Non-calculous chronic gall-bladder disease

NONCALCULOUS

CHRONIC

GALL/BLADDER DISEASE *t

MERLE J. BROWN, M.D. Fellow in Surgery, SAYRE,

Robert Packer HospitaI PENNSYLVANIA

T

HE unsatisfactory resuhs in surgery on the non-caIculous chronic gaIlbIadder are attested by the writings of Ieaders in this heId of medicine. The aim of this paper is to emphasize the vaIidity of this statement by summarizing the Iiterature and to present the anaIytical data derived from a cIinica1 and foIIow-up study of 346 uncompIicated cases of chronic non-caIcuIous ChoIecystitis. It is hoped that these data may Iend some inffuence in changing the methods of attack on this disease in an effort to improve the resuIts. The cases used in this study were selected from a series of 2,079 operations on the biIiary tract performed at the Robert Packer Hospital and Guthrie CIinic from January IO, rgro to JuIy I, 1936. PHYSIOLOGY

In man, about 500 C.C.of biIe are secreted daiIy, aIthough the amount varies at different hours of the day and with various conditions. Hemorrhage decreases secretion whiIe a meat diet increases the secretion. BiIe output is decreased in starvation but continues to be secreted unti1 the moment of death. The normal galI-bladder is designed to store the excess biIe secreted under various conditions; it is abIe to concentrate hepatic bile from four to ten times by absorption of water and certain inorganic salts. GaII-bladder biIe is acid whiIe that directly from the Iiver is aIkaIine. This concentrating function of the gail-bIadder aIIows it to handIe rather Iarge amounts of hepatic biIe; it may store a tweIve to twenty-four-hour output of hepatic biIe. Mann and BoIImanl expIained that this

was the reason why dogs without gaII-bladders became jaundiced sooner after obstruction of the common duct than dogs with norma gaII-bIadders. Ivy2 stated that an acuteIy inff amed gaIIbIadder does not concentrate biIe, but it may do so if the inffammation of the mucosa is “patchy” or IocaIized to the mucosa or serosa. According to this author, the acuteIy inffamed gaII-bIadder does not evacuate, but after the acute inffammation has subsided, the gaII-bIadder may again concentrate and evacuate. Fibrosis resuIting renders concentration absent or sIight. It has been found by CayIor and BoIIman3 that gaII-bIadders with hypertrophied and papiIIomatous rugae concentrate exceedingIy weI1. According to IIIingworth,4 the pathoIogic state of choIesterosis does not affect the concentrating powers or evacuation of the gaII-bIadder unIess associated with moderate or severe ChoIecystitis. Ravdin and his associates5 found evidence of concentration of caIcium or bile saIts or both in specimens of biIe from chronic non-caIcuIous ChoIecystitis cases. The galI-bladder possesses some secretory activity, and its product is normaIIy a mucoid biIe. The rate of secretion is not known, but Birch and Spong6 noted in human cases of cystic duct obstruction and gaII-bIadder fistuIa that 20 C.C. for each twenty-four hours couId be coIIected. Likewise, the ducts were abIe to secrete a sIightIy viscid and coIorIess substance, particuIarIy when obstructed. Rous and McMaster’ found that when the common duct had been obstructed for tweIve to fourteen days with a norma galI-bladder

* Thesis submitted to the Faculty of Surgery of the Graduate SchooI of Medicine of the University of PennsyIvania in partia1 fulfiIIment of the requirements for the degree of Master of MedicaI Science [M. SC. (MED.)] for graduate work in surgery. t From the Guthrie Clinic, Robert Packer HospitaI, Sayre, Pennsylvania.

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present, green Auid or a “green system” was found in the ducts. When the common duct was obstructed for tweIve to fourteen days and the gaII-bIadder functionIess or removed, a white Auid or “white system” was found. The surgeon often Iinds this white biIe or “white system.” The gaII-bIadder has two types of motor activity : rhythmic tonus changes and tonic contraction of the musculature as a whole. WhiIe the force of contraction has not been and evacuation measured, 2 contraction have been directIy observed. The chief stimuIus causing gaII-bIadder contraction, is, according to Ivy, “choIecystokinin,” a hormone produced at the stimuIus of acids and fats acting in the upper part of the intestine. Of the foods known to be effective, egg yoIk, cream and meats are the most potent stimulants. During the first or second day foIlowing an operation on the upper abdomen, the gaII-bIadder may show a marked atonic distention, according to SandbIom.8 The abiIity of the gaLbladder to contract and evacuate depends on the tone of the sphincter of Oddi. In the presence of a spasm of the sphincter, the gaILbladder may not have enough expuIsive pressure to overcome the spasm and permit emptying. Ivy and associates9 have shown that a spastic sphincter in humans may cause biIiary coIic. When magnesium suIphate was introduced into the duodenum, the pain was relieved and bIack biIe soon appeared. In clinica work these facts and observations on galI-bIadder functions are important because ChoIecystography depends upon the concentrating and evacuating powers. CHOLECYSTOGRAPHY

