President Medical and Chirurgical Faculty 2. Presentation of portrait of Dr. Sloane..... Dr. Joel E. Goldthwait 9.30 to 10.00 a.m. 10.00 to 10.30 a.m. 10.30 to 11.00 a.m. 11.00 to 11.30 a.m. 11.30 to 12.00 m. Annual Smoker, Banquet Hall, 10.00 p.m. WEDNESDAY, APRIL 26, 1922 Morning Session Clinics at Johns Hopkins Hospital Quinindine, a new cardiac remedy.....Dr. G. Canby Robinson Causes of unsatisfactory results in surgery of gastric and 2. A critical review of the diagnosis and therapeutic value of the Lyon method of gall bladder drainage.... 3. Clinical aspects of epidemic encephalitis. 4. Gall bladder disease..... 5. Infections of the accessory sinuses in children.. Evening Session, Osler Hall, 8.30 p.m. Pneumonoconiosis: Clinical features and diagnosis.... 9.30 to 11.30 a.m. Dance 9.30 p.m. THURSDAY, APRIL 27, 1922 Morning Session Clinics at University of Maryland Exhibition of cases by the staff. Osler Hall, 12.00 m. .Dr. T. R. Brown Dr. A. C. Gillis .Dr. A. C. Harrison .Dr. E. A. Looper Dr. H. R. M. Landis Philadelphia, Pa. Election of State Board of Medical Examiners 3 THE GALL BLADDER BY DR. A. H. HAWKINS President Medical and Chirurgical Faculty Ladies and Gentlemen: It is not my purpose to enter into a lengthy discussion of the types and incidence of gall bladder disease. There are numerous lengthy and authoritative dissertations upon this subject in all the journals. The function of the gall bladder (if it really plays an important rôle in the physiology of the present day human organism) is brilliantly worked out in two recent articles in Surgery, Gynecology and Obstetrics for March, 1922, the first by Harer, Hargis and Van Meter, of Philadelphia; second by W. O. Johnson, of Cleveland. How the gall bladder becomes infected; whether through the blood stream or by living bacteria in the bile coming down from the liver-which have escaped the destructive action of the liver-or whether infection can gain entrance into the ducts through the sphincter of oddi and travel upward into the gall bladder-all these questions have been abundantly discussed by numerous authorities and are at the disposal of all. Indeed, when one considers the vast amount of literature that is printed weekly upon the various phases of gall bladder disease, more especially the varying opinions expressed by the best students in this field, one hesitates which way to turn for helpful concrete information for guidance to the true solution of this most vital problem. There are certain things, however, that we can feel assured have been established as facts. The gall bladder does become infected and probably through each or all of these sources mentioned. We believe we are safe in asserting that gall stones are in some way the result of infection of the gall bladder and ducts. And we might go so far as to say that gall bladders containing stones are in a state of inflammation or suspended function—in other words, no healthy gall bladder contains stones. We may also claim as a fact that there are many gall bladders the seat of inflammatory process-producing all the disturbances of function and secretion in the liver, pancreas, duodenum and stomach-that have no stones and probably would not develop stones. The gall bladder, of course, does not become inflamed unless there is some focus of infection elsewhere in the body-what or where it is, of course, may be a question. Bad teeth, tonsils, sinuses or infectious agents 4 gathered by the portal system somewhere along the alimentary canalall are possible and probable. It has been abundantly shown that the mucous membrane of the gall bladder is exceedingly resistant to infection. It undoubtedly does become inflamed under favorable conditions, but it seems to prefer to allow the infectious agents to filter through into the more susceptible fibro-muscular layer where inflammatory processes from the mildest to the severe destructive processes proceed and pass the infection on through the lymphatics to the duodenum and pancreas. How can any manner of treatment or medication reach the infectious process going on in these gall bladder walls? How can any amount of drainage of the gall bladder, either through surgically placed drains or the duodenal tube, reach this process in the walls of the gall bladder? Even if drainage could restore the gall bladder to a fairly normal state, it is clear that this organ is a favorable site for infection, quite susceptible; also that it has a way while inflamed of pulling a string on the stomach, duodenum and pancreas, as well as a more pernicious habit of passing infection on to these organs. All these are attributes of the appendix. Why should we go to such lengths to spare the gall bladder-Ay, even to risking the patient's safety at 2-3 drainage operation upon the gall bladder before deciding to sacrifice that organ? How the human gall bladder has managed so long to retain the sympathy and clemency of the Medical Courts I cannot see. He has always been a criminal-of course there are good ones too, mind you-but when one starts wrong there is no hope for regeneration. With all this there yet remains a question, cholecystostomy or cholecystectomy, if drainage of the gall bladder fails to reach the infected area, hence fails to remove the infection-then why drain? An operation which fails of result is obviously an error in judgment and better not have been. Further, drainage unquestionably imposes upon an already damaged gall bladder an additional obstacle the adhesions. In my own experience a large number of gall bladders that were drained at a previous operation, some of my own early ones and some from other surgeons, came back; some complaining that they have had no relief; some that their relief was temporary and others that they are worse than before the operation. All of these are relieved by cholecystectomy. Those of us who labor long and earnestly upon the fine points of differentiation between gall bladder disease, gastric and duodenal ulcer and pancreatitis are frequently suffering precious moments to slip by during which time the condition may and frequently does pass from a simple easily handled process to one of extreme gravity. Eight years ago I read a paper before one of our local societies with a prologue thus: Any discussion of the signs and symptoms of gall stone |