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t^<i 
 
 2Ai2S.^. 
 
 NOTES ON SOME RECENT GALL-STONE CASES. 
 
 BY 
 
 JAMBS BELL, M.D., 
 
 Surgeon to the Royal Victoria Hospital ; Consulting Surgeon to the Montreal General 
 Hospital ; Professor of Clinical Surgery in McGill University, &c. 
 
 (Reprinted from t/te Montreal Medical Journal, January, 1898.) 
 
-V **' 
 
 :ir« I 
 
 NOTES ON SOME RECENT (iALL-STONE CASES 
 
 BY 
 
 James Bei,l, M.D., 
 
 Surgeon to the Royal Victoria Hospital ; Consulting Surgeon to the Montreal General 
 Hospital ; Professor of Clinical Surgery in McGill University, &c. 
 
 Mr. pRESinENT AND GENTLEMEN : , 
 
 It is not my intention to read a paper on the snliject of cholelithi- 
 asis, nor even on any portion of the subject, hut simply to present, in 
 connection with the specimens removed V)y operation, very condensed 
 reports of the cases upon which I have operated during the past 
 summer and autumn. They are as follows : 
 
 Case I. — Mrs. T., aet. 40, a slight woman, normal weight 100 lbs., 
 married 18 yeax-s, the mother of three children, the youngest eight 
 years of age, came under observation on the 11th of May, 1897. Her 
 first attack was nini- years ago ami is described as a severe aching 
 pain through the right side and more or less through the whole upper 
 zone of jhe abdomen, lasting about half a day, accompanied hy vomit- 
 ing and followed' by a tumour the size of a man's tist, just inside the 
 I'ight anterior superior iliac spine. This was tender and painful and 
 she was confined to her bed for seven weeks. During this time the 
 tumour was painful on movement of the body. She was then quite 
 well for three years, except that she felt some pain in the side after 
 every unusual exertion. Six years ago she had a second attack, 
 accompanied by nausea and vomiting and lasting about the same 
 length of time ; athough she was not confined to her bed for so long 
 a period and had no tumour following the attack. She then remained 
 well until March, 1897, except that on exertion she felt some pain in 
 the right side. She had a series of attacks siniilai- in charactei* about 
 
 ^ Read l)C"fore the Montreal Medico-Chirurgical Society, Pec, 10, 1S97. 
 
the first and fifteenth of March and the first of April (1897), and two 
 others durinpf the month of April, while in bed, which slie only left to 
 come to Montreal on the 11th of May. On being (|ueationed, she 
 remembered having had indefinite abdominal pains for years prior to 
 the first attack nine years ago. She had always enjoyed good general 
 health and had never suffered from jaundice, dyspepsia or uterine 
 troubles. During her illness her weight had fallen to 89 lbs. On 
 examination of the abdomen a hard and tender mass was felt just 
 external to, and about an inch below the umbilicus on the right side 
 It could be traced up more or loss indefinitely to the costal margin, in 
 the nipple line, and moved slightly with the movements of respiration. 
 On account of the evident inflammatory nature of the attacks and the 
 situation of the tumour a diagnosis of appendicitis had been made. 
 The operation of cholecystostomy 'was performed on the 17th of May. 
 when four large and 132 small stones were removed. The four large 
 stones stood one upon another in a column extending outwards from 
 the neck of the cystic duct, the deepest one being firmly impacted in 
 the duct and broken in removal, which was effected with much diffi- 
 culty. The small stones were free in the gall-bladder, which contained 
 a small amount of pus, the latter being sterile on cultivation. 
 
 This patient made an uninterrupted recovery, and was discharged 
 on the 5th of July, with the wound not quite closed. Within the last 
 three months I have heard from her that her health is excellent but 
 that the fistula still persists. 
 
