- Email: [email protected]
Acute emphysematous cholecystitis: Report of a case
ACUTE
EMPHYSEMATOUS CHOLECYSTITIS: REPORT OF A CASE
K. G R A I N G E R , M.B., CH.B., F.F.R., D.M.R.D., D.M.R.(D.)
Department of Radiodiagnosis, Liverpool Royal Infirmary ACUTE emphysematous cholecystitis is a rare inflammatory condition of the gall bladder. Gas forming organisms cause the disease and characteristically gas becomes demonstrable within the gall bladder lumen and also in the pericholecystic tissues. Stolz (1901) first described the condition at autopsy in three patients with gas in the gall bladder and biliary ducts. He concluded that there was a terminal invasion by gas forming bacteria and that the gas formation was a post-mortem feature. Lobingier (1908) was the first to find the condition at operation and Hegner (1931) made the first pre-operative diagnosis by radiological examination of a man aged sixty-two, who had the symptoms of acute cholecystitis. Since then many reports of the disease have appeared in the literature both in America and on the Continent. Edinburgh and Geffen (1958) collected forty-nine authenticated cases and added one of their own. The diagnosis was made by x-ray findings in forty-three of these cases in which pre-operative films were taken, and in the other seven cases, diagnosis was made at operation. In the British literature, however, only two case reports of the condition are to be found. Hutchinson (1946) described a case diagnosed at operation, no pre-operative radiograph of the abdomen having been takep. Wilson (1958) reported a case diagnosed by a straight radiograph of the abdomen, and treated conservatively. The purpose of this communication is to add one further case to the British literature and to call attention to the main clinical and radiological features of the disease.
100'5 ° F., pulse 80/min. There was no pallor or icterus. The tongue was slightly furred, but moist. The upper abdomen was rather distended and there was tenderness and guarding in the right hypochondrium, but no definite mass was palpable. The cardiovascular and respiration systems were normal, and the B.P. 130/80 ram. Hg. A white cell count was 7,000 per c.mm., with 70 per cent neutrophil polymorphs, 18 per cent lymphocytes, and 12 per cent monocytes. Haemoglobin--15.1 G. per cent, The liver function tests were normal. Urine examination was normal, apart from a faint trace of albumin. There was no excess of urobilinogen in the urine, and no bile salts or pigments. Acute cholecystitis was diagnosed, and medical treatment instituted, with bed rest, drugs as required to relieve pain, and a light fat-free diet. On 10th April, a straight radiograph of the abdomen showed a large oval translucency in the right hypochondrinm considered to be a large gas-distended gall bladder. Surrounding this translucency there was a thin band of gas forming a " halo " effect (Fig. 1). A film taken with the patient erect revealed a gas-fluid level in the gall bladder and a further fluid level posteriorly, interpreted as being within a loculated abscess (Fig. 2). On 15th April, ten days after the onset of the pain, a combined examination by oral Telepaque
CASE REPORT A male, aged sixty-two years, complaining of severe upper abdominal pain, was admitted to the Liverpool Royal Infirmary on 9th April, 1959,. under the care of Mr A. C. Brewer. The pain had started suddenly four days previously, being worse in the right hypochondrium and was accompanied by nausea and the vomiting of food and bile-stained fluid. He had no jaundice at any time, and his faeces were normally pigmented. His urine appeared to him to be rather dark. He became constipated during the attack, and lost his appetite. Two days after the onset of the illness, the pain lessened and became localised to the right hypochondrium. Prior to this present trouble, he had been healthy, with a good appetite, no digestive troubles, and had never experienced any episode similar to this one. On examination after admission to hospital, the patient appeared to be in some pain, but his general condition was good. Temperature
FIG. 1 A straight film of the abdomen taken five days after the onset of the illness shows the lumen of the gall bladder distended by gas. Around this, gas in the walls of the gall bladder is seen as a narrow band of translucency. 66
ACUTE EMPHYSEMATOUS
CHOLECYSTITIS;
FIG, 2 An erect lateral film of the gall bladder shows the gall bladder containing gas with a fluid level, and a further fluid level in an abscess cavity posterior to the gall bladder shadow. Gas is also seen in the tissues around the fundus of the gall bladder.
