EMPHYSEMATOUS CHOLECYSTITISREPORT OF A CASE WITH SUCCESSFUL TREATMENT*

WILLIAM C. RETTERBUSH, M.D., MELVIN B. FISHMAN, M.D.,WARREN A. BAIRD, M.D., AND JAMES I. COLLINS, M.D.

TOLEDO, OMO

FROM THE SURGICAL SERVICE OF THE MAUMEE VALLEY HOSPITAL, TOLEDO

EMPHYSEMATOUS CHOLECYSTrITS is a

somewhat rare inflammatory disease of thegallbladder caused by a gas-producingorganism and characterized by air withinthe gallbladder lumen, frequently with in-filtration of air into its wall and perichole-cystitic tissues. Other names such as acutepneumocholecystitis, cholecystitis emphyse-matosa, pyopneumocholecystitis, and acutegaseous cholecystitis have been given to thisclinical entity. Because of the paucity ofcases reported and the apparent confusionwhich still exists with regard to the correctmethod of management, the authors feeljustified in reporting an additional case withsuccessful treatment.

Only 21 bona fide cases of cholecystitisemphysematosa have been reported to date.Kirchmayrl in 1925 was the first to drawattention to this condition. He operated ona 64-year-old male who had a gangrenousgallbladder distended with gas. A cholecys-tectomy was performed and the patient re-covered. Culture of the gallbladder fluidrevealed Frankel's bacillus (Cl. perfrin-gens).

It was Hegner,2 however, in 1931, whofirst recognized the typical roentgen find-ings of this disease. He describes a case ina 62-year-old man who had an area of gasin the region of the gallbladder simulatingthe contour of that organ. There was alsomottling of gas in the pericholecystic area.This patient was treated conservatively atfirst but the gaseous area increased to four

* Submitted for publication October, 1950.

times the original size during the next fourdays. Surgical intervention revealed an en-larged gallbladder filled with gas which wasunder enough pressure to push the plungerout of a 20 cc. syringe. A number of smallabscesses were found in its wall. The gall-bladder was drained and the patient didwell until the fourth postoperative day,when he died of a pulmonary embolus.B. welchii was recovered from the gallblad-der area on culture.

One year later Simon3 described a casein a 32-year-old man who was admitted witha diagnosis of acute cholecystitis. Roentgenexamination revealed gas over a fluid levelwithin the gallbladder plus additional infil-tration of gas into the pericholecystic area.Here too, in spite of the fact that the pa-tient felt better clinically, roentgen raysshowed increasing pericholecystic infiltra-tion. Surgery was performed and when theperitoneum was opened, gas and bile-stained pus escaped from the fundus of agangrenous gallbladder. Calculi were pres-ent. Cholecystectomy was performed andthe patient recovered. No cultures weretaken but smears of the pus showed "sporesand anaerobic type organisms."

Wybauw,4 in 1936, described a case in a53-year-old woman with symptoms ofcholecystitis who revealed roentgenograph-ically a gas-filled gallbladder with the wallalso outlined by gas. At operation gas wasfound within the gallbladder wall. Thecourse following cholecystectomy was re-markably smooth. Cultures were not taken.

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EMPHYSEMATOUS CHOLECYSTITIS

In 1938, Schmidt5 reported a 38-year-oldmale who had recurring pains in the rightupper quadrant plus the typical gas-filledgallbladder on roentgen ray examination.Cholecystography showed this identicalarea definitely, though faintly, filled withgallbladder dye. Further examinationsafter barium meal and enema definitely ex-

cluded gas accumulations in the gastro-in-testinal tract as sources of the reportedshadow. Under a dietary regimen and bedrest the patient improved rapidly so thatsurgical intervention was deemed unnec-

essary.