 Case II. — Mrs. W., a stout woman, ret. 50, an epileptic, married, 
 and the mother of one child, now grown up. Her first symptoms 
 appeared in April, 1895, a.s an attack of biliary colic, accompanied by 
 vomiting, chills and fever, for which she spent three weeks in the 
 Homeopathic Hospital. She says she was jaundiced then. Since 
 then she has had a great many similar attacks and was admitted to 
 the Royal Victoria Hospital on tlic 18th of July, 1897, with slight 
 yellowness of the skin. Cholecystostomy was done on the 24th of July, 
 and 124 stones removed. The patient made an uninterrupted recovery 
 and was discharged on the 14th of August in good health and with 
 the wound soundly healed, although there had been for some time 
 after operation a very great flow of bile externally. 
 
 Case III. — Mrs. B., aet. 48, the mother of six children, had suffered 
 from a dull pain about the right hypochondrium for 22 years. In 
 December, 1895, she began to have attacks of sharp pain about every 
 three weeks, and about Christmas of that year a dull pain extending 
 into the right shoulder region. In March, lS9fi, she had the first 
 attack of severe biliary colic, accompanied by chills, perspiration and 
 
3 
 
 vomiting. These attacks continued, sometimes recurring as often as 
 every three weeks, and an attack in January, 1H97, was followed by 
 jaundice. In the intervals between the severe attacks she suffered 
 from the dull pain above described. When admitted to the hospital 
 on the 24th of July, 1897, she was a well nourished woman with a 
 systolic murmur at tlu; ape.K of the heart, but otherwise healthy 
 A smallish smooth round tumour could be felt in the region of the 
 gall-bladder and on palpatic^n the crepitus of the stones moving upon 
 one another could be distinctly felt. She was operated upon on the 
 29th of July. The gall-bladder was moderately distended, containing 
 a small quantity of normal bile. Sixty-six facetted stones were 
 removed ; (j2 of them wen; free in the gall-bladdin- and were removed 
 without difficulty. Another was removed with great difficulty fron» 
 the neck of the duct, and a group of three were impacted in the cystic 
 duct .so firmly that an incision was ma'le through its walls, through 
 which they were removed. This incision was closed by tino silk 
 sutures. There was no flow of bile during the operation, after the 
 gall-bladder had been emptied. The gall-bladder was fixed in the 
 wound in the usual way, and after a few days bile began to How 
 through the tube, though never in great (juantity. The patient made 
 an uneventful recovery and was discharged on tlu; 8th of September, 
 with a very slight serous discharge from the site of the wound. 
 
 I have since heard that the sinus persists, although her health is 
 good and she is free from pain. 
 
 Case IV. — Mrs. C., fet. 47, a large woman with flabby pemlulous 
 abdomen, the mother of 1 1 children, the last born six years ago, was 
 admitted to the Royal Victoria Hospital, in a deeply jaundiced con- 
 dition, on the 13th of August, 1897, with the following history : She 
 had her first attack of pain in the right hypochondria.:, in 1881. 
 This was not accouipanied by vomiting or chill, but was followed by 
 jaundice. Similar attacks occurred about once in two years up to 
 1894, when she had a much more severe attack, in which she suffered 
 for 12 days. In the next two years she had one attack each year. 
 Each of these attacks was also followed b}' jaundice. Since May 
 1897, she has had many attacks, and the jaundice has never entirely 
 disappeared. The .stools have been colourless and the urine dark all 
 the time. The last attack began on the 2Gth of July, and lasted for 
 three days. Since then the jaundice has been extreme, and has 
 increased rather than diminished. The abdomen was opened on the 
 17th of August. The gall-bladder was found empty and shrunken. 
 The liver was enlarged and firm, and the lower border thick and 
 rounded. There were many firm old adhesions between the lower 
 
surface of the liver ami the adjacent viscera. On exposing the ducts 
 a stone was felt in, the common duct, about half an inch from the 
 duodenum. It appeared to be about the she of a large marble and 
 was firmly fixed in the duct, and could not bo moved along it in 
 either direction. A longitudinal incision was made in the duct and 
 the stone removed. It was not a haril stone and was broken in 
 removal. As it was turned out of the duct a gush of bile followed 
 This was sponged out and the incision^ closed by sutures. A drainage 
 tube was passed down to tln' border of the duct and iodoform gauze 
 packed around it. The patient made an excellent recovery, Tlie 
 jaundice grndiially disappeared, nnd the stools and urine regained their 
 normal colour in a few day.s. She was di.schnrged on the 1st of 
 Octolier quite well. 
 