and intravenous Biligrafin together with t o m o g r a p h y demonstrated a normal c o m m o n bile duct, but no evidence of any contrast medium in the gall bladder. Gas was seen extending into the cystic duct and the gas-filled lumen of the gall bladder now contained mottled bubble-like defects, due probably to a mixture o f gas and thick pus. The band-like translucency had broken up to f o r m numerous blebs in the pericholecystic tissues (Fig. 3). The presence of n o n - o p a q u e calculi could not be excluded radiologically. A barium meal examination performed on 15th April showed an irritable duodenal cap with thickening of the mucosa o f the second part o f the d u o d e n u m due to oedema (Fig. 4). The meal otherwise was normal and there was no fistula shown between the intestinal tract and the gall bladder. A t this time the patient was fairly well and almost symptom free, but his temperature remained persistently elevated between 99 and 101 ° F. and a tender mass was n o w palpable in the right hypochondrium. This mass persisted over the next seven days, together with the slight pyrexia. On the 22nd April, M r A. C. Brewer performed a laparotomy through a Kocher's incision. O m e n t u m was found to be adherent to the liver, and there was a large indurated mass in the subhepatic area, surrounding the gall bladder. Cholecystectomy was impossible, but the gall bladder was palpated and no calculus was felt. A needle was inserted into the mass and thick green pus was aspirated. Two million units of Penicillin were then introduced. Nothing further was done. The w o u n d was closed in layers without drainage. Culture of the pus yielded an atypical actinomyces producing gas. Post-operatively the patient was given Penicillin
R E P O R T OF A CASE
67
FIG. 3 A straight film taken nine days after the onset of the illness shows that the gas in the gall bladder walls has broken up into bubbles. The mottled appearance within the lumen of the gall bladder is due to admixture of gas and fluid.
I megaunit and Streptomycin 0.5 G. b.d. intramuscularly for nine days. Recovery was uneventful. The patient was discharged from hospital on 9th May. A film taken immediately before discharge showed that the gas had been almost completely absorbed.
DISCUSSION Clinieal features.--The clinical picture is that of acute cholecystitis. O f the reported cases, males have been more commonly affected than females in the ratio of about 2.5 : 1, in contrast to the more usual preponderance of female cases in gall bladder disease. The ages ranged from thirty-two to seventy-five years, and more than 80 per cent of patients were over fifty years of age. The onset is usually abrupt with upper abdominal pain becoming localised to the right hypochondrium, and often radiating to the back and shoulders. The temperatures may be raised to 103 ° F., but is often of low-grade between 99 ° and 102 ° F. The patient is often more ill and toxic than can be accounted for by the clinical findings. Nausea and vomiting are almost invariably
68
CLINICAL
FIG. 4 A barium meal examination on 15th April, shows thickening of the mucosa in the second part of the duodenum due to oedema. Fluid levels are seen within the gall bladder and in the subhepatic abscess.
present. Jaundice was present in 40 per cent of the cases collected by Edinburgh and Geffen, but is usually mild or moderate in degree. A mass is frequently palpable. The course is generally prolonged. Diabetes appears to dispose to this condition, being present in 24 per cent of the reported cases. Calculi were found in 50 per cent. Radiological features.--Sufficient gas may not have collected in the first twenty-four to forty-eight hours of the illness to be shown by x-ray, but after this, a pear-shaped translucent area is seen in the right hypochondrium, forming the outline of the gas-distended gall bladder. There is likely to be fluid in the gall bladder and a radiograph taken with the patient erect or in lateral decubitus will then show a well-defined fluid level. If the disease progresses gaseous infiltration of the walls of the gall bladder results, appearing as a thin dark layer of gas immediately peripheral to that in the lumen of the gall bladder. Friedman, Aurelius and Rigler (1949) attribute this to gas accumulating between the muscularis and the mucous membrane. Later, this thin layer broadens, and disintegrates into numerous bubbles. The gas in the gall bladder lumen also usually increases in
RADIOLOGY