Del Campo and Otoro,6 in 1940, de-scribed a case of a 74-year-old man whopresented symptoms of acute cholecystitisand whose roentgenograms showed no gas

in the biliary tract, but subsequent films on

the fifth hospital day showed the bile ductsto be filled with gas. Even though the pa-

tient was a poor surgical risk, operation was

performed the following day. A diagnosis ofcholecystitis emphysematosa was not madebefore exploration. The gallbladder re-

vealed a large amount of gas under pressure

and reddish-yellow pus. Cholecystostomywas performed, but the patient died on thefourth postoperative day. Postmortem ex-

amination showed a large calculus impactedin the ampulla of Vater and necrotic areas

containing gas in the lungs, heart, kidneysand liver. Clostridium perfringens was re-

covered from the gallbladder pus at thetime of operation, but no cultures were

taken at autopsy.Ramey and Scott7 (1942) merely men-

tion a case of emphysematous cholecystitismade on the basis of a roentgen ray filmwithout dye. No mention was made of thehistory, physical findings, or disposition ofthis case, and for these reasons we are notincluding this patient in the group of bonafide cases.

McCorkle and Fong8 in 1942 reportedthree cases of gas in the gallbladder. Thefirst patient was a 49-year-old male who had

intermittent cramping abdominal painwhich localized in the right upper quadrant.Fever and leukocytosis were present. Threedays later a flat plate of the abdomen re-

vealed a gas-filled gallbladder, although thesite of this gas in the right upper quadrantwas noted only in retrospect. On explora-tion, a gangrenous gallbladder was drained,but the patient died about 48 hours afteroperation of a fulminating anaerobic gasbacillus infection of the peritoneum and ab-dominal wall.

The other two cases reported by McCor-kle and Fong presented the typical signs andsymptoms of acute cholecystitis plus a gas-filled gallbladder on roentgen examination.Both films showed gas overlying a fluid levelin the gallbladder. These two patients weretreated conservatively with one therapeuticdose of polyvalent gas gangrene antitoxinand a course of sulfathiazole. The gas in thegallbladder gradually subsided and the pa-tients recovered. The authors concludedthat conservatism is the desirable course tobe pursued in the therapeutic managementof cases in which gas in the gallbladderresults from anaerobic gas-producingorganisms.

Three cases of emphysematous cholecys-titis treated successfully were reported byStevenson.9 The first patient was a 64-year-old male diabetic, who had been acutely illfor two days with right upper quadrantpain. Roentgenograms were typical of em-

physematous cholecystitis. At operation a

completely gangrenous gallbladder withstones, surrounded by a zone of gas, was

found. A cholecystostomy was performedand the patient made an uneventful re-

covery.

Stevenson's second case was a 63-year-old acutely ill male, who also had the signsand symptoms of acute cholecystitis, but be-cause of the patient's age, obesity, and poor

general condition, he was treated sympto-matically. Fever and leukocytosis continuedand a large mass became palpable in the

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right upper quadrant. In the meantime, on

roentgen ray examination, the gaseous out-line of the gallbladder became more dis-seminated, indicating rupture of that organ.

On the eleventh hospital day abdominal ex-

ploration was performed. Upon opening theperitoneum a definite hiss of escaping gaswas heard and large quantities of green pus

exuded. A ruptured gangrenous gallbladderwith a stone lodged in the neck was re-

moved. The patient made an uneventful re-

covery. No intensive effort was made toculture anaerobic organisms in either case.

The third case was a younger man, 52-years of age, who had right upper quadrantpain, nausea, vomiting, fever, and leukocy-tosis. Roentgenograms were typical ofemphysematous cholecystitis. The patient-was treated with roentgen therapy as sug-gested by Kelley and Dowell,10 specific gas

gangrene antisera, and sulfathiazole. Thepatient did not improve remarkably untilthe sixth day of treatment, after which heimproved quite rapidly and was dischargedon the twenty-fourth hospital day. Subse-quent films of the gallbladder, after admin-istration of radiopaque dye, showed no evi-dence of concentration of the dye.

