Urachal cyst simulating appendicular abscess : arrested development of genital tract : with notes on recently reported cases of urachal cysts / by Alban H.G. Doran.

Doran, Alban H. G. (Alban Henry Griffiths), 1849-1927

Date:: 1909

Credit: Urachal cyst simulating appendicular abscess : arrested development of genital tract : with notes on recently reported cases of urachal cysts / by Alban H.G. Doran. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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$The Lancet, old womanVwho for seven days had suffered from intestinal obstruction Widently low down in the ileum. As she was dying I left h\r alone and death took place within an hour of my first seeingher. At the necropsy I found a stone of the size of a florin tightly impacted in the lower end of the ileum six inches above\its termination. The patient’s daughter assured me that her mother had never suffered from biliary colic, and this was 'explained by the fact that this was a solitary stone whiclk had ulcerated into the duodenum, leaving an opening between the gall-bladder and this segment o| the intestine. \ A more frequent resulK of gall-stones is the presence of dense fibroid adhesions abound the pylorus and the com- mencement of the duodenum, which so narrow these parts as to give rise to gastric dilatation and call for the perform- ance of gastro-enterostomy. 1 have several times found gall-bladder, liver, duodenum,'and pylorus imbedded in adhesions (in one case so dense Vs to simulate a neoplasm when examined through the abdominal wall), and have been enabled, to give relief to the gastrf^ symptoms by the per- formance of gastro-enterostomy. Permanent Obstruction of the Biliary Ducts. We have hitherto considered cases in v^hich the gall-stone obstruction in either duct was only temporally. We now turn to such in which the calculus remains permanently impacted. When this happens in the cystic duct the Bale no longer enters the gall-bladder, which may undergo various changes. It may dwindle to a shrivelled sac with thickened walls which may, in part, calcify it may become distended with clear, ropy fluid derived from the mucosa until it attains so vast dimensions that it may. be mistaken for an ovarian cyst or a hydronephrosis, or the fluid in the gall-bladdeX may become pus, and lead to perforation of the viscus and peri/ tonitis. Much more serious is the case when the comrfrpfi bile-duct is permanently and totally obstructed by a calcul for in such (he bile is prevented gaining access to /the- intestine and jaundice results. This, however, not invariably occurs, for I have operated upon several cases in which the common bile-duct was, to all appearance, blocked by .calculi varying in number from one to nine, and yet bile was able to find its way adequately into the intestine. It is noteworthy that in some instances the common duct is obstructed by calculi so completely as to cause jaundice, and yet the closest examination of the patient reveals no history of gall-stone colic. Complete blockage of the common duct may cause no symptom beyond jaundice with clay stools and slight hepatic enlargement. In other cases sooner or later ehsue the results of infection—viz., suppuration of the biliary passages and gall-bladder, cirrhosis (biliary) of the liver, suppuration of the intrahepatic ducts, or of the liver substance. Allow me now. to direct your attention to infection of the biliary ducts and its results. Normally the entire biliary apparatus is sterile. I have (in Vir chop’s Arohiv, 119. Band, 1890) shown that in animals the introduction of bile into the peritoneal cavity does not cause a (atal peritonitis, and that the bile is really free from micro-organisms. The bile, however, though sterile, has no antiseptic qualities, but is a suitable medium in which microbes may grow and flourish. Hence it follows that the entrance of pathogenic bacteria into the biliary passages is fraught with utmost danger. The ampulla of Vater is normally/swarming with microbes which may be found at least half an inch up the duct. These are in health washed out by the dow of bile, but the arrest of this secretion enables them to ascend the duct and thus to produce their baleful action. I am convinced that in such cases ascending infection is the rule, though I do not deny the possibility of infection by the blood stream. Experimental ligation of the common duct may produce ascending infection df the biliary passages, especially if it be performed in the Last inch of the duct. Here injury to the duct wall acts as; a locus rcsistcnticc minoris. Ascending infection of the biliary passages is usually ushered in by rise of temperature, 101° to 105° F., with rigors and profuse sweats. The fever is markedly intermittent and frequently simulates malaria. Between the exacerbations the tempera- ture may fall to the normal or remain somewhat elevated. In other cMes, which are of serious omen, the temperature remains th/whole time at or near its maximum, this beine- an indication that the infection has reached and seriously pasts es the hVCr in addition t0 fche extrahepatic biliary Angiooholitis.