 This was a solitary stone which had evidently been in tlu; ooniUKm 
 duct for a very long time. 
 
 Ca.sk V^. — Mrs. H., mt. 2.'}, married, the mother of two children, the 
 youngest 14 months old, had her first attack of biliary colic on the 
 1st of April, 1.S97 Fronj that time to the 1st of June, she had five 
 similar attacks, very severe pain in the I'ight hypochondriuu), lasting 
 about four or five liouis, accompanietl by vomiting an<l followed by 
 per.'<piration. The sixth attack on the 1st of June lasted more or less 
 for nine <lays, and was followed by .slight jaundice. Then she had an 
 attack every 24 hours for ten days with more intense juandice, colour- 
 less stools and high coloured urine. From that time until her admis- 
 sion to hospital she had attacks ever}- three or four days, lasting 
 about three hours each, and with persistence of the juandice. Her 
 physician was able at this time to palpate a tumour in the region of 
 the gall-bladder. On the evening of the IHth of Augu.st, she left 
 home to come to Montreal, a distance of some 60 miles, by train. She 
 suttered intensely during the trip and all through the night, but was 
 relieved in the morning. She was operated upon on the 25th, one 
 week later. During this week she had no attacks, the tenderness 
 dimini.she(l greatly and the jaundice lessened perceptibly. The first 
 two stools were colourless, the next two slightly coloured, and the last 
 two (in this week) almo.st normal in colour. Careful examination of 
 the stools, however, failed to discover any gall-stones. It was there 
 fore a question whether this woman should be submitted to operation 
 or not. ()p»;ration was decided upon and the abdomen was opened 
 on the 25th of August (as already stated). The gallbladder was 
 found large and flabby and the bile ducts dilated to the size of a large 
 lead pencil. The head of the pancreas was hard and thickened 
 (apparently inflammatory thickening), but there were no stones in any 
 
\ 
 
 of tho bile passages. The stone, or atonos, had evidently been passed 
 in tho hwt attack, altliough tlit'y were not found in the stools. The 
 patient made an uneventful recovery and was dischorged on the 23rd 
 of September. 
 
 Case VI. — Mrs. P., ret 30, a medium .sized, well nourished woman, 
 tho mother of five children, ranging in age from 12 years to 11 
 months, was admitted to the Royal Victoria Hospital, on the 13th of 
 September, 1897, with the following history : On the 27th and 28th 
 of August she had had an attack, each day, of biliary colic. Tender- 
 ness persisted and a mass was palpable in the right side of the 
 abdomen, below the co.stal margin. She had sutl'ered froin more or 
 less constant uneasiness in this region for six years, and during her 
 labors she had suffered more in this region than in the uterus. 
 
 Cholecystostomy was done on the 13th of Septentber. The gall- 
 bladder contained about an ounce of colourless viscid fluid, sterile on 
 cultivation and seven facetted stone.s. The operation was simple and 
 recovery uneventful. She was discharged with the wound completely 
 healed on the 14th of October, 18D7. 
 
 Case VII. — Miss C, jet. 35, unmarried, and previously healthy, 
 while suffering from typhoid fever, (about the end of the second 
 week), was seized with pain, vomiting and a tall of temperature, (to 
 94.5''F), — a condition of collapse suggesting jierf oration, — early in the 
 morning of the 21st of September, 1897. She rallied in a few hours, and 
 a painful, tender and rigid condition developed just below the right 
 costal margin. The abdomen was opened in the linea semilunaris 
 on the 24th of September, at 4.30 p.m. There was no general peri- 
 tonitis, bnt the gall-bladder was distended and covered with patches 
 of lymph, which extended over the lower border of the liver and to 
 the adjacent coils of colon and duodenmn. There was no perforation. 
 The gall-bladder was aspirated and 6 oz. of pus, which gave pure 
 cultures of the typhoid bacillus, withdrawn. It was then incised and 
 152 facetted stones removed, and the operation of cholecystostomy 
 completed in the usual way. The wall of the gall-bladder was very 
 dark, cedematous and friable. A drainage tube was inserted and bile 
 flowed freely. On account of the pre-existing localized peritonitis an 
 opening was left on the lower angle of the abdominal wound, through 
 which a drainage tube and iodoform gauze packing were carried up 
 along the under surface of the liver between the bile passages and the 
 intestines. The patient's condition was excellent until the morning of 
 the 26th, when «vmptoms of perforative peritonitis began about 7 
 p.m., and she .sar/.. and died at 4 a.m. next morning, the 27th of Sep- 
 tember. The wound was dressed at 4.30 p.m. on the 26th and the 
 