The two cases reported by Heifetz andSenturall (1938) are interesting. Both pa-

tients were treated conservatively at first,but due to-a lack of response to this therapy,surgical intervention was deemed necessary.

One patient, a 52-year-old male, was admit-ted with a clinical diagnosis of acute chole-cystitis. Admission roentgenograms showedthe gallbladder to be distended with gas andthe wall sharply outlined. The authors de-cided to postpone surgery because they con-

sidered that the optimum period for per-

forming a cholecystectomy in the acutestage had passed. The patient was givenpolyvalent gas gangrene antitoxin, penicil-lin, sulfadiazine, and a high carbohydrate-high protein diet. At first the patientshowed some signs of improvement, but thetemperature and pulse remained moderately

elevated. In a few days, however, the tem-perature and pulse became normal althoughthe leukocyte count remained elevated andthe gallbladder palpable. Gradual dailyrises in temperature to 1000 F. were noted.Serial films of the abdomen during this timeshowed increasing gaseous distention of thegallbladder and pericholecystic infiltration.Operation was then performed over a pal-pable right upper quadrant mass and gashissed out of a walled-off abscess cavitywhich included the necrotic fundus of thegallbladder. Cholecystostomy was deemedthe procedure of choice. The patient didwell except for a slight drainage from theincisional site which persisted for a fewdays.

The second case was a 57-year-oldwhite female, who had acute right upper

quadrant pain and vomiting of two days'duration. Marked tenderness, rigidity, andrebound tenderness was noted in the rightupper quadrant and epigastrium. The pa-

tient was treated with penicillin and a highcarbohydrate diet. Although considerableimprovement was noted in the patient's gen-

eral condition the gallbladder remained pal-pably enlarged and tender. Because of thispersistently enlarged mass it was decided tooperate. An acute gallbladder with numer-

ous small necrotic areas in its wall was re-

moved with considerable difficulty. Arather large quantity of pus spilled into theperitoneal cavity, but in spite of this thepatient did remarkably well. Penicillin andsulfadiazine were given postoperatively.Cultures revealed Clostridium filiforme. Theauthors believe that surgical therapy aloneis effective in emphysematous cholecystitissince the gallbladder wall is subject togreater tension when gas is present andthere is a consequent greater risk of gan-

grene and perforation.Culver and Kline12 added a case of a

60-year-old diabetic who had recurrent at-tacks of right upper quadrant pain and mildicterus. Roentgen rays showed a gas-filled

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gallbladder. Penicillin and sulfadiazineameliorated the clinical condition for ashort while but the pain, jaundice androentgen shadow recurred. The dispositionof the case is not discussed by the authors.

Another case recently reported in theliterature was by Jemerin13 (1949). His pa-tient was a 68-year-old diabetic who hadhypertension and a poor cardiac status. She,too, had the typical signs, symptoms, androentgen findings of emphysematous chole-cystitis, but because of her poor physicalcondition, it was decided to postpone sur-

gery. Fourteen days after admission the pa-

tient seemed well enough to withstand oper-

ation. Exploration revealed a gangrenousgallbladder filled with air, pus, and stones.The gallbladder was removed and the abdo-men drained. The postoperative course was

uneventful until the tenth day when the pa-

tient had a sudden chill with a temperaturerise to 104.4° F. Blood culture was positivefor B. coli. Treatment with sulfadiazine,penicillin, and blood transfusions was insti-tuted and the temperature became normalin two days. The following day, however,the patient expired of a cerebrovascular ac-

cident.Friedman, Aurelius, and Rigler14 have

added four cases to the literature. Only one

of these was treated surgically and all pa-

tients survived. Staphylococci were isolatedfrom the cholecystectomized individual, butno anaerobic cultures were taken. The otherthree patients, two of whom were diabetics,were treated conservatively and only one

received any antibiotic therapy.The last case of emphysematous chole-

cystitis has been reviewed by Gowdey andCopeland.15 Their patient was similar tothe rest with regard to clinical and labora-tory findings. The patient entered the hos-pital soon after onset of a gallbladder attackbut pain, fever, and leukocytosis persistedfor many days in spite of penicillin therapy.Operation was performed the fifth hospitalday. The temperature fell to normal the day

after removal of the gallbladder and the pa-tient did well thereafter. Because of theunresponsiveness of the patient to conserva-

FIG. 1.-Note the mottled gas shadow inthe right upper quadrant which has the configura-tion of a gallbladder.

tive therapy, the authors concluded thatearly operation is the treatment of choice foremphysematous cholecystitis.