volume. As the infection extends into the pericholecystic tissues, abscesses containing gas and fluid levels appear. On recovery there is evidence of slow absorption. The gas in the lumen loses its contour first, then the bubbles in the walls and pericholecystic tissues become smaller and less well defined. Gas may be seen in the soft tissues long after the gas in the gall bladder has disappeared. In mild cases, as that described by Schmidt (1938), the gas may be completely absorbed in twelve days. Rarely the inflammation fails to localise, perforation of the gall bladder occurs early with a pneumoperitoneum. Gas may be then demonstrable beneath the diaphragm, as in the two cases described by Rabinovitch, Rabinovitch, Pines and Lipton (1958). The appearances of acute emphysematous cholecystitis are usually characteristic. Conditions in which air gains entrance to the biliary system from the bowel must be considered in the differential diagnosis. (1) Reflux of air into the bile ducts from the duodenum through a relaxed or rigidly patent sphincter of Oddi. The common bile and main hepatic ducts and smaller hepatic radicles are thus outlined. No gas is present in the walls of the gall bladder or pericholecystic tissues. (2) An internal biliary fistula, arising spontaneously, or by surgical anastomosis of the gall bladder to stomach, duodenum or jejunum. A barium meal and enema will eliminate a fistula, whilst in emphysematous cholecystitis gas is not usually seen in the bile ducts. The clinical details assist in the differentiation. Other rare causes of gas in the right hypochondrium are a gas-containing abscess arising from a highly placed appendix, and a posteriorly perforated duodenal ulcer with a loculated abscess. In both of these conditions, the abscess is posteriorly placed and the radiologic appearances do not resemble emphysematous cholecystitis. A subcapsular haematoma of the liver with infection, hepatic and perihepatic abscesses containing gas may cause more difficulty, but in the absence of jaundice a cholecystogram will usually show a normally functioning gall bladder. In lipomatosis of the gall bladder, a narrow translucent zone is seen by x-ray around the walls of the gall bladder. This is caused by infiltration of fatty tissue. Gas is not seen in the lumen of the gall bladder. Bacteriology.--Gordon-Taylor and Whitby (1930) recovered C1. welchii from 9 per cent of a series of fifty consecutive cholecystectomy specimens cultured, and from 13 per cent of gallstones
A C U T E EMPHYSEMATOUS C H O L E C Y S T I T I S : R E P O R T OF A CASE
obtained post-mortem. It is not surprising, therefore, that in emphysematous cholecystitis C1. welchii is the commonest organism found either alone or in combination with Bact. coli. Other organisms of the Clostridial group have been found; also Strep. faecalis, other aerobic and anaerobic streptococci and Ps. Pyocyanea have all been incriminated in separate cases. In this present case, an atypical gas-producing actinomyces was cultured. Treatment.--If emphysematous cholecystitis is diagnosed whilst the gas is confined to the gall bladder lumen, then immediate cholecystectomy is indicated to avoid the complications of perforation and abscess formation. When the condition is established with gas in the gall bladder walls and localised abscess formation conservative treatment with antibiotic and chemotherapeutic agents is safer. It appears to be generally agreed that cholecystectomy should be carried out within forty-eight hours of onset, if at all. Surgery is also indicated if there is early perforation of the gall bladder and failure of localisation of the inflammation. Persistence of the mass, or increase in its size, may necessitate later surgery of a limited nature. Cholecystectomy at this stage almost invariably is technically impossible.
69
SUMMARY A discussion of the main clinical and radiological features of acute emphysematous cholecysfifis is presented, and a further case of this rare condition has been described. Straight radiographs of the abdomen, including erect or lateral decubitus views, in cases of acute cholecystitis showing toxicity disproportionate to other clinical findings will enable the condition to be diagnosed early, and prompt surgery performed. Aeknowledgements.--I wish to thank Mr A. C. Brewer, Consultant Surgeon, and Dr P. H. Whitaker, Consultant Radiologist, Liverpool Royal Infirmary, for permission to publish this case, and for their advice and encouragement. REFERENCES EDINBURGH,A., & GEFFEN, A. (1958). Amer. J. Surg. 96, 66. FRIEDMAN, J., AURELIUS, J. R., & RIGLER, L. G. (1949). Amer. J. Roentgenol. 62, 814. GORDON-TAYLOR,G., & WmTBY,L. E. H. (1932). Brit. dr. Surg. 19, 619. HEGNER,C. F. (1931). Arch. Surg. (Chicago), 22, 993. HuxcrmqSON,W. R. S. (1946). Brit. med. ,1".1,915. LOBINGIER,A. S. (1908). Ann. Surg. 48, 72. RABINOVITCH,J., RABINOVITCH,P., PINES, P., & LIPTON, R. (1958). Arch. Surg. (Chicago), 76, 502. SCHMtDT,E. A. (1938). Radiology, 31, 413. STOLZ,A. (1901). Virchows Arch. path. Anat. 165, 90. WILSON,W. A. (1958). Brit. J. Surg. 45, 333.
