A CASE OF BILIARY CALCULUS: 
Cholecyslolomy; Duodenal Fistula; 
J. F. A. ADAMS, M.D., 
PITTSFIELD, MASS. 
iY 
Reprinted from the Boston Medical and Surgical Journal of 
January 21, 1892. 
BOSTON: 
DAMRELL & UPHAM PUBLISHERS 
No. 283 Washington Street. 
1892. s. J. PARKHILL & .CO., PRINTERS 
BOSTON A CASE OF BTLIARY CALCULUS; CHOLECYS- 
TOTOMY; DUODENAL FISTULA; RECOV- 
ERY.1 
Mr. B., aged thirty-eight, married, manufacturer, 
residing at Bridgeport, Conn., consulted me November 
22, 1890, and gave the following history: 
For ten years past he has suffered from attacks of 
severe abdominal pain, at intervals varying from two 
or three weeks to two or three mouths. The first of 
these attacks was followed by local peritonitis, since 
which he has had four other attacks of peritonitis fol- 
lowing the pain, which has always been in the region 
of the gall-bladder. 
Two years ago, after an unusually severe attack, he 
had jaundice for the first time, accompanied with nausea 
and itching. In three or four weeks the skin resumed 
its normal color. Since then the attacks of pain have 
not usually been followed by jaundice. 
In August, 1890, while in England on business, he 
had a severe attack of pain, followed by local periton- 
itis, but not by jaundice, except a slight yellow tinge of 
the conjunctiva. He returned home immediately after 
and suffered on the voyage from constant pain and 
tenderness. After reaching home he was confined to 
his bed for ten days with a temperature of 101° to 
103°. Since that time the attacks of pain have in- 
creased in severity, and have occurred about once in 
two weeks, relieved only by hypodermic injections of 
morphia. Jaundice also appeared in September, and 
has since been persistent and very deep in color. 
BY J. F. A. ADAMS, M.D., PITTSFIELD, MASS. 
1 Read at the quarterly meeting of the Berkshire District Medical 
Society, July 29, 1891. 2 
Since jaundice appeared each attack has been accom- 
panied with nausea, which had not previously occurred. 
There has been constant tenderness over the gall- 
bladder since the attack in August, and the stools have 
been white or light clay-colored, as they have always 
been for a few days after an attack of pain. The 
urine has been coffee-colored. The patient has lost 
fifty pounds in weight during the last three months. 
He is naturally a robust, vigorous, cheerful man. He 
is now thin, yellow and feeble, with a haggard and 
dejected expression. 
At this time I gave him some general advice, and 
advised an operation. 
The patient came to see me again the last of De- 
cember. He had had an attack of pain December 
17th, since when the jaundice was diminished and he 
had felt generally better. 
On December 30th I went with him to see Dr. Wil- 
liam W. Seymour, of Troy, who had himself sub- 
mitted to the operation of cholecystotomy in Decem- 
ber, 1889, at the hands of Mr. Lawson Tait, and had 
reported his case in very attractive style in the Medical 
Record for December 6, 1890. Dr. Seymour gave us 
a detailed account of his former sufferings, of the oper- 
ation, and of the completeness of the cure; showed us 
his cicatrix and phial containing his one hundred and 
fourteen calculi. We saw in him a big, active, athletic 
man, a monument to the success of cholecystotomy. 
Mr. B. was very favorably impressed, and made up 
his mind that he would submit to the same operation 
if the attacks continued. But, as he then thought 
himself much better, he preferred to wait a little. 
The next day, December 31st, while on his way to 
Bridgeport, he had one of his severest attacks, and 
during the next three weeks he had one severe attack 
and three milder ones. 3 
On January 24th he came to Pittsfield by way of 
Boston. Just before leaving Boston pain came on 
again and caused him intense suffering during the 
journey. There was no hypodermic syringe at hand, 
and he felt only slight relief from the inhalation of 
chloroform. Soon after his arrival he was relieved by 
morphia, but the pain returned and continued for more 
than twenty-four hours, requiring morphia again on 
the following day. On that day the temperature was 
normal and pulse 80 to 100. There was tenderness 
over the region of the gall-bladder and pain there, and 
also below the right scapula. No increased dulness 
or other indication of a distended gall-bladder, and no 
enlargement of the liver ; urine very dark brown ; skin 
deeply jaundiced. 
On the third day the pain was less, but the temper- 
ature rose to 101.5°, and pulse to 108. On the fourth 
day, a sharp attack of pain came on with nausea and 
vomiting. He was again relieved by morphia. After 
this there was no more severe pain, but tenderness 
was great for three days longer. During the week he 
had taken almost no food, and for a week after he 
took only liquid food in small quantities. 