Case History. A 65-year-old colored male was

admitted to Maumee Valley Hospital on August13, 1949, after having been in a fight with a

group of men. Roentgenograms on admission re-

vealed a comminuted fracture of the right ilium.No other abnormalities were found. He was

treated conservatively for the next two monthsand improved sufficiently to be discharged fromthe Orthopedic Service, but remained in the hos-pital for a few days awaiting disposition.

On October 13, 1949, at 12:30 A.M., thepatient was suddenly seized with a dull, persistent,rather severe epigastric pain which did not radiateand which was worse on deep inspiration. Slightnausea was also present. He denied having hadany previous similar attacks. The temperature at

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that time was 990 F. and there was slight guardingof the right rectus muscle but no ngidity or re-bound tenderness. He was apparently relievedwith a grain of codeine and 1/150 of a grain ofatropine. The pain recurred at 5:00 P.m. the sameday and his temperature rose to 101.30 F. Thenext morning (32 hours after the initial suddenonset of pain), he vomited his breakfast and com-plained of severe pain in the right upper quadrantof the abdomen.

Physical examination at this time revealed awell-developed, well-nourished, colored male whoappeared acutely ill. The temperature was 98.60F. and the pulse 120. The essential physical find-ings were as follows: there was rather markedgeneralized abdominal tenderness and rigiditywhich was most pronounced in the right upperquadrant, rebound tenderness was present, noabdominal masses were palpable, and bowelsounds were absent on auscultation.

White blood count was 26,400 with 88 percent polymorphonuclears, nine of which were

bands and 12 lymphocytes. Serum amylase was36. Upright AP (Fig. 1) and lateral decubitusscout films of the abdomen revealed a pear-shaped mottled shadow in the right upper quad-rant having the configuration of an enlarged gall-bladder and outlined by a thin layer of radio-lucency. The mottling in this shadow suggestedthe appearance of gallstones. The lateral decubitusfilm (Fig. 2) showed an air-fluid level in thisregion. No free air was noted in the abdomen.On the basis of the history, physical findings, andtypical roentgen ray picture, a diagnosis of em-

physematous cholecystitis was made.The patient was prepared for immediate opera-

tion and the abdomen was opened through a rightupper quadrant transverse incision. There were

multiple fine adhesions between the gallbladderand contiguous structures. A small collection ofbrownish fluid surrounded an enlarged gallbladderand numerous small pericholecystic abscesses werepresent. The wall of the gallbladder was thick-ened, showing emphysematous blebs and numeroussmall areas of necrosis. Crepitation was felt inthe wall of the gallbladder revealing the presenceof gas. The gallbladder was decompressed, andit was noted that it contained air under pressureas well as purulent fluid and multiple small stones.Cultures of the gallbladder fluid were obtained.After doubly ligating the cystic artery and cysticduct, the gallbladder was removed with no greatdifficulty, the dissection being carried from thefundus to the region of the cystic duct. No stoneswere palpated in the common duct. A cigarettedrain was placed in Morrison's pouch. Theabdomen was closed with interrupted figure-eight

sutures of No. 32 wire in the fascia andperitoneum, and interrupted sutures of silk wereused to approximate the skin. The patient wasreturned to his room in good condition.A Levine tube was inserted and continuous

Wangensteen suction was applied for 2 days.Crysticillin, 300,000 units twice a day, and strep-tomycin, 0.5 Gm. every 6 hours, were administeredintramuscularly. Nutrition and electrolyte balancewere maintained with intravenous fluids augmentedwith supplemental vitamins. The drain was re-moved on the seventh day after surgery. Thepostoperative course was essentially uneventfulexcept for the persistence of a slight amount ofseropurulent discharge from the drain site. Thetemperature did not rise higher than 99.80 F.,and the patient was discharged on the thirteenthpostoperative day.