EMPHYSEMATOUS CHOLECYSTITIS: REPORT OF A CASE
K. G R A I N G E R , M.B., CH.B., F.F.R., D.M.R.D., D.M.R.(D.)
Department of Radiodiagnosis, Liverpool Royal Infirmary ACUTE emphysematous cholecystitis is a rare inflammatory condition of the gall bladder. Gas forming organisms cause the disease and characteristically gas becomes demonstrable within the gall bladder lumen and also in the pericholecystic tissues. Stolz (1901) first described the condition at autopsy in three patients with gas in the gall bladder and biliary ducts. He concluded that there was a terminal invasion by gas forming bacteria and that the gas formation was a post-mortem feature. Lobingier (1908) was the first to find the condition at operation and Hegner (1931) made the first pre-operative diagnosis by radiological examination of a man aged sixty-two, who had the symptoms of acute cholecystitis. Since then many reports of the disease have appeared in the literature both in America and on the Continent. Edinburgh and Geffen (1958) collected forty-nine authenticated cases and added one of their own. The diagnosis was made by x-ray findings in forty-three of these cases in which pre-operative films were taken, and in the other seven cases, diagnosis was made at operation. In the British literature, however, only two case reports of the condition are to be found. Hutchinson (1946) described a case diagnosed at operation, no pre-operative radiograph of the abdomen having been takep. Wilson (1958) reported a case diagnosed by a straight radiograph of the abdomen, and treated conservatively. The purpose of this communication is to add one further case to the British literature and to call attention to the main clinical and radiological features of the disease.
100'5 ° F., pulse 80/min. There was no pallor or icterus. The tongue was slightly furred, but moist. The upper abdomen was rather distended and there was tenderness and guarding in the right hypochondrium, but no definite mass was palpable. The cardiovascular and respiration systems were normal, and the B.P. 130/80 ram. Hg. A white cell count was 7,000 per c.mm., with 70 per cent neutrophil polymorphs, 18 per cent lymphocytes, and 12 per cent monocytes. Haemoglobin--15.1 G. per cent, The liver function tests were normal. Urine examination was normal, apart from a faint trace of albumin. There was no excess of urobilinogen in the urine, and no bile salts or pigments. Acute cholecystitis was diagnosed, and medical treatment instituted, with bed rest, drugs as required to relieve pain, and a light fat-free diet. On 10th April, a straight radiograph of the abdomen showed a large oval translucency in the right hypochondrinm considered to be a large gas-distended gall bladder. Surrounding this translucency there was a thin band of gas forming a " halo " effect (Fig. 1). A film taken with the patient erect revealed a gas-fluid level in the gall bladder and a further fluid level posteriorly, interpreted as being within a loculated abscess (Fig. 2). On 15th April, ten days after the onset of the pain, a combined examination by oral Telepaque
CASE REPORT A male, aged sixty-two years, complaining of severe upper abdominal pain, was admitted to the Liverpool Royal Infirmary on 9th April, 1959,. under the care of Mr A. C. Brewer. The pain had started suddenly four days previously, being worse in the right hypochondrium and was accompanied by nausea and the vomiting of food and bile-stained fluid. He had no jaundice at any time, and his faeces were normally pigmented. His urine appeared to him to be rather dark. He became constipated during the attack, and lost his appetite. Two days after the onset of the illness, the pain lessened and became localised to the right hypochondrium. Prior to this present trouble, he had been healthy, with a good appetite, no digestive troubles, and had never experienced any episode similar to this one. On examination after admission to hospital, the patient appeared to be in some pain, but his general condition was good. Temperature
FIG. 1 A straight film of the abdomen taken five days after the onset of the illness shows the lumen of the gall bladder distended by gas. Around this, gas in the walls of the gall bladder is seen as a narrow band of translucency. 66
ACUTE EMPHYSEMATOUS
CHOLECYSTITIS;
FIG, 2 An erect lateral film of the gall bladder shows the gall bladder containing gas with a fluid level, and a further fluid level in an abscess cavity posterior to the gall bladder shadow. Gas is also seen in the tissues around the fundus of the gall bladder.
