[Reprinted from The Medical News, November 4, 1893.] 
CHOLECYSTOTOMY NECESSITATED BY OB- 
STRUCTION OF THE CYSTIC DUCT. 
By GEORGE S. BROWN/k.D., 
OF BIRMINGHAM, ALA. 
P. H. L., white, twenty-five years of age, a contractor, 
and a strong, hearty man with a splendid personal and 
family record, has lived all his life out of doors. On July 
i, 1893, at 11 p.m., after having eaten a hearty supper, 
he was awakened from sleep by severe colic in the epi- 
gastrium. The usual household remedies failed to give 
relief, and he suffered all night. At 11 a.m. on the next 
day I saw him, and at once administered a hypodermatic 
injection of morphin (}4 gr.), and gave him an ounce of 
castor oil by the mouth. He vomited the oil at once. The 
vomiting, which soon became bilious in character, con- 
tinued at frequent intervals all of that afternoon and night; 
and the pain was so severe as to necessitate repeating the 
morphin injection about every four hours. At 4 a.m. on 
July 3d I was hurriedly sent for. I found the man with 
all of the symptoms of a general peritonitis. His tempera- 
ture was 103°, his pulse 110; the belly was swollen, hard, 
and tender; the legs were drawn up, and the face anxious. 
Vomiting was frequent. A rupture of some kind being sus- 
pected, preparation was made for an exploratory incision. 
By the time our arrangements were completed, however, 
about two hours later, the pulse and temperature had 
fallen a little, and the left side of the abdomen seemed 
not quite so tense. It seemed probable now that the 
peritonitis would prove to be limited to the right side, and 
we therefore deferred the exploration. 2 
Although the chances were in favor of the appendix 
being the seat of trouble, no tumor was discoverable in 
that region, and the pain and tenderness were greatest in 
the epigastrium, although the whole right side was tense 
and sensitive. During the next forty-eight hours the 
patient was in constant pain, and he was again given 
morphin (gr. ) with the needle every four or five hours. 
He had hiccough now at times, and complete obstipa- 
tion. All of this time we had been using enemata of every 
kind without result. The localized peritonitis in the epi- 
gastrium was clear enough now, and as he said that he 
thought he had swallowed some plum-seeds just before 
his attack began, obstruction from them was considered 
possible, with appendicitis, some trouble with the gall- 
bladder, and volvulus. 
On the fifth day after the attack began, a little fecal 
matter came away in the warm-water enema. He was then 
given one- drop and two-drop doses of croton oil cautiously, 
until he had taken in all fourteen drops, over a period of 
two days. All of this moved his bowels very slightly. He 
was then given ten grains of calomel, which had the de- 
sired effect. On the eighth day the pain and fever and 
tenderness began to subside, and on the tenth day his 
pulse and temperature were normal, and he had no pain 
and only slight tenderness. 
His diet was limited to peptonized milk, and during 
the three days in which he had no fever he complained 
that even a very small quantity of the milk made him 
feel unaccountably full. On the night of the thirteenth 
day, after having taken more of the milk than usual, he 
had a painful vomiting attack, and the old pain and 
fever gradually came back. After daily examinations 
of the hepatic region, a slight fulness of the liver was 
apparent. The right side was an inch larger than the 
left, and there was a visible fulness of the intercostal 
spaces in the axillary line. 
On the sixteenth day the obstipation returned. On the 3 
eighteenth day the temperature reached 1020. On the 
seventeenth the temperature remained at 102°, the pulse 
was no, and patient was altogether worse. On the 
eighteenth he was again given ten grains of calomel, 
with no result. At this time a tumor in the region of the 
gall-bladder was apparent, and a slight jaundice appeared 
for the first time. 
At 8 a.m. on the twentieth day I cut down on this 
tumor. It was found to be the transverse colon, the 
border of the liver, and the gall-bladder, all massed 
together by inflammatory material, undoubtedly the re- 
sult of the localized peritonitis of two and a half weeks 
before. The gall-badder was greatly distended, but was 
covered in front by the colon. With a little difficullty 
the adhesions were broken up, and the gall-bladder was 
exposed. 
I now attempted to break through the adhesions suffi- 
ciently to palpate the ducts, but on the escape of a little 
bile, the attempt was abandoned and the torn adhesions 
were packed with gauze. I now stitched the gall-bladder 
to the abdominal wall and freely incised it. It contained 
eight or ten ounces of dark-colored bile. On introducing 
the irrigator about a tablespoonful of hardened par- 
ticles was washed away. None of them was hard 
enough to be called a stone, nor could any stone be 
found with the forceps. The pouch-like cavity was about 
five inches deep. The wound was dressed with a strip 
of gauze for drainage. More of these particles were washed 
out on the second and third days, and on the fourth 
day the wound was discharging a large quantity of golden- 
yellow bile. At this time the jaundice had disappeared, 
and the pulse and temperature were again normal. 
The patient now gained strength very slowly up to the 
fourteenth day. As he had no fever or pain, and was eat- 
ing and sleeping well, this slowness seemed to be directly 
due to the large quantity (at least two pints every twenty- 
four hours) of the bile he was losing. One or two lumps 4 
of the inspissated bile came away on the dressing every 
day, and an occasional washing brought away more. 
On the fourteenth day after operation, he again com- 
plained of fulness after eating; his stools became putty- 
colored, and the amount of bile from the fistula markedly 
increased. He was put upon full doses of sodium phos- 
phate. The amount of fluid was now very much in- 
creased, and very much diluted, so that it was almost 
colorless; this seemed to be due directly to the sodium 
phosphate. 
On the night of the eighteenth day he had another 
severe attack of colic, and on the next day the bile again 
appeared in the stools, and the amount discharged from 
the fistula very rapidly diminished, so that from that time 
on the dressings were only slightly stained. 
This last attack of pain the patient thought was due 
to the omission of the sodium phosphate, because the fluid 
discharged immediately became thicker and less in 
quantity. And it seems to me that this was a very good 
explanation, in that it probably allowed a piece of 
inspissated bile to lodge in the common duct. After this 
the bile had an uninterrupted flow into the duodenum, 
and from this on the recovery was rapid. The fistula 
was entirely closed six weeks after the operation. 
I think it most probable that this patient’s trouble was 
caused by a small stone, which first lodged in and then 
ruptured the cystic duct. Had it been in the hepatic or 
common duct there could not have been the free flow of 
bile which he vomited all through the first day and night. 
After this the inspissated bile which was present in the 
gall-bladder allowed the bile to enter, but acting as a 
valve prevented its outflow into the intestine. The 
escaping stone and a small quantity of the fluid were 
sufficient cause for the localized inflammation. 
I was rendered invaluable advice and assistance in 
this case by Drs. Cunningham, Wilson, and Thomas D. 
Parke, of this city.