On subsequent visits to the Outpatient De-partment, the patient felt fine and had no com-

plaints.

DISCUSSION

In a review of the literature a numberof important points become apparent. Thefirst is the age distribution of patients withemphysematous cholecystitis. Although thedisease has been reported in a patient as

young as 32 years of age, the great majorityof cases occur in people in the fifth and sixthdecades of life. Probably a more strikingfeature is the fact that 17 out of 21 cases

occurred in males. It is difficult to speculatewhy such a preponderance of cases shouldoccur in males, especially since the inci-dence of acute cholecystitis is higher infemales.'6

A still more interesting finding is that sixof the 21 cases occurred in diabetics. Chole-cystitis has long been known to occur more

commonly in diabetics but this ratio is muchhigher than would be predicted by chance.

Another rather constant clinical featureof emphysematous cholecystitis is that thepatients appear considerably more sick thanthe temperature would indicate. This wefound to be true in our case. Our patientappeared acutely ill in spite of a normal tem-perature (98.60 F.) the day of operation. Inthe majority of cases reported the temper-ature ranged from 100 to 1010 F.

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Gas in the gallbladder may occur in oneof two ways: first, as a result of gas forma-tion from gas-producing organisms withinthe gallbladder itself, or, more commonly,from a fistula between the gallbladder orextrahepatic ductal system and some part ofthe gastro-intestinal tract. The etiology,pathogenesis, symptoms, and treatment ofthe two conditions are entirely different.The differentiation can readily be made byroentgen ray.

A likely sequence in the pathogenesis ofemphysematous cholecystitis is as follows:first, there is lodgment of a stone in thecystic duct. This permits concentration ofthe bile and multiplication of anaerobic bac-teria which are already present in the bileand gallbladder wall. Local spread throughthe gallbladder wall as emphysematousblebs, with finally invasion of the perichole-cystic tissues, may result. If the gaseousdistention within the gallbladder is greatenough and if the inflammatory process re-

sults in sufficient necrosis of the gallbladderwall, then rupture of the gallbladder withresultant peritonitis may ensue. Not infre-quently, however, the omentum and con-

tiguous structures will become adherentto the gallbladder and prevent further per-foration.We are not in a position to state whether

lodgment of a stone in the cystic duct isnecessary for the production of emphysema-tous cholecystitis. In a review of the litera-ture, however, most of the patients whowere operated had stones within the gall-bladder and frequently a stone was foundimpacted in the cystic duct. Because of thenecrosis and inflammatory adhesions it isfrequently impossible to tell, even if a dili-gent search be made, whether or not a stoneis present within the cystic duct.

Space does not permit us to consider indetail the bacteriology of this disease. How-ever, the most commonly encountered bac-teria in acute cholecystitis are Streptococci,colon bacilli, and Staphylococci. Authors

disagree on the incidence of gas-forminganaerobes. Gordon-Taylor and Whitley1"reported in 1930 that B. welchii was presentin 18 per cent of their 50 cases of acutecholecystectomized gallbladders. But in a

series of 4395 collected cases by Rehfuss andNelson,18 many of the authors did not men-tion B. welchii, or found it present in only a

very small percentage of the cases.