and intravenous Biligrafin together with t o m o g r a p h y demonstrated a normal c o m m o n bile duct, but no evidence of any contrast medium in the gall bladder. Gas was seen extending into the cystic duct and the gas-filled lumen of the gall bladder now contained mottled bubble-like defects, due probably to a mixture o f gas and thick pus. The band-like translucency had broken up to f o r m numerous blebs in the pericholecystic tissues (Fig. 3). The presence of n o n - o p a q u e calculi could not be excluded radiologically. A barium meal examination performed on 15th April showed an irritable duodenal cap with thickening of the mucosa o f the second part o f the d u o d e n u m due to oedema (Fig. 4). The meal otherwise was normal and there was no fistula shown between the intestinal tract and the gall bladder. A t this time the patient was fairly well and almost symptom free, but his temperature remained persistently elevated between 99 and 101 ° F. and a tender mass was n o w palpable in the right hypochondrium. This mass persisted over the next seven days, together with the slight pyrexia. On the 22nd April, M r A. C. Brewer performed a laparotomy through a Kocher's incision. O m e n t u m was found to be adherent to the liver, and there was a large indurated mass in the subhepatic area, surrounding the gall bladder. Cholecystectomy was impossible, but the gall bladder was palpated and no calculus was felt. A needle was inserted into the mass and thick green pus was aspirated. Two million units of Penicillin were then introduced. Nothing further was done. The w o u n d was closed in layers without drainage. Culture of the pus yielded an atypical actinomyces producing gas. Post-operatively the patient was given Penicillin
R E P O R T OF A CASE
67
FIG. 3 A straight film taken nine days after the onset of the illness shows that the gas in the gall bladder walls has broken up into bubbles. The mottled appearance within the lumen of the gall bladder is due to admixture of gas and fluid.
I megaunit and Streptomycin 0.5 G. b.d. intramuscularly for nine days. Recovery was uneventful. The patient was discharged from hospital on 9th May. A film taken immediately before discharge showed that the gas had been almost completely absorbed.
DISCUSSION Clinieal features.--The clinical picture is that of acute cholecystitis. O f the reported cases, males have been more commonly affected than females in the ratio of about 2.5 : 1, in contrast to the more usual preponderance of female cases in gall bladder disease. The ages ranged from thirty-two to seventy-five years, and more than 80 per cent of patients were over fifty years of age. The onset is usually abrupt with upper abdominal pain becoming localised to the right hypochondrium, and often radiating to the back and shoulders. The temperatures may be raised to 103 ° F., but is often of low-grade between 99 ° and 102 ° F. The patient is often more ill and toxic than can be accounted for by the clinical findings. Nausea and vomiting are almost invariably
68
CLINICAL
FIG. 4 A barium meal examination on 15th April, shows thickening of the mucosa in the second part of the duodenum due to oedema. Fluid levels are seen within the gall bladder and in the subhepatic abscess.
present. Jaundice was present in 40 per cent of the cases collected by Edinburgh and Geffen, but is usually mild or moderate in degree. A mass is frequently palpable. The course is generally prolonged. Diabetes appears to dispose to this condition, being present in 24 per cent of the reported cases. Calculi were found in 50 per cent. Radiological features.--Sufficient gas may not have collected in the first twenty-four to forty-eight hours of the illness to be shown by x-ray, but after this, a pear-shaped translucent area is seen in the right hypochondrium, forming the outline of the gas-distended gall bladder. There is likely to be fluid in the gall bladder and a radiograph taken with the patient erect or in lateral decubitus will then show a well-defined fluid level. If the disease progresses gaseous infiltration of the walls of the gall bladder results, appearing as a thin dark layer of gas immediately peripheral to that in the lumen of the gall bladder. Friedman, Aurelius and Rigler (1949) attribute this to gas accumulating between the muscularis and the mucous membrane. Later, this thin layer broadens, and disintegrates into numerous bubbles. The gas in the gall bladder lumen also usually increases in
RADIOLOGY