The patient was now told that surgical interference 
could no longer be deferred with safety, and readily 
consented to the operation. It was decided that this 
should be performed by Dr. William T. Bull, of New 
York, at the House of Mercy, in Pittsfield, on the 
15th of February. 
On the morning of the 13th he took a dose of Carls- 
bad salts which caused two dejections, soon after which 
he was again seized with pain which lasted all day, 
with excessive tenderness and vomiting. The next 
day he was free from pain, but had slight tenderness 
and occasional nausea. Pulse and temperature normal. 
On Sunday morning, February 15th, be went to the 4 
House of Mercy, where cholecystotomy was performed 
by Dr. Bull, who has kindly furnished me the follow- 
ing description of the operation : 
“ A four-inch vertical incision over the cartilage of 
the ninth rib exposed the abdominal cavity. The gall- 
bladder was not prominent, but was easily brought 
into view by wedging the adjacent intestine out of the 
way with flat sponges. It appeared to be constricted 
about its middle. The fundus was aspirated and two 
drachms of bile removed. It was then opened, the 
wound held apart with artery clamps; a soft bougie 
and also a probe was passed through the constricted 
body, and was arrested by a calculus which could be 
distinctly felt with the finger. It could be moved to 
and fro, a distance of two inches, apparently in the 
dilated cystic and common duct. The structure was 
overhung by the duodenum, and united to it by such 
firm adhesions that I could not separate them without 
fear of tearing the wall of the intestine. In conse- 
quence of this adhesion, the finger felt the calculus 
through the wall of the duodenum, when it was pushed 
in the lowest position it would occupy. When it was 
forced into its highest position it was close against the 
under surface of the liver, and the part of the duct it 
occupied appeared to be free from the duodenum. It 
was difficult in the field of operation to determine the 
precise limits of the duodenal wall. In making the 
incision to remove the calculus the wall of the gut was 
incised for a distance of half an inch where it lay over 
the duct. The wound was closed with a continuous 
catgut suture through the mucous coat, and outside 
this interrupted Lembert sutures. 
“ The incision in the wall of the duct was left open, 
a rubber drain inserted in it, and the edges of the in- 
cised gall-bladder sutured with catgut to the parietal 
peritoneum. The viscus was not long enough to per- 5 
mit the skin to be included in this suture. The drain 
was surrounded with tampons of iodoform gauze and 
the abdominal wound closed by silk sutures about them 
and the tube.” 
Duration of operation two and one-half hours : chloro- 
form was the anaesthetic. 
The calculus was oval, of the size and shape of a 
nutmeg, and weighed 55 grains. Its longer diameter is 
inch and its shorter diameter f inch. 
This operation was beset with unusual difficulties, 
for the following reasons : 
(1) The gall-bladder was hidden behind the in- 
testines and liver, and when found was contracted and 
contained no calculus. 
(2) The calculus was in the dilated duct, was hidden 
behind the duodenum, and united by firm adhesions to 
the surrounding structures. 
(3) The operation was protracted by the necessity 
of sewing up the incised duodenum. 
(4) Owing to the deep position of the gall-bladder 
and duct and to the adhesions which held it there, the 
incised edges could not be accurately stitched to the 
abdominal wall, as is usually done, and the danger of 
the escape of bile into the peritoneal cavity was great. 
After the operation the patient was greatly pros- 
trated. In the evening he had a pulse of 108, tem- 
perature 98° and respiration 36. For four days fol- 
lowing, the pulse, which was feeble, ranged from 120 
to 150. Temperature 100.4° the second day, and 
100.2° the third day, after which it was nearly normal. 
On the second day the urine contained albumen one- 
tenth of its volume, but this disappeared on the third 
day and did not return. He suffered from severe pain 
in the wouud and whole of right side, and required 
hypodermic injections of morphia during the first few 
days. For forty-eight hours he took nothing by the 6 
mouth. Ou the third day he took champagne and on 
the fourth day he began to take peptonized milk. 
From the first he had eneinat.a of peptonized milk, after- 
wards alternated with beef-juice. 
The bile was discharged very copiously. For three 
days it was very watery and pale, being mixed with 
serum. After this it was thicker and bright yellow. 
The dressings were changed at first twice a day, but it 
was soon necessary to change them every eight hours and 
afterwards more frequently, sometimes every two hours. 
Great masses of absorbent cotton were completely 
saturated, as well as the bandase, clothing and bedding. 
This inflamed and excoriated the skin and caused great 
suffering. It caused him such pain to be moved that 
the dressing became a very difficult matter. The bile 
escaped arouud the tampon and not through the tube. 
On the eighth day the sutures were removed. The 
wound had then healed, except where kept open by 
the tampons. The bile flowed chiefly from the lower 
angle of the wound and not through the tube. It was 
yellow and green, with much watery fluid, and the 
skin was inflamed wherever touched by the wet dress- 
ings and clothing. 