The etiologic organism in emphysema-tous cholecystitis may vary somewhat, but a

member of the Clostridium genus seems tobe the most common offender. Kirchmayr,Hegner, and del Campo all isolated Clos-tridium perfringens (B. welchii) from theircases. McCorkle and Fong also found "an-aerobic gas-producing bacilli resemblingClostridium welchii." Heifetz and Senturacultured Clostridium filiforme from one pa-

tient. Jemerin believed Clostridium oede-matiens to be the gas-producing organismin his patient. Gowdey and Copeland dem-onstrated from their case a heavy growthof gram positive gas-forming bacilli, not spe-cifically identified, and small numbers ofgram negative bacilli. McCorkle and Fongfound B. coli, as did we in our culture of thegallbladder pus. It is surprising that B. colidoes not produce gas in the gallbladdermore often since it is a rather common in-habitant of that organ. The remaining re-

ported cases of emphysematous cholecys-titis either were not operated or anaerobiccultures were not taken.

Considerable difference of opinion existsamong the various authors in regard to themanagement of cases of emphysematouscholecystitis. Since the total number ofcases reported is relatively small it is some-what difficult to evaluate treatment. How-ever, upon careful scrutiny of the cases pre-

viously reported and with our experience ofone case, a number of important points be-come apparent. It was surprising to us tofind that the average length of time betweenhospital admission and the day of operationwas nine days. Add to this figure at least

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one day or more during which time the pa-tient had symptoms but failed to consult aphysician or be immediately admitted to thehospital, and one is aware that the averagecase was not operated upon until ten daysor more after the initial onset of acute symp-toms. It is this delay, we believe, which is

originally to be treated without operation.However, because either the patient failedto respond clinically to this treatment or

showed an increase in the gaseous infiltra-tion by roentgen ray, or a combination ofthe above, these exigencies finally forced thesurgeons' hands.

FIG. 2.-Lateral decubitus film shows an air fluid level in the gallbladder.

the cause of such a high mortality in thesurgical treatment of th;s disease. Our pa-tient was the only known case of emphyse-matous cholecystitis to be diagnosed pre-operatively and treated by immediate sur-

gical intervention.Why was there such a delay in the oper-

ation of these cases of emphysematouscholecystitis? Of course, a few of the pa-tients were not in adequate condition towithstand an operative procedure at thetime of original hospital admission. Jeme-

rin's patient was an obese, uncontrolleddiabetic with an "uncertain cardiac status."One of Stevenson's cases was also very obeseand in poor physical condition. Hence, op-eration was delayed. As a general rule thegreat majority of patients were intended

To better illustrate that a frequent mani-festation of conservative therapy is a dis-semination of the infection rather than a

quiescence of the disease, the followingcases are reviewed. Hegner's patient, on

conservative management, showed an in-crease in size of a right upper quadrant massas well as an increase in the gaseous area inthe gallbladder region to four times theoriginal size. Simon's case, too, showedmarked increasing pericholecystic infiltra-tion on similar treatment. Stevenson's sec-

ond case clearly showed on serial roentgenray films that spread, with ultimate ruptureof the gallbladder, can occur. This was sub-stantiated by surgical exploration. One ofthe patients treated by Heifetz and Senturaalso showed on serial roentgen films a pro-

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gression of the disease in spite of antibiotictherapy. Culver's case responded tempo-rarily to antibiotics but had a recurrence ofthe same symptoms a few weeks later.Lastly, the case reported by Gowdey andCopeland entered the hospital only four andone-half hours after the initial onset of acutegallbladder symptoms but penicillin failedto ameliorate the condition. The above casereports serve to illustrate that this inflam-matory process is frequently a progressiveone and not amenable to the usual meansof therapy.We do not deny that subsidence of a case

of emphysematous cholecystitis on antibi-otic therapy or other conservative manage-ment may occur. But how is one to tellwhich case belongs to this group? Just as itis difficult to tell whether or not an acuteappendix will perforate, so likewise, it isimpossible to prognosticate that the gall-bladder in emphysematous cholecystitis willnot rupture.

