Introduction to the differential diagnosis of the separate forms of gallstone disease, based upon his own experience gained in 433 laparotomies for gallstones

Introduction

TO THE

DIFFERENTIAL DIAGNOSIS

OF THE

SEPARATE FORMS OF

BASED UPON

HIS OWN EXPERIENCE GAINED IN 433 LAPAROTOMIES FOR GALLSTONES

BY

PROFESSOR HANS KEHR

HALBERSTADT

WILLIAM WOTKYNS SEYMOUR, A. B., YALE, M.D., HARVARD

FORMERLY PROFESSOR OF GYNECOLOGY IN THE UNIVERSITY" OF VERMONT ; FELLOW

OF THE AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS ;

SURGEON TO THE SAMARITAN HOSPITAL, TROY-, NEW YORK

WITH AN INTRODUCTION BY PROF. KEHR

PHILADELPHIA P. BLAKISTON'S SON & CO.

I O I 2 WALNUT STREET I 9O I

Copyright, 1901, by WILLIAM WOTKYNS SEYMOUR

PRESS OP SHERMAN &. CO., "P H I I . A -n-RT.-PTTT A

TRANSLATOR S DEDICATION

TO THE MEMORY OF MY FATHER

WILLIAM PIERCE SEYMOUR, A.B., WILLIAMS, M.D., UNIV. OF PENNA.

1825— 1893

A RARE PRACTITIONER, AN ACCOMPLISHED OBSTETRICIAN

HE ADVOCATED OPERATION FOR TYPHLITIS IN 1 85 7 :

FOR A GENERATION TAUGHT THE INFECTIOUS NATURE OF PNEUMONIA :

THAT A VISIBLE MEMBRANE WAS NOT ESSENTIAL TO THE MALIGNANCY OF

DIPHTHERIA OR ITS DISTRIBUTION, AND WHILST PROF. OF OBSTETRICS

AT UNION UNIVERSITY TAUGHT THE EXISTENCE

OF THREE PHYSIOLOGICAL PLANES IN THE OBSTETRIC PELVIS :

THE PLANES OF ENTRANCE, ROTATION

AND THE PLANE OF THE ARCH

TRANSLATOR'S PREFACE.

The translator has, from the time of Tait's first operation, had a decided interest in gallstone surgery, which was increased bysome personal operations in that field. It was his painful experience to himself develop gallstone disease, which plagued him several years, and caused a still more lively interest in the treatment of cholelithiasis, especially the various operations for its relief. The tortures became so severe and the attacks so frequent that his professional work was done only under the greatest exercise of will power, and he was constantly pursued by the fear of morphinism or a break-down in middle life. In November, 1889, he underwent a cholecystostomy at the hands of Mr. Lawson Tait, with a complete restoration to health. Since then he has frequently advised operation for gallstone disease, and has himself in all done 30 operations, with 2 deaths. This includes 5 cases of stones in the common duct, 2 lithotripsies and 3 choledochotomies, which have all recovered. Gallstone surgery has not received in America the acceptation which it deserves. Not but that in McBurney, Richardson and others we have as good operators as exist anywhere, but because the large majority of the profession still cherish the delusion that gallstones can be dissolved, and regard at best operations for gallstone disease as a last resort. The works accessible to the general practitioner are written either from the standpoint of the internist, who still believes operation to be a last resort, or from the standpoint of the operating surgeon who devotes more attention to the technique of the different operations than to the diagnosis of the various forms of gallstone disease. It is the very great merit of Professor Kehr's book that it discusses fairly and thoroughly the viii TRANSLATOR'S PREFACE.

nature of the many-sided gallstone disease, particularly its differential diagnosis, and bases its surgical treatment upon the facts learned by an unrivalled experience at the operating table. He who carefully reads what Professor Kehr has written cannot fail to become a better diagnostician of this disease, which too often now remains years long unrecognized, to the suffering and loss of the patient. The results attained by experienced operators in this field are such that the dangers of early operation are as nothing compared with the tortures, loss of working capacity and danger to life associated with the disease. The labor of translation has been a labor of love, and I trust that in its English garb it may prove helpful to many who may become propagandists in the field of gallstone surgery.

Troy, New York, February, 1901.

PROF. KEHR'S INTRODUCTION FOR THE AMERICAN TRANSLATION.

Professor Seymour has in an amiable manner desired me, in an introduction to this translation of my " Diagnosis of Gallstone Disease," to give a brief resume of the results attained by my gallstone operations. To this I heartily accede. Until the present (on the 25th of November, 1900) I have had 547 gallstone operations, and have thus, of all living surgeons, done the most gallstone operations. The number is not so important ; the results are the chief thing, and of them I can report the following :

After 204 conservative operations on the gall-bladder (cystostomies, cystocotomies, cystendyses) I had 4 fatal results, whilst of 121 cystectomies 4, and of 97 choledoehotomies or hepaticus drainage cases 6 pursued a fatal course. Of gallstone disease complicated with carcinoma of the liver, of the gall-bladder, of the choledochus or the pancreas, or if there existed diffuse purulent cholangitis, peritonitis or cirrhosis of the liver, then the mortality rose to 47 per cent.

