TWO OPERATIONS PERFORMED UPON THE LIVER THROUGH THE CHEST WALL
Authors: G. P. Newbolt
Journal: BMJ (1903)

I=L JOU 6fER&TIONS 0 TAE- TrTJAM fIA;24, L3.stones was then felt.These were eagily removed easily, until the neck of the g,ll bladder.was reached.Here was found a large and very dense mass, which seemed to be made up of gall bladder.cystic duct.stones, afd dense adhesions.The bladder was therefore stripped as cleanly asPossi6lldfrom the duodenum and-colon, to both of which it adhered.A large stone was felt impacted in the neck of the gall bladder and was found almost to have ulcerated through.It was somewhat doubtful whether the dense thickening was due to malignant disease, and as, whether simple or malignant, tbe gall bladder was uselessoand harmful, it was determined to remove it.This was done, asmall portion of the liver also being taken away, the gall bladder being inseparably welded with it.Several bleeding points in the liver were --caught by a suture..The out end of the cystic duct, from, which bile flowed freely, was liga- .turedand aperitoneal flap stitched over, Drainage was employed.For the first three days.tbe patient's condition was very critical;.the pulse ran up to 120, and frequent vomiting and hiccough were very distressing.For forty-eight hours-between twenty-'6nr and seventy-two bours after the operation-there was haematemesis, inky-black fluid .beingvomited every hour or two in quantities of 2 to4-oz.The voit was very acid, the corner of the patient's mouth and hts lips and chin being scalded by it.The stomach was washed out, and all fluids withheld.High. enemata of hot saline solution were given.The vomiting ceased.and for the next three days great progress was made; the bowels acted, there.was no vomiting, and fluid, increasing from xs oz. to 4 pints, was taken -each twenty-four hours.On the seventh day ihe eecretion of urine sud-denly1stgpped.Before this, urine had been passed in quantities of 30 to 42 oz.daily.On the seventh day he did not Dass urine for fourteen hours, and I therefore introduced a catheter, but drew o" only I drachm.of etite, almost solid with alumen.-Forforty-eight hoursafter this, less .thena.o. of urine passed, in spite of saline infusion, pilocarpin, and othor remedies.During this time the patient complained a little of aull abl4d.iq the left lumbar region.All the urine drawn off was highly ilburipnous.On the ninth day I cut down on the left kidney, Incisedthe ca*ff)le,, and stripped most of it away, and then incised the kidney thr:ougl.theconvex,outer border into the pelvis.,During the next forty-.eig:}i hours,, I, oz.Qf urine were 'passed, thie earlier discharge being sliglttly bloodstained.No adequate relief, however, was afforded, and tthq patfent became eomatose and died eleven aDd a-half days after the operation.The abdominal wound was soundly healed.Indeed, on the -evening of the sixtll day I felt assured of the patient's recovery, and I am conflde:t that,,but for the suppression. of urine, he would have made a good recovery.CASE v.-Chronic Sclerosing ChoZecilstitig-MIultiple Perforations: Stone in the Common Duct.History.-Mrs.M. S., aged 5I.sent to me by Dr. W. Graddon Mortimer.-of Thorne, had suffered for between three; and four years from attacks of acute pain in the epigastric and right hypochondriac regions, lasting three or four hours, and then passtng gradually away, leaviLng a sense of stiffness and soreness for a few days.Though these were the first severe attacks, the patient had for many years experienced sensations of dis- comfort, and grave uneasiness in the epigastriun, which was called "indigestion."In June of this year an exceptionally severe attack was -followed, for the first time, by jaundice, and the jaundice has continued up to the present time.During this period-three months and a half- the de0th of the tiDge had varied; it is less in the morning, and gets gradually deeper during the day.There have been several attacks of shivering and faintness, followed by sweating, and after all of them a deepening of the jaundice has been observed.The -motions have been like putty, and the urine hais been high-coloured.A floating stone in the common duct was diagnosed.Operation, October 3rd, g102.-Theabdomen was opened through the right rectus muscle and the upper end of the iDeision was prolonged towards the xiphoid cartilage.An imutense number of adhesions were found and separated.It was then found that three stones.each equal in size to a-Barcelona nut, had ulcerated almost through the walls of the gull bladder.Two of I hese lay in pockets in the omentum, and one was almost hidden in a cavity in, tne liver.The gall bladder was shrunken.'The stones were removed and the gall bladder cleared.A stone was then found in the common duct.and was removed.The rest of the common duct was explored carefully 'and found to be clear.The gall bladder, which was shut off from the bile channel by an impervious cystic duct, was then removed.Drainage by a split rubber tube and gauze was adopted for forty-eight hours.The patient is now quite well.CASE VI.-Acute