With the discharge appeared a few white specks 
which, on examination, proved to be milk-curd. It 
was therefore evident that the wound in the duodenum 
was not united, and that its contents were escaping. 
The three tampons surrounding the tube were re- 
moved on the eleventh, twelfth and thirteenth day. A 
cavity was then left, two inches in diameter and two 
inches deep, lined with healthy granulations. The 
tube was removed and found to penetrate one inch 
deeper than the bottom of this cavity. The tube was 
not obstructed. It was cleansed and replaced and 
surrounded with tampons. The bile, however, con- 
tinued to flow out around the tube uutil March 7th, 7 
the twenty-first (lay, when additional fenestrae were 
cut close to the inner end of the tube and the cavity 
packed very tightly with wool. After this the dis- 
charge came chiefly through the tube. 
The discharge from the duodenal fistula continued 
till March 14th, four weeks after the operation. For 
one week longer, bubbles of gas escaped during the 
dressing, and after this the fistula remained closed. 
As long as nothing but milk and liquids were taken 
by the mouth, the discharge from the fistula was very 
watery. It was at first acid in reaction, but after- 
wards neutral ; but it was excessively irritating, and 
excoriated the whole side and back. It never con- 
tained more than a few small particles of curd, though 
very large quantities of milk were taken. The caseous 
mass passed onward through the duodenum, while the 
watery portion poured freely out from the fistula. 
When solid food was taken the discharge from the 
fistula was genuine chyme. 
When the tampons were removed, as they were 
daily, the cavity surrounding the tube would imme- 
diately fill with half an ounce or more of bile and food. 
The bile came from the right side of the tube, and the 
food from the small orifice at its left side. As soon 
as this was withdrawn by a syringe it would well up 
again from the bottom. The amount of bile was 
amazing, but it could not be measured. 
The wound granulated rapidly, and on March 26th, 
five and a half weeks after the operation, had closed 
firmly about the drainage-tube. This was then re- 
moved and a smaller one substituted, which was kept 
in for two weeks longer. On April 4th, seven weeks 
after the operation, the discharge of bile ceased for a 
time, and bile was then first seen in the stools. Bile 
was occasionally discharged from the tube, however, 
until April 18th, after which no more was seen. This 8 
was nine weeks after the operation. When the flow 
of bile was first checked, pains would be felt like the 
premonitory pains of of his former colics. When bile 
reappeared at the wound, the pain ceased. A slight 
serous oozing continued till May 13th, since when 
there has been no discharge of any kind. 
The stick of nitrate of silver was occasionally used 
to facilitate the closure of the sinus. The grauulatiug 
surface was liberally dusted over daily with aristol, 
which acted admirably. For the protection of the 
skin, ointments were at first used, such as lanoline and 
zinc ointment; but the dry application of bismuth was 
found more comforting and healing. Tampons of 
wool were found better than cotton or gauze, as by 
their elasticity they kept the bile out of the wound 
and forced it to flow through the tube. 
The bowels were at first obstinately constipated. 
Repeated enemata were given, as well as salines by 
the mouth; but nothing came away except the debris 
of the nutrient enemata until the twelfth day, after 
which the stools were liquid and dark-colored until 
the twenty-first day, when the first milk-curd appeared 
in the stools. These were colored till the twenty-sixth 
day, after which they were nearly white in color aud 
very copious till the forty-ninth day, when the normal 
color returned. There was therefore no movement 
from the upper portion of the bowels for three weeks, 
owing in part, no doubt, to the escape of the liquid 
portion of the food, as well as to the morphia which 
had to be given to a greater or less extent during that 
period. 
No periodicity could be discovered in the discharge 
of bile ; but the duodenal discharge varied with the 
feeding. It was constant as long as liquid food was 
taken at short intervals ; but when regular meals were 
taken, it came in floods about an hour after meals. 9 
For the first two weeks the patient was unable to 
turn himself in bed. At the end of four weeks he sat 
up in bed, and at the end of six weeks was walking 
about the hospital. He became greatly emaciated dur- 
ing the first four weeks, while the duodenal fistula was 
open, but began to gain flesh as soon as this was closed. 
The jaundice began to fade immediately after the 
operation, and at the end of six weeks had all disap- 
peared except a slight yellow tinge upon the abdo- 
men. 
I went out of town on the 1st of April, six and a 
half weeks after the operation. He was then wearing 
the small tube, but was up and dressed. Dr. F. K. 
Paddock took charge of him during my absence. On 
my return on the 13th of May, Mr. B. met me at the 
station, looking well and very happy. Since then he 
has been well, though not very strong. He has had 
regular bilious stools, no pain, no jaundice and has 
gained flesh. Two Volumes yearly, beginning with the first Nos. in January and July. But 
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