tubii njiiiovfd. The intraperitoneal drain and packing were also 
 rcniovod and the packing renewed at the .same time, wlien everything 
 lot»ked (|uit<' well and promising. Bile continued to How from the 
 opening in the gall-bliidder to the end, and there was no evidence that 
 it had given way, A partial post-mortem examination wa8 nuide 
 through the operation wound, 11 hour.s after death. A general 
 purulent peritonitis was found and four .small facetted stones were 
 removed fiom a pocket at the lower angle of the wound. The 
 walls of the gall-bladder were injected *nd its mucosa much thickened 
 and of a deep green colour. The .surrounding liver tissue was pale 
 and leathery, with multiple focal miliary necrosis. The small intes- 
 tine was removed and showed the typical anatomical lesions of 
 typhoid fever. A rupture through a typhoid ulcer was found, (but 
 may have been made in the removal of the intestine), about eighteen 
 inches abovt? the ileocecal valve. In the absence of a complete post- 
 mortem examination of the abdomen, my interpretation of the sudden, 
 fatal termination in this case i.s, that ulceration of the deeper part of 
 the gall-bladder or the cystic duct had taken place into, or upon the 
 adjaeont under-surface of the liver, and that it was the bursting and 
 emptying of this abscess cavity which set up the fatal peritonitis. In 
 no other way can I account for the presence of four gall-stones in the 
 peritoneal cavity, as I am sure they did not e.scape into the abdomen 
 at the time of operation and the steady flow of Itile externally for 
 hours after the fatal symptoms set in, showed that there could not be 
 any direct communication with the abdominal cavity. Moreover, the 
 wound was examined and the gall-bladder sutures were found intact 
 live hours after the onset of the symptoms. 
 
 Ca.sk VIII. — Mrs. P. H. A., set 25, a medium-sized, well nourished 
 woman, the mother of thi'ee children, was admitted to the Royal Vic- 
 toria Hospital on the 10th of October, and operated upon the next day. 
 In August, 1893, two weeks after confinement, she had her first attack 
 of biliary colic, preceded by a chilly feeling and followed by vomiting. 
 She then had attacks every two weeks, until the end of September, 
 1893, when she had a very severe attack, which was followed by 
 jaundice for 24 hours. She remained well until the 15th of August, 
 1897, when .she contracted measles and the attacks returned ; and 
 the gall-bladder became tender and palpable. The last attack of 
 biliary colic was on the 6th of September, 1897. 
 
 At the operation, the gall-bladder was tense and distended, and 
 contained several ounces of thick creamy pus, and a single stone. 
 Cultures from the pus showed the colon bacillus only. Her progress 
 after operation was most satisfactory, and she left the hospital in nine 
 days, — October 28th, — to be taken charge of by her own physician. 
 
i 
 
 The wound is completoly henlcd and ht^r general health in first-rate.' 
 
 An interesting ([Uestion in this case is whether or not the choleeys- 
 titis was caused hy t\ut attack of measles. 
 