Emphysematous cholecystitis has untilrecently been considered a rare disease.Lately, however, increasing attention hasbeen focused on this clinical entity. Since1944 there have been 12 cases reported. Webelieve that this apparent awakening in re-gard to emphysematous cholecystitis as adefinite clinical entity is a direct result notonly of the dissemination of information re-garding the existence of this disease but alsobecause more routine scout films are beingtaken in cases of acute abdominal emer-gencies. It is also our belief that the diseaseis not as rare as the number of cases re-ported in the literature would indicate. Asmore roentgen ray films are reviewed inretrospect, and as more films are taken incases of suspected acute cholecystitis, then,and only then, will the true incidence of thisdisease be revealed.

SUMMARY

A review of the 21 reported cases ofemphysematous cholecystitis is presented.

An additional case which was diagnosedpreoperatively and subjected to immediatesurgery is added to the literature.

Emphysematous cholecystitis is an acuteinflammatory condition of the gallbladdercharacterized by air within the organ itselfor its wall, frequently with dissemination ofthe disease process into the pericholecystictissues.

The symptoms are similar to acute chole-cystitis but roentgen films serve to differen-tiate the two conditions. Some gas-produc-ing organism, most commonly a member ofthe Clostridium genus, is the etiologic factorfor the production of gas within the gall-bladder.

The disease occurs most frequently inthe fifth and sixth decades of life and pre-dominately in males. Diabetics seem tohave a special predilection.

In our opinion, immediate surgical in-tervention with cholecystectomy, if possible,is the preferred method of treatment.

BIBLIOGRAPHYKirchmayr, L.: Ueber einen Fall von Gosbrand

der Gallenblase. Zentrabil f. Chir., 52: 1522,1925.

2 Hegner, C. F.: Gaseous Pericholecystitis withCholecystitis and Cholelithiasis. Arch. Surg.,22: 993, 1931.

3 Simon, J.: Le Pyopneumocholecyste et sonDiagnostic Radiologique. Presse Med., 40:1938, 1932.

4 Wybauw, L.: Image Vesiculaire Inhabituelle.J. belge Gastro-Enterol., 4: 123, 1936.

5 Schmidt, E. A.: Emphysematous Cholecystitisand Pericholecystitis. Radiology, 31: 423,1938.

6 Del Campo, J. C., and J. P. Otoro: NeumatoxiaEspontanea de las Vias Biliares. Arch. Urug.de Med., Cir. y especialid., 17: 341, 1940.

7 Ramey, P. M., and A. C. Scott, Jr.: TheManagement of Acute Cholecystitis. TexasState J. Med., 37: 664, 1942.

8 McCorkle, H., and E. E. Fong: The ClinicalSignificance of Gas in the Gallbladder. Sur-gery, 11: 851, 1942.

9 Stevenson, C. A.: Emphysematous Cholecystitis.Am. J. Roentgenol., 51: 53, 1944.

10 Kelley, J. F., and D. A. Dowell: Roentgen275

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1 Heifetz, C. J., and H. R. Sentura: Acute Pneu-mocholecystitis. Surg., Gynec. & Obst., 86:424, 1948.

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13 Jemerin, E. E.: Cholecystitis Emphysematosa.Surgery, 25: 237, 1949.

14 Friedman, J,. J. R. Aurelius, and L. G. Rigler:Emphysematous Cholecystitis. Am. J. Roent-genol., 61: 814, 1949.

15 Gowdey, J. F., and N. N. Copeland: AcuteGaseous Cholecystitis. New England J.Med., 242: 647, 1950.

16 Bockus, Henry L.: Gastro-Enterology. 1946,W. B. Saunders Co., Philadelphia.

1r Gordon-Taylor, G., and L. E. Whitley: Bac-teriological Study of 50 Cases of Cholecys-tectomy with Special Reference to AnaerobicInfections. Brit. J. Surg., 18: 78, 1930.

18 Rehfuss, M. E., and G. M. Nelson: The MedicalTreatment of Gallbladder Disease. Phila-delphia, 1936, W. B. Saunders Co.

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