A CASE OF GALL-STONES IN THE CYSTIC DUCT 
IN WHICH THE DIAGNOSIS WAS OBSCURED 
BY SYMPTOMS DUE TO PELVIC 
DISTURBANCES. 
BY HUNTER ROBB, M. D., 
Professor of Gynaecology, Western Reserve University. Gymecologist to 
Lakeside Hospital. 
The following case is of interest owing to the marked thick- 
ening in the walls of the gall-bladder, its small size which together 
with the tenseness of the abdominal parietes rendered it difficult 
or impossible to palpate the tumor mass when the patient first pre- 
sented herself for examination, and secondly, from the fact that 
pelvic symptoms were present which completely obscured those 
referable to the gall-bladder. The history of the patient who was 
referred to me by Dr. Geo. Holmes, of Cleveland, is briefly as 
follows : 
Mrs. F., aged 52, has had three children and one miscarriage; 
the second labor was instrumental. The menses first appeared at 
15; they were always irregular, lasted as a rule four days, very 
profuse with clots and accompanied with a great deal of pain. 
For four years she has been complaining at times of sharp pains 
in the region of the gall-bladder. Recently the attacks have ap- 
peared nearly every month and have been associated with the men- 
strual period. For the past five months she has been having them 
sometimes twice a month, and for the past three weeks, they have 
come on almost every day. The pains start in the back and pass 
around towards the epigastrium. The paroxysm lasts as a rule 
from three-quarters of an hour to an hour and then gradually 
passes off. The patient is quite anaemic and weighs ninety 
pounds. The personal history otherwise is negative. She has 
never had jaundice. The family history has no especial bearing 
on the case. 
The first examination of the pelvis showed considerable 
relaxation of the vaginal outlet and some prolapse of the vaginal 
walls. The cervix was in the axis of the vagina; it was bilaterally 
lacerated and the lips were thickened and everted. The uterus 
was forwards and movable but was much enlarged and very sensi- 
tive. On the anterior surface of the fundus an irregularity could 
be detected which suggested a myomatous condition. Dilating 
and cureting of the uterus with the repair of the cervix and per- 
inaeum was advised, with removal of the left ovary if it should be 
♦Read before the Cleveland Medical Society March 10, 1899. 2 
Robb: A Case of Gall Stones in the Cystic Duct. 
found adherent. At the same time advantage of the anaesthesia 
was to be taken to examine carefully the gall-bladder. She was 
admitted to the Lakeside Hospital January io, 1898, and examina- 
tion under anaesthesia showed both ovaries to be movable, al- 
though prolapsed. The gall bladder could not be palpated. The 
uterus was dilated and curetted and the cervix and perinaeum 
were repaired. For the next two weeks and a half except for a 
slight attack on one occasion the patient remained entirely free 
from any pain in the region of the gall-bladder. 
It was not until three weeks after her return home that the 
same pains in the region of the gall-bladder began again to trouble 
her. On one occasion while visiting me in my office she had an 
attack, and observation at this time made me feel almost certain 
that the gall-bladder was the seat of the trouble. As has been 
said before she had never shown any signs of jaundice. An ex- 
ploratory operation was undertaken and after opening the peri- 
toneum a very much thickened gall-bladder was found, adherent 
to the under surface of the liver. After separating the adhesions 
I opened the gall-blader and removed three stones, two of which 
were well down in the cystic duct. The gall-bladder was stitched 
to the abdominal muscles and to the parietal peritoneum. The 
cavity was washed out with salt solution and sterile gauze for 
drainage was introduced. The patient made an uninterrupted 
convalescence and the fistulous tract had healed over completely 
four weeks after the operation. She now appears perfectly well 
and has gained much in health and strength.