If one excludes these cases, against which every sort of treatment is absolutely powerless, then there are 422 gallstone laparotomies and 14 deaths ; 3.3 per cent, mortality.

Among the last 35 choledoehotomies or hepaticus drainage cases I have had no deaths to bemoan, which is to be regarded as the direct consequence of the operative procedure itself.

The more one operates, so much the more certain does one learn, naturally, to master the technique.

Choledoehotomies, for which I formerly required two or three

(ix)

X PROF. KEHR'S INTRODUCTION.

hours, I now complete in a half hour, and an easy cystectomy I do now frequently in ten minutes.

My statistics are, as also Dr. Muller of Wurzburg makes conspicuous in an article, well worth reading, in the Wurzburg Transactions, " Gallstone Disease and its Treatment," on this account very instructive, in that the simple operations involving the gall-bladder almost always ran a favorable course, and even difficult choledochotomies show a relatively small mortality of 6 per cent., whilst in the protracted cases, in which (unfortunately often by protracted internal treatment) peritonitis, cirrhosis of the liver, cholangitis, perforative processes, carcinoma of the gall-bladder had developed, we were far too frequently reminded of the impotence of surgical skill. Therefore it is most fitting to operate when the stones still remain in the gall-bladder, and not to dawdle with operative interference until they reach the deep ducts. This requirement will only seldom be followed. So long as cholelithiasis is limited to the gall-bladder, a positive diagnosis is always for the experienced no easy matter, and then it is implanted in the nature of man that the patient, in his dread of knife and narcosis, should submit himself more readily to a Carlsbad cure than to an operation. When, however, what I expect, the special diagnosis of cholelithiasis will be so much further advanced than heretofore, and the astounding results of gallstone surgeons shall become still better known, then will doctors earlier advise operation, and then will this branch of the operative healing art develop into a magnificent fruition and bear many beautiful fruits.

Since the publication of this book, in the summer of 1899, that is in the course of one and a half years, I have done 113 further gallstone laparotomies. With reference to the indications for operation, I have introduced no notable changes. In the selection of operative methods I have employed more and more the cystectomy in combination with hepaticus drainage. If I am compelled to appeal to the knife in an acute attack (in serous or purulent cholecystitis), then I give the preference to cystostomy,

PROF. KEHR'S INTRODUCTION. xi

the formation of a fistula. If I operate in the free interval, then I extirpate the gall-bladder, open up the cysticus and choledochus, and finally drain the hepaticus. Only in this manner will we avoid with certainty true and false recurrences. Concerning this very important point, I have sufficiently expressed myself in three very recently appearing articles :

1. " What is the Proportion of Recurrences after our Gallstone Operations?" Von Langenbeck's Archiv f. Klin. Chir., 61 Band. Heft 2.

2. " Concerning Recurrences after Gallstone Operations." Berlin Klinik, 1899, October.

3. Contributions to Abdominal Surgery, with Especial Attention to Eighty-four Gallstone Laparotomies done in the Past Year." Berlin, 1900. Fischer's Med. Verlag.

These last contributions form, in a way, a continuation of the introduction to the learning of the diagnosis of the separate forms of gallstone disease. May the translation of Professor Seymour, whom I heartily thank for the friendly interest shown in me and my book, contribute to gallstone surgery finding in America the same extension as is the case to-day in Germany. There still is in the entire capital surgery no field in which the operator can attain such brilliant results and earn so many thanks as in the field of gallstone operations.

Prof. Hans Kehr.

Halberstadt, 26 November, loco.

Part I. Page

Lecture I. — The Pathology and Pathological Anatomy of Cholelithiasis, . 19

On the general and special diagnosis of gallstone disease, 19 ; the latency of cholelithiasis, 25 ; cholecystitis, 26; Naunyn's views of gallstone colic, 27 ; the different forms of cholecystitis, 28 ; Riedel's foreign body inflammation, 28 ; pathologico-anatomical condition in cholecystitis, 30 ; hydrops of the gall-bladder, 31 ; spontaneous cure of cholecystitis, 32; conception of a cure of cholecystitis, 33-35 ; pericholecystitis, 36 ; peripyloritis, 37 ; fistula formation between gall-bladder and the hollow organs of the abdomen, 38 ; Contraction processes in the gall-bladder, condition of liver in cholecystitis, absence of jaundice, 39 ; Riedel's lobe, 39 ; different forms of jaundice, inflammatory, true lithogenous and functional, 41, 42; stones in the common duct, 44 ; thrombophlebitis and cholangitis, 44 ; sepsis, pyaemia, carcinoma of the gall-bladder, 45, 46 ; the pathological anatomy is the foundation for the special diagnosis and treatment of gallstone disease, 48.

