THE IMPORTANCE OF THE EARLY RECOGNITION AND TREATMENT OF DISEASED CONDITIONS OF THE GALL-BLADDER AND BILE DUCTS.

EVERETT J. MCKNIGHT, A.B., M.D.,

HARTFORD.

The conviction has of late been forced upon me that a large amount of unnecessary suffering and loss of usefulness and production on the part of the individual, as well as an appreciable shortening of the average duration of human life, is due to the failure of the physician to early, or even at any time in their course, recognize and properly treat diseased conditions of the gall-bladder and bileducts, is my excuse for preparing this paper.

As I know of no word which can be used to include both diseased conditions of the gall-bladder and bileducts, I shall in the remarks which follow, for convenience, consider the term "Gall-bladder Disease" as applying in a general way to all diseased conditions having their inception in the gall-bladder and bile-ducts.

It will be our endeavor to show that the number predisposed to gall-bladder disease is large; that the unrecognized cases are many; that few have the proper treatment at a time when it can be most serviceable; that the condition of those suffering from chronic diseases of this class is most unhappy and often intolerable; that the complications produced by the presence of gall-stones may set up diseases in other organs and cause serious impairment of their functions which of themselves may prove fatal; that early surgical interference offers the best possible results; and that operations upon these organs are not so serious as is usually considered.

Diseased conditions of the gall-bladder are of much more frequent occurrence than is usually supposed.

Nearly ten per cent. of all adults are said to have gallstones, but only about five per cent. of these, fortunately, suffer from any appreciable discomfort therefrom. While, then, only about one in twenty of all gall-stone subjects ever has any symptoms calling attention to these conditions, there are no marked indications by which one can select beforehand those who will become sufferers from gall-bladder disease. It is now a pretty well-established fact that calculi of the gall-bladder are of themselves of little importance, provided there is a free passage of bile in and out of this viscus. A considerable amount of infection may in this way be taken care of by constant flushing of the gall-bladder with healthy bile, but when the free flow of bile is interfered with, either by inflammation or obstructions of the ducts, or by the fundus of the bladder becoming dependent, giving rise to a considerable amount of residual bile, in which any infectious material may speedily become more effective, there are rapidly developed the symptoms of gall-bladder disease.

Case two of my series, was a lady of about sixty-five, in whom a prominent member of this Society had discovered a tumor in the right hypochondrium twenty years previously. This had given her no trouble until about six weeks before operation, when the infection evidently commenced. It is a common experience to find at autopsies gall-stones in subjects in whom there had been no symptoms whatever of their presence during life. Cases of gall-bladder disease often occur independently of the presence of gall-stones. These are probably due to an infection which has traveled up the ducts from the intestines and which has become implanted upon the gall-bladder wall. Ricketts, in a recent article, says that this is much more common than will be supposed, and that "continuous infection of the gall-bladder and its ducts, minus gall-stones, is the most serious."

In my last case, that of a young girl, fourteen years old, there was an acute infection of the gall-bladder

which was imbedded in a mass of recent exudate, but at no time in the history of the case did we find any evidence of the presence of a gall-stone. This case was supposed to be a case of appendicitis until the time of operation, all the symptoms being characteristic of that disease. There is always the possibility, however, that a gall-stone may have been present at some time in the history of these cases and passed out in the usual way, leaving the cholecystitis behind.

Of the variety of conditions which may occur in this locality and which may pertain in connection with the progress of the disease or course of the calculi, it is not within the scope of this paper to consider. Neither is it our intention to enter into any detailed consideration of the etiology or diagnosis of these conditions.

We will then consider it as an established fact that one adult in every ten or twelve has gall-stones, which means that in this assemblage there are certainly several individuals who are unconsciously harboring these unwelcome and unbidden guests, and that it is impossible to predict which out of every twenty of these so affected will become seriously invalided thereby.

That these conditions are often unrecognized cannot be denied. How many of our own cases, who have suffered and perhaps died with chronic ill-defined disturbances of the digestive organs have actually had unrecog nized inflammatory conditions of the biliary passages, neither you nor I will ever know. I believe it is true that more experience and more careful attention to diagnosis in such cases will show that a large number of them have some abnormal condition of these organs. It is probable that many who have died from supposed cancer of the liver, or even of the stomach, have actually suffered from gall-bladder disease. Surely the diagnosis between these conditions is not easy.

Case two, already referred to, was seen a few days before operation by a surgeon of eminence in a neighbor

ing city, one in whom we could all have confidence and upon whose judgment we would be willing to rely. He was ready to stake his reputation upon the diagnosis of cancer of the liver, and said that no amount of money could tempt him to operate.

I remember a case seen a few years ago, which appeared to be malignant disease in which a tumor could easily be made out a little to the left of the median line. There was not, however, the amount of cachexia and exhaustion which you would expect, and an exploration was advised and allowed. At the Hartford Hospital later, Dr. H. G. Howe found a large cyst, which by pressure upon surrounding organs produced the existing symptoms. There was found in the fluid fragments of old brokendown gall-stones, and it was evident that the tumor was originally either a part of the gall-bladder or a cyst formed around the gall stones, which had at some time passed out through the wall of the gall-bladder or ducts into the abdominal cavity. This case made a slow recovery, but is in good condition at the present time.

Dr. Harry Dorr Niles, in the March number of the Annals of Surgery, relating a case resembling cancer of the stomach, says: "There was evidently an obstruction at the pylorus, which I am sure five years ago we all in view of the other symptoms would have pronounced malignant."

But it is not always unrecognized cases which are not properly treated. I can recall several fatal cases which were recognized in ample time to have been relieved by an operation which was positively denied or postponed until the patient was in such a condition that no interference of this kind could be successful.

Last winter I saw a lady, in middle life, very fleshy, who about two weeks previously had commenced to have pain in the right side, with fever gradually increasing. Her symptoms had grown rapidly worse, and there was discovered a much distended gall-bladder which was evi

dently the seat of an acute infection. Operation was refused and an unnecessary death recorded.

It is hardly necessary for me to place before you the picture of the most unhappy condition of those suffering from this disease in its chronic form, with all its pain, inconvenience and danger. The complications which may be caused by gall-stones are so numerous that I cannot in the time allotted to this paper consider them in detail. They are, however, so extensive and far reaching that I take the liberty of quoting the following list from Mayo-Robson's work on this subject:

(1).

Ileus due to atony of the bowel, leading to enor mous distention, and to symptoms and appearances of acute intestinal obstruction apparently the consequence of the violent pain.

(2). Acute intestinal obstruction dependent on

(a) Paralysis of gut due to local peritonitis in the neighborhood of the gall-bladder.

(b) Volvulus of small intestine.

(c) Stricture of intestine by adventitious bands originally produced as a result of gall-stones. (d) Impaction of a large gall-stone in some part of the intestine after ulcerating its way from the bile-channels into the bowel.

(3). General hemorrhages, the result of long-continued jaundice, dependent either on gall-stones alone, or on cholelithiasis associated with malignant disease.

(4.) Localized peritonitis producing adhesions, which may then become a source of pain even after the gallstones have been gotten rid of. We believe that nearly every serious attack of biliary colic is accompanied by adhesive peritonitis, as experience shows that adhesions are found practically in all cases where there have been characteristic seizures.

(5.) Dilatation of the stomach dependent on adhesions around the pylorus.