—In this condition the intrahepatic biliary ducts are involved in the infective process. On post-mortem examination the liver is found to be swollen, pulpy, and infiltrated with pus. Some off the pus lies in the dilated intrahepatic biliary ducts, sonifi in real abscesses which have their origin in the periductal .connective tissues. * . fVir Gall-stone choleoystitis is/the result of ascending biliary duct infection attacking g gall-bladder containing calculi. Should the infection occur in a gall-bladder only recently occupied by gall-stones, the gall-bladder will form a definite swelling. If, however/’ it occur in a gall-bladder long the container of gall-stones and the subject of previous inflamma- tion, the sac, now cojftracted and shrunken, will not be able to assume tumour dimensions. The fluid in the gall-bladder be sero-purul'ent, purulent, or hemorrhagic, and in of some standing the viscus itself is adherent to may cases Vli (the duodenum, the transverse colon, iese adhesions are not infrequently dense and icter. neighbouring the pylorus), fibroid in chara Regarding the question of diagnosis, let me draw attention to the value/ of radiography. In many cases my colleague, Dr. W. Iropside Bruce, has given me assistance of very real value and has confidently and correctly diagnosed the gall- stones prfesent. In other cases he has reported that the evidence was inconclusive. Such have commonly been in fat patients, in some of whom I have found, in others failed to fincf, gall-stones. I think it only due to my colleague to say that in no case in which he has stated that calculi were present have I failed to find them. I conclude, therefore, that in skilled hands such as his a positive diagnosis has a sitive value. In some cases of calculous cholecystitis there Will be found just outside the margin of the right rectus abdominalis, at its junction with the costal margin, a swelling and in all a point of tenderness on deep pressure. The treatment of calculous cholecystitis is purely surgical, and it may be laid down that no delay, once the diagnosis has been established, is permissible. My preference in nearly ,11 such cases is for cholecystotomy with drainage of the ,11-bladder, an operation that, except in gangrene of the ga^l-bladder, has afforded me results that leave little to be desired. Cholecystectomy, or extirpation of the gall-bladder, has always appeared to me to be a more serious operation and to lack the virtue of drainage of the biliary passages which cholecystotomy affords. I reserve it solely for those cases in which I fear that the gall-bladder wall is seriously com- promised Ip whole or part. Cholecyst-duodenostomy—i.e., making an opening between the gall-bladder and the intestine (duodenum) or transverse colon (cholecyst-colostomy)—should, I consider, be purely performed and should be reserved for those rare cases' in which the common bile-duct obstruction cannot be relieved. I have in two such cases performed cholecyst-duodenostomy. Of suppurative pylephlebitis I have personal experience of one case only, and can therefore give you no information of any value concerning this condition. Gall-stone peritonitis is a condition which I have not in- frequently met with. Many cases are fortunately localised by adhesions and thus fori» encysted abscesses. Frequently the origin of the abscess is not diagnosed. I have twice last year opened a subhepatic abscess without obtaining any history of biliary colic. In onh case seven gall-stones were immediately passed by the incision and rapid healing resulted. In the other a biliary tjstula resulted which per- sisted for five months. A large gallstone was then felt with a probe at the bottom of the sinus. \ The sinus having been dilated, a large single stone was extracted with forceps and six weeks later the sinus closed. \ Far more serious are the cases of acute generalised peri- tonitis in which infected bile is poured out into the peritoneal cavity owing to sloughing of the wall of the gall-bladder or of one of the biliary ducts.' In my experi- ence this is a very fatal complication. Of the five cases that have come under my care, three occurred during an attack of biliary colic, and I confess that in two I did not immediately recognise, amid the agonising pain of biliary colic, that perforation had occurred. In the remaining cases perforation of the gall-bladder took place without any history of biliary colic, and the diagnosis of perforative peritonitis was easily made, though I attributed it to a duodenal or gastiic ulcer in both. One recovery out of five cases is my melancholy experience of this grave condition. Of biliary fistulas the result of gall-stones I have seen but few which$

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Urachal cyst simulating appendicular abscess : arrested development of genital tract : with notes on recently reported cases of urachal cysts / by Alban H.G. Doran.

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