Lecture II. — The Amnesis and Examination in Cholelithiasis, . . 50

The importance of an exact amnesis, 50 ; attention to age and sex, 52 ; the diseases of parents, brothers and sisters, 52 ; to the previous illness of the patient, 52 ; to the character of the pain, 53 ; to the occurrence of jaundice, 53 ; to fever, 54 ; to the condition of the stomach, 54 ; to the condition of the bowels, 54; to the bodily weight, 55; to the appearance of nervous symptoms, 55; to the use of morphine, 56; the examination of gallstone patients, 56 ; general examination, 57 ; special examination, 59; inspection, 59 ; palpation, 60 ; percussion, 63 ; auscultation, 63 ; exploratory puncture, 64 ; anaesthesia, 64 ; Rontgen ray examination, 65 ; examination of the blood, 65.

Lecture III. — The Special Diagnosis of Cholelithiasis, . . . 67

The different kinds of pain in cholelithiasis, 67 ; most gallstone colics the evidence of inflammation, 67 ; with stones in the gall-bladder the pain is

TABLE OF CONTENTS.

PAGE

mostly in the right bypochondrium, 68 ; variability of the pain according to the location of the stones, 68 ; difficulty of distinguishing ulcer ventriculi from gallstones by the pain, 68 ; ulcer of stomach difficult to demonstrate during a gallstone operation, 69 ; localization of pain in gallstones and ulcer of the stomach, 71 ; cramps of the stomach usually due to gallstone colic, 72 ; pathological anatomy of appendicitis and cholecystitis similar, 73 ; intestinal colic, 73 ; ileus, 73 ; liver colic of nervous origin doubtful, 74 ; peritonitis, 74 ; renal colic, 74 ; syphilis of the liver, 75 ; gastric crises of locomotor ataxia, 75 ; hernia of the linea alba, 75 ; pancreatic colic, 76 ; pancreatic cysts, 77 ; characteristics of gall-bladder tumors, 78, 79 ; typical cholecystitis, 79 ; differential diagnosis of gall-bladder tumors and tumors of pylorus, colon, etc., 80; from right-sided movable kidney, 81 ; acute obstruction of the common duct, 82 ; table in which the typical groups of gallstone disease are shown, 84, 85, 86 ; on the use of the table, 87 ; explanation of the table, 89 ; chronic obstruction of the choledochus by stone, 90 ; differentiation of chronic obstruction by stone and cancer, 91 ; the difficulty of anatomical diagnoses in certain cases, 94 ; fistulous communications, 94 ; Naunyn's classification of gallstone disease, 97 ; Kehr's classification, 97, 98; Riedel's, 98.

Lecture IV. — The Treatment of Cholelithiasis,

Frequency of gallstone disease, 99 ; latency of gallstones, 99 ; two methods of treatment, Carlsbad cure and operation, 99 ; no solvent for stones exists,

100 ; cholagogues, 100; the aim of internal treatment to bring about latency,

101 ; effect of Carlsbad springs, 101 ; von Winiwarter and Kraus as to the indications for operation, 102 ; results from various operations, 103 ; results improve with experience, 105 ; operations in two stages to be decried, 105 ; sutures causing recurrences, 105 ; conception of early operation, 106 ; the slight danger of early operation bears no sort of relation to the danger of the disease itself, 107 ; at Carlsbad mostly mild cases come under observation. 107 ; Naunyn's regular and irregular forms of gallstone disease, 108 ; Fiirbringer regards cholelithiasis as a grave disease, 109; Naunyn's clinical material and his views of the disease, no ; indications for a Carlsbad cure, 114; indications for operation, 115; the foundation for these views, 117; operation unnecessary in acute obstruction of the choledochus, 121 ; operation in all cases of cholecystitis cholangitis acutissima, 121 ; operation less dangerous in all suppurative processes in the abdomen than expectant treatment, 122; adhesions, 125 ; exploratory operation, 125 ; treatment of chronic recurring cholelithiasis, 127 ; treatment of chronic obstruction of the choledochus by stone, 129; morphinism an indication for operation, 130.

TAJ ILK Ol ( '( )N"I l.\ I S

XV

PART II. Cystic duct patent

Contents pur

One Hundred Clinical mjd Operation histories, of which the Close Study Assists Greatly in Learning the Special Diagnosis of Cholelithiasis,

Introduction, author's results in 409 gallstone operations, . . . .

Ouglit the practicing physician do gallstone operations, . . . . .

1. Stones in the gall-bladder with normal or but slightly altered walls. Cystic

duct patent. Contents clear bile. No adhesions, ....

2. Stones in the already often inflamed gall-bladder.

Contents pure or but little altered bile. Adhesions,

3. No stones in the gall-bladder. Cystic duct patent.

Adhesions, .......

4. Acute cholecystitis in a relatively but little altered distensible gall-bU

5. Acute cholecystitis in contracted gall-bladder,

6. Hydrops chronicus cystidis fellere, .

7. Empyema chronicuin cystidis felle:e,

8. Carcinoma of the gall-bladder,

9. Acute obstruction of the choledochus by stone, 10. II. Chronic obstruction of choledochus by stone,

12. Chronic obstruction of choledochus by tumor,

13. Inflammatory or lithogenous jaundice,

14. Stomach or gall-bladder or both affected,

15. Gallstone ileus, ......

16. The difficulty and impossibility of special diagnoses in certain cases, e biie. adder,

135 136

293 308 311