome fistulæ, however, are apt to remain.
In cholecystectomy, on the other hand, hæmorrhage from breaking down of adhesions between the gall bladder and the surface of the liver, it is claimed, is a frequent and troublesome complication. It is claimed by Thiriar, however (“De l’intervention chirurgicale dans certains cas de lithiase biliaire,” Revue de chirurgie, 1886, No. 3), that cholecystectomy is a less dangerous operation than simple cholecystotomy. Again, by Bardenheuer, that hæmorrhage from the liver can be readily arrested. The abstractor witnessed an operation in which the liver was accidentally wounded and the resulting hæmorrhage arrested by the thermo-cautery.
Hertin, a French naval surgeon, in 1767, after experiments made upon dogs, proposed, in wounds of the gall bladder, extirpation of the latter, after ligature of the cystic duct. In these experiments he demonstrated the feasibility of the operation of cholecystectomy upon the lower animals, at least.
Campaignac, in 1826, proposed ligature of the cystic duct, with partial resection of the gall bladder (Journ. hebdom. Bd. ii, 1829). K. Zagorski has recently attempted this latter procedure on dogs, with fatal results (Przegl. lekarski, 1887, No. 48). Nevertheless, to Zielewicz belongs the credit of being the first to demonstrate, by its successful performance, the feasibility of combining in man the two operations of ligature of the cystic duct and cholecystotomy with suture of the gall bladder to the abdominal wound. Upon further trial the operation may prove to be not only feasible, but to follow out a rational indication with relative safety.
SUPRA-PUBIC PROSTATECTOMY.
A. F. McGill, F.R.C.S. (The Lancet, February 4, 1888). The operation consists of two parts: (1) The opening and drainage of the bladder; and (2) The removal of the prostatic valve which prevents the egress of the urine. A full sized silver catheter, curved according to the nature of the case, is passed into the bladder, its contained urine withdrawn and its cavity washed out with a warm saturated solution of boracic acid till this is returned clean and unchanged. The usual rubber rectal bag is now introduced and filled with fourteen ounces of water. The bladder is now rendered prominent by injecting it with a sufficient amount of warm boracic acid solution. The catheter is retained in the bladder, and the fluid with which the latter has been distended, prevented from escaping. The usual median supra-pubic incision is now made, the bladder exposed and made to project into the abdominal wound by depressing the catheter. A large curved tenaculum is now passed transversely into the bladder, touching as it goes the point of the catheter. An incision is now made longitudinally through the bladder wall, the fluid being prevented from escaping by plugging the opening with the finger. The bladder is now seized with nibbed forceps, and applied on each side of the incision, the catheter is withdrawn from the urethra and the bag from the rectum, and the first part of the operation is complete. The interior of the bladder and its neck is now examined, in order to ascertain the exact nature of the prostate enlargement. A pedunculated middle lobe can be removed with the curved scissors, but in the case of a sessile middle lobe, this must be assisted with the finger and forceps. The “collar” enlargement is removed with greater difficulty. In order to insure the patency of the urethra, it is advised to pass the forefinger into the canal as far as the first joint. It is claimed that the hæmorrhage is not excessive. The operation completed, drainage is effected by passing a rubber tube out of the abdominal wound, the latter being partially closed by a point or two of suture. The tube is removed after forty-eight hours.
The author’s experience is limited to five cases, four of which have proved successful, while the fifth case is still under treatment. He claims that, in cases operated upon early, before diseased bladder or surgical kidney have developed, a radical cure may confidently be expected.