CHOLECYSTENTEROSTOMY

WITH

MURPHY'S BUTTON; REMOVAL OF A FOREIGN BODY FROM THE LEFT BRONCHUS; THE EXAMINATION AND REVIEW OF A "SUCCESSFUL" CŒLIOTOMY.

CLINICAL LECTURE DELIVERED AT ASBURY METHODIST HOSPITAL.

BY JAMES H. DUNN, M.D.,

Professor of Genito-Urinary Surgery in the Medical Department of the University of Minnesota; Surgeon to St. Mary's and Asbury Hospitals, Minneapolis, Minnesota.

GENTLEMEN,-This woman, thirty-seven years of age, and the mother of six children, presents nothing in her family or individual history previous to her present trouble which need detain us. It will be observed that she is poorly nourished, is so emaciated that she appears older than her years, and is slightly jaundiced. She has not been herself physically since the beginning of her present disease, about four years ago. An acute seizure of severe pain in the right hypochondrium radiating into the shoulder and across the abdomen, vomiting, and intense headache, then ushered in her malady. Relieved by morphine, she gradually recuperated, and left her bed in a few weeks, but with impaired digestion, constipation, soreness in the right hypochondrium, and some jaundice. At intervals of three or four months ever since, similar attacks, more or less well marked, have occurred, relegating her to bed for from three to eight weeks, and frequently requiring morphine for their final relief. Several times she has been markedly jaundiced, and she has eventually become practically invalided all the time. She has been in the hospital ten days, during which time she has had one acute attack requiring the hypodermic use of morphine. Her urine is highly colored with bile-pigment; her bowels are torpid, and the movements clay-colored.

On examining the abdomen, the whole right hypochondrium is found tender, but the most sensitive point is apparently just under the costal cartilages at a point about three inches from the mesial line.

Careful palpation reveals the presence of a slight enlargement in the anatomical location of the gall-bladder under the margin of the liver. The obscure tumor appears to slip away, and the patient has called my attention to having felt it herself, and describes it as slightly movable and specially sensitive when manipulated. Just exterior to this is a much more distinct, larger, and harder mass continuous with the liver, also sensitive to pressure and manipulation. It is either simply the edge of the liver projecting very low beneath the costal border, or, as I have suspected, the hepatic border plus inflammatory exudate and adhesions from repeated inflammatory reactions in this vicinity. In short, the patient presents a very fair history of cholelithiasis. What consecutive changes obstruction and irritation may have led to I cannot say. In fact, it might be more prudent not to be even thus explicit in diagnosis, and, going only as far as we know, say, as I have said, to the patient, that we evidently have obstruction in the gall-passages sufficiently serious to demand an exploratory incision, after which we will cope with the conditions found to the best of our ability. If so far mistaken that nothing can be done, we will close the wound after achieving only the small but not altogether unpractical comfort of arriving at a positive, if disappointing, diagnosis. To be sure, there are advantages and comforts in knowing just what is going to be done before beginning an operation, but in abdominal surgery this is not always entirely possible; hence it is well to consider carefully the different conditions which might be encountered, so that being forewarned we may be forearmed.

1. This obstruction could be due to a variety of conditions,-viz., (a) to cholelithiasis or gall-stones; (b) to cancer or neoplasms involvng the gall-ducts; (c) to cholecystitis.

2. Assuming the cause to be gall-stones, these might be located,(a) in the gall-bladder; (b) in the cystic duct; (c) in the hepatic duct ; (d) in the common duct, or in diverticula.

3. The state of the gall-bladder and neighboring parts may present a variety of conditions. There may be adhesions and various secondary changes. The bladder may be greatly distended, or, as in a case successfully operated upon in this hospital last year, it may be contracted to the size of a bean and occupied by a sandy débris.

In dealing with these varying conditions incident to the same primary disease the procedure must obviously vary. In the case just mentioned the remnant of the organ was removed,-cholecystectomy. Finding calculi in the gall-bladder, it might be incised and the stones

evacuated, cholecystotomy,-after which the incision might be sutured and the abdomen closed, or the bladder could be stitched to the abdominal walls and the fistula established. The former treatment has been associated with too discouraging a mortality to allow of its meeting with general approval; the latter leaves a fistula more or less troublesome to close, while if all the gall be thus discharged by it the patient perishes of inanition, since the bile appears to be indispensable to digestion. Nature has sometimes by adhesions and ulceration into the duodenum indicated what appears to be the best treatment of the most common obstructions of the bile-passages,-viz., establishment of a

The Murphy button in position in cholecystenterostomy.

fistula between the gall-bladder and the duodenum,-cholecystenterostomy. Until recently, however, this operation has been so difficult of successful performance as to be practically out of the question. Thanks to the genius of a brilliant American surgeon, Dr. J. B. Murphy, of Chicago, we are now in possession of a mechanism—the Murphy anastomosis button-which reduces cholecystenterostomy to one of the most simple, rapid, and precise of surgical procedures, and one apparently safer by far than any method heretofore devised.