volume. As the infection extends into the pericholecystic tissues, abscesses containing gas and fluid levels appear. On recovery there is evidence of slow absorption. The gas in the lumen loses its contour first, then the bubbles in the walls and pericholecystic tissues become smaller and less well defined. Gas may be seen in the soft tissues long after the gas in the gall bladder has disappeared. In mild cases, as that described by Schmidt (1938), the gas may be completely absorbed in twelve days. Rarely the inflammation fails to localise, perforation of the gall bladder occurs early with a pneumoperitoneum. Gas may be then demonstrable beneath the diaphragm, as in the two cases described by Rabinovitch, Rabinovitch, Pines and Lipton (1958). The appearances of acute emphysematous cholecystitis are usually characteristic. Conditions in which air gains entrance to the biliary system from the bowel must be considered in the differential diagnosis. (1) Reflux of air into the bile ducts from the duodenum through a relaxed or rigidly patent sphincter of Oddi. The common bile and main hepatic ducts and smaller hepatic radicles are thus outlined. No gas is present in the walls of the gall bladder or pericholecystic tissues. (2) An internal biliary fistula, arising spontaneously, or by surgical anastomosis of the gall bladder to stomach, duodenum or jejunum. A barium meal and enema will eliminate a fistula, whilst in emphysematous cholecystitis gas is not usually seen in the bile ducts. The clinical details assist in the differentiation. Other rare causes of gas in the right hypochondrium are a gas-containing abscess arising from a highly placed appendix, and a posteriorly perforated duodenal ulcer with a loculated abscess. In both of these conditions, the abscess is posteriorly placed and the radiologic appearances do not resemble emphysematous cholecystitis. A subcapsular haematoma of the liver with infection, hepatic and perihepatic abscesses containing gas may cause more difficulty, but in the absence of jaundice a cholecystogram will usually show a normally functioning gall bladder. In lipomatosis of the gall bladder, a narrow translucent zone is seen by x-ray around the walls of the gall bladder. This is caused by infiltration of fatty tissue. Gas is not seen in the lumen of the gall bladder. Bacteriology.--Gordon-Taylor and Whitby (1930) recovered C1. welchii from 9 per cent of a series of fifty consecutive cholecystectomy specimens cultured, and from 13 per cent of gallstones
A C U T E EMPHYSEMATOUS C H O L E C Y S T I T I S : R E P O R T OF A CASE
obtained post-mortem. It is not surprising, therefore, that in emphysematous cholecystitis C1. welchii is the commonest organism found either alone or in combination with Bact. coli. Other organisms of the Clostridial group have been found; also Strep. faecalis, other aerobic and anaerobic streptococci and Ps. Pyocyanea have all been incriminated in separate cases. In this present case, an atypical gas-producing actinomyces was cultured. Treatment.--If emphysematous cholecystitis is diagnosed whilst the gas is confined to the gall bladder lumen, then immediate cholecystectomy is indicated to avoid the complications of perforation and abscess formation. When the condition is established with gas in the gall bladder walls and localised abscess formation conservative treatment with antibiotic and chemotherapeutic agents is safer. It appears to be generally agreed that cholecystectomy should be carried out within forty-eight hours of onset, if at all. Surgery is also indicated if there is early perforation of the gall bladder and failure of localisation of the inflammation. Persistence of the mass, or increase in its size, may necessitate later surgery of a limited nature. Cholecystectomy at this stage almost invariably is technically impossible.
69
SUMMARY A discussion of the main clinical and radiological features of acute emphysematous cholecysfifis is presented, and a further case of this rare condition has been described. Straight radiographs of the abdomen, including erect or lateral decubitus views, in cases of acute cholecystitis showing toxicity disproportionate to other clinical findings will enable the condition to be diagnosed early, and prompt surgery performed. Aeknowledgements.--I wish to thank Mr A. C. Brewer, Consultant Surgeon, and Dr P. H. Whitaker, Consultant Radiologist, Liverpool Royal Infirmary, for permission to publish this case, and for their advice and encouragement. REFERENCES EDINBURGH,A., & GEFFEN, A. (1958). Amer. J. Surg. 96, 66. FRIEDMAN, J., AURELIUS, J. R., & RIGLER, L. G. (1949). Amer. J. Roentgenol. 62, 814. GORDON-TAYLOR,G., & WmTBY,L. E. H. (1932). Brit. dr. Surg. 19, 619. HEGNER,C. F. (1931). Arch. Surg. (Chicago), 22, 993. HuxcrmqSON,W. R. S. (1946). Brit. med. ,1".1,915. LOBINGIER,A. S. (1908). Ann. Surg. 48, 72. RABINOVITCH,J., RABINOVITCH,P., PINES, P., & LIPTON, R. (1958). Arch. Surg. (Chicago), 76, 502. SCHMtDT,E. A. (1938). Radiology, 31, 413. STOLZ,A. (1901). Virchows Arch. path. Anat. 165, 90. WILSON,W. A. (1958). Brit. J. Surg. 45, 333.