 Case IX. — Mrs. C, a lar<,'e, fleshy woman, ret 61, the mother of 14 
 children, intensely jaundiced, and stiffering from two large carbuncles 
 on the right side of the abdomen and on the right loin, was admitted 
 to the Roynl Victoria Hospital on the l.'Jth of October, 1«<I7. Her 
 history was as follows : She had always enjoyed the V)esf of health 
 until March, 1H94, when she slipped and fell, striking her right side 
 against a barn door. The immediate effects of this injury pusscMl ofi'in 
 a few days, but a month later she had a severe attack of spasmodic 
 pain about the right costal margin, unocompanied by chill or vomit- 
 ing. She had similar attacks about twice; a y<!ar for the next three 
 years, each being accompanied and followed by tenderness, just below 
 the right co.stal border. On the 10th of August, ]H{)7. a very severe 
 attack came on and persisted, witfi short intervals of relief, until she 
 came to hospital. It was accompanied by chills, a sense of fuliifss at 
 the stomach and persistent vomiting. Three weeks after its onset 
 jaundice appeared and grew steadily more and more intense. The 
 stools were colorless and putty-like, and the urine very dark. The 
 carbuncles were treated on the 14th of October, and the al)doimMi was 
 opened on the 4th of November. A facetted stone was fouinl freely 
 movable in the common duct, and removed thnmgh a longitudinal 
 incision, which was closed by suture. The gall bladder was shrunken 
 and contracted and contained 6 facetted stone.M, whieh were removed 
 through an incision in its walls. There was no evidence of communi- 
 cation between tlu; common duct and the gall-bladdei", and the wound 
 in the latter could not be brought up to the parietal peritoncnni 
 The liver border was round and firm. A drainage tube was carried 
 down to the wound in the duct, along the under-surface of th(; liver, 
 and the space packed off' bj- strips of iodoform gauze. The patient 
 made an uninterrupted recovery, and, although still in ho.«pital, she is 
 practically well and ready for discharge. The bile-staining disap- 
 peared gradually from the skin and urine, and within a week the 
 vstools were of normal color. 
 
 An interesting feature in this case is the fact that the group of 7 
 stones which had hitherto given rise to no symptoms whatever, seems 
 to have been disturbed by the traumatism in March, 1894, and that 
 this disturbance was the starting point in u series of changes which 
 culminated in the conditions above desci'ibed. 
 
 Case X. — Mrs. C. C, a pale woman, somewhat deaf, aot. 27, the 
 mother of one child, had an attack of biliary colic about a year ago 
 
8 
 
 accompanied by chills and voin'ting. She recovered from this and 
 remained well until November 8th, 18!)7, when she had another attack. 
 Sine had a third attack cm the 13th of November, and was sent into 
 the Royal Victoria Hospital. She also had similar attacks on the 
 20th and 28rd of November, and was operated upon (cholecystostomy) 
 on December 2nd, 1897. Seven facetted stones weie removed from 
 the base of! the gall-bladder, the sac also containing some bile. This 
 sac was found to be completely closed off from the remainder of tlie 
 gall-bladder, which also contained fij>ct'tted stones. An incision was 
 made lower down in the gall- bladder, through which these stones were 
 removed, and the incision was closed by suture. A connnunication 
 was then made through the occlusion, and a drainage tube inserted 
 down to the cystic duct. 
 
 This patient's progress since operation ha.s been (|uite satisfactory. 
 
 It will be noted that all these patients were women, who were, with 
 one exception, the mothers of families, and that their ages varied 
 from 23 to 61 years. There were two cases of solitary stone ; the 
 others were all multiple. 
 
 The operations were : Simple cholecystostomy, 5 ; cholecystostomy 
 with incision (and suture) of the cystic duct for the removal of a 
 group of impacted stones, 1 ; incision (and suture) of the common 
 duct for the removal of a solitary impacted stono, 1 ; incision (and 
 sutui'e) of the common duct for the extraction of a movable facetted 
 stone, and incision of the shrunken gall-bladder in the same patient 
 for the removal of six other similar stones, 1 ; and in the tenth cast? 
 the discovery that the stone (or stones) had already passed through 
 the ducts. 
 
 Results. — With the exception of the typhoid patient, all recovered, 
 and in no case was there at any time a symptom to cause anxiety. 
 One patient had, at the end of three months, a biliary fistula, another 
 had a sinus persisting, six are completely healed and one was operated 
 upon only eight days ago. 
 
 Case VII. is another case in evidence of the frequency of cholecys- 
 titis as a sequel to or complication of typhoid fever, and emphasizes 
 the fact that bile, so far from being destructive to the typhoid bacillus, 
 is, actually, an excellent medium for its growth and reproduction. In 
 all the cases the operation was completed at a single sitting. 
 
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