We are indebted to Professor F. A. Dunsmoor for this case, but, owing to his own serious illness, he is unable to operate, after having made the diagnosis and set the day for the operation. I now make

STOMACH

an incision three inches long in the right linea semilunaris from the costal border downward, and dissect down to the peritoneum. Now, pausing a moment to stanch all hemorrhage as thoroughly as possible, this membrane is opened, and the border of the liver, with its notch, from beneath which the gall-bladder slightly projects, comes to view. The bladder is not materially abnormal in size, but is felt to be nearly filled with concretions. A little search brings to view the adjacent part of the duodenum. Having no mesentery,

FIG. 2.

it is not easily drawn up into the wound, but being the largest portion of the small intestine, and lying so close to the gallbladder, there is no great difficulty in bringing it within easy reach. It is necessary to avoid mistaking the colon or other portions of the intestinal tract for the duodenum. I now relieve the tension of the gall-bladder by aspirating three drachms of abnormal bile. Now, Application of sutures for the use of with a straight needle armed with silk, two running stitches are taken in that viscus, then the needle is turned and two more stitches are placed parallel to and one-fourth inch distant from the first. This is exactly repeated on the duodenum. (Fig. 2.)

the Murphy button.

A small incision in each organ admits the respective ends of the button, the loops of thread are drawn down and tied around their necks, the adjacent peritoneal surfaces slightly scratched, the halves of the button pressed together, and the wound is ready to be closed with carefully applied silkworm-gut sutures. These should be so placed as to secure the most exact apposition of the several parts, peritoneum to peritoneum, fascia to fascia, muscle to muscle, and skin-border to skin-border. To best accomplish this result the needle is entered near the border of the skin, so passed as to surround more and more of the wall until the centre of its depth is reached, then less and less until its exit just behind the peritoneal border; then on the opposite side exactly the same procedure in reverse. So placed, the stitches enclose a round mass of tissue so pressed together as to insure the most perfect apposition of tissue to tissue.

I have taken out some twenty-five or thirty of these stones (Fig. 3) to show you before putting in the button, but this is not only not necessary, but not in accord with the theory of the operation, since they will readily pass into the intestine when the fistula is established

by surgical interference, and the time spent in removing them is simply so much time lost. There are still a number left in this case to be passed through the intestine. The great service of the button in such a case lies in the case, rapidity, and safety with which a cholecystenterostomy may be effected. The operation has been performed in ten or twelve minutes, while to make it by safe suturing would require an hour or more at the hands of a most expert operator, and sometimes might present almost insurmountable difficulties, to say nothing of the long handling, the possible soiling, and the uncertainties and dangers of many stitches, which must not leak, must not penetrate all the coats of the intestine, and the fate of which must be

FIG. 3.

Calculi from the gall-bladder. At the right end of the cut is shown the button as it appeared after passing through the patient's intestinal tract.

uncertain and fraught with more or less danger. The button is easily manipulated, has almost the precision of mathematics, and appears to be the ne plus ultra of cholecystenterostomy. So far as I am informed, there have been about twenty successful operations reported since the introduction of this truly ingenious mechanism by Dr. J. B. Murphy in June, 1892. Thus far I know of no failures chargeable to this mode of operation. In some cases of biliary obstruction due to advanced malignant disease the patients have died of their incurable disease. It is not often that we can decide positively concerning the worth of a new surgical procedure in so short a time,-only mature judgment after wide and large experience can ordinarily fix its status, -but in this instance the principle is admitted, and the means of its accomplishment has given such uniform experimental and clinical results that it would appear established as the most perfect yet devised for the relief of a large part of the not infrequent and serious cases of biliary obstruction.

[NOTE. The patient made a good recovery, the highest temperature recorded after the operation being 100°. The jaundice rapidly cleared up, the appetite became keen, and the button (Fig. 3) was passed on the eighteenth day. It contained the two loops of thread and a small ring of necrotic tissue.]