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THE following case exemplifies a most serious complication resulting from the technical blunder of overlooking stones in the common or hepatic ducts.Case Report.-A. D., a white female, married, aged 44, was admitted to the hospital January 25, I937, complaining of pain in the stomach and vomiting. Her past history was essentially irrelevant. The present illness probably began before I923, with pain under the right costal margin associated with nausea, vomiting and pruritus. By I936, jaundice was added to the previous symptom-complex and the attacks occurred with increasing frequency. A provisional diagnosis of stone in the common duct was made.Physical Examination.-There were no significant findings other than tenderness on pressure in the right upper quadrant which was increased by pressing the fingers under the costal margin on inspiration.Laboratory Data.-The gallbladder could not be visualized roentgenologically; bile and albumin were present in the urine, the van den Bergh direct was slightly positive and the icteric index was eight. -Other determinations were of no particular interest.Operation.-February II, I937: The gallbladder was normal in size and appearance and contained a few stones. A large nest of them was noted at the junction of the common and cystic ducts. Numerous pigmented calculi, ranging in size from a few millimeters to I.5 cm., were milked out of the ducts through an incision in the cystic and common ducts. The ducts were explored with sounds and a gallbladder scoop. Olive sounds were easily passed through the sphincter of Oddi into the duodenum and up into the hepatic duct without grating or resistance. The common and hepatic ducts did not admit a finger for intraductal digital exploration. The ducts were irrigated with saline solution through a soft rubber catheter but no further stones were found. The gallbladder was excised. The common duct and the i cm. long stump of the cystic duct were sutured, water-tight, around a soft rubber catheter.Postoperative Course.-The first two weeks of convalescence were uncomplicated. The incision healed per primam and the catheter drain was taken out on the eighth day. Bile drainage from the stab wound fistula ceased on the seventeenth day. On the following day there was upper abdominal pain, persistent vomiting, and a temperature rise to I040 F. Two days later the attack subsided with the passage of a greenish stool. Ten days later, however, there was again biliary drainage from the fistula.The fistula closed a second time on the thirty-eighth day; bile appeared in the stool one week later; two weeks after this second closure the fistula reopened. A fistulogram on the fifty-eighth day showed a complete common duct obstruction (Fig. i) but the third and final closure of the fistula occurred on the sixtieth postoperative day. Bile was present in the stool. For one month after this the patient seemed perfectly well and was ready to be discharged.Suddenly, on the ninety-sixth postoperative day, a biliary peritonitis occurred with severe upper abdominal a...

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