The detaiIs of this important phase of gaII-bIadder diagnosis cannot be discussed here; onIy a review of the principIes wiI1 be attempted. Graham and CoIe’O introduced ChoIecystography in 1924, and the test was immediateIy accepted as a cIinica1 aid in diagnosis of gaIl-bIadder disease. In

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1927, Graham” restated the principIe upon which ChoIecystography was founded. “Theoretically,” he said, “any substance used for choIecystography must be excreted by the Iiver into the bile. It must pass with the biIe into the gall-bladder where it must be concentrated by absorption of water in order to give the densest shadow. It is obvious, therefore, that the densest shadows wiI1 be found in norma subjects. It is equaIIy apparent that there may be no shadow at al1, or onIy a faint one, if the cystic duct is occIuded, if the gaII-bIadder is unabIe to concentrate its contents because of a diseased waI1, or if the Iiver is unabIe to excrete the substance normaIly. Moreover, as bile is poured out from the galI-bIadder into the common duct, it is obvious that the shadow wiI1 diminish in size and graduaIIy disappear entireIy. Since the presence of food in the duodenum is accompanied by an outpouring of biIe the necessity of fasting during the period of concentration of the substance in the gaII-bIadder becomes evident. It is seen, therefore, that chorecystography is reaIIy a means of studying the functional activity of the gaILbladder rather than a means of indicating the exact pathoIogica1 Iesions present.” Graham gave the correctness of cholecystographic readings as 97.28 per cent, as confIrmed by operation. Zink12 stated that faiIure of dye absorption, when given oraIIy, might account for the absence of a gaILbladder shadow. He aIso noted that very earIy “strawberry types” of gaII-bIadders showed a marked inhibition of the concentration phenomena and often a deIayed appearance of the shadow. He reported the procedure to be g6 per cent diagnostic. KirkIin,13 in 1933, showed an accuracy of go to IOO per cent for the ora method as used by him, but in 8 per cent of the total cases he found it advisabIe to repeat the tests before drawing fina concIusions. Burden14 feIt that the choIecystogram was not a reIiabIe diagnostic aid in earIy or miId choIecystitis. The history of a patient with chronic gaII-

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bladder disease is more diagnostic than choIecystographic &dings, as shown by PaImer.15 We can concIude, therefore, that the Graham-CoIe test measures galI-bladder physioIogy and not the extent or the character of the pathologic lesion present. AIso, the test is not to be accepted as the fIna diagnostic aid in chronic non-caIcuIous ChoIecystitis.

Gall-BIadder

AUGUST,1938

proper operation at the proper time, and in the proper way was chieffy responsible for our bad results.” After studying the end resuIts of operation of ninety-nine cases of stoneIess gaII-bIadder disease in ig 1 I, StantonlB “operations for choleconcIuded that, cystitis without stone have not shown better resuIts than couId probably have been secured by medica means.” REVIEW OF LITERATURE UntiI 1918, changes and enIargement of the Iiver had been observed in stoneless The history of the development of surgall-bladder disease by many writers, but gery of the biIiary tract is interesting. Records show that, in the year 1618, it was Grahamlg who proved that hepatitis was a rather constant accompaniment of Fabricious HiIdanus was the lirst to remove chronic ChoIecystitis. He emphasized its gaIlstones from a Iiving patient. An Italian, importance in diagnosis of obscure and Zambeccari, in 1630, performed the first doubtfu1 cases of biIiary tract disease. In choIecystectomy on a dog. Jean Louis spite of this observation, which might have Petit (1743) was the first surgeon deliberbeen expected to aid in eIimination of some ately to carry out an operation for remova of the poor .results in this phase of galIof gaIIstones. Then, in 1882, Langenbuck performed a cholecystectomy with speedy bIadder surgery, AIvarez (1923) and his co-workers20 admonished that surgeons results. Mayo-Robson has been given who became enthusiastic over the results credit for his pioneer work in surgery of the gall-bladder. of early cholecystectomy would have to Moynihan, l6 in agog, caIIed attention to check up on their work in order to avoid the the subject of chronic non-caIcuIous choIedanger of removing normal gaII-bladders. In 1924, after studying 888 cases of cystitis of the so-caIIed “strawberry type.” He wrote that he had “met every grade of ChoIecystitis, BIaIock21 concIuded that his ChoIecystitis from the miIdest to the very findings justified the beIief that the gaIIsevere. The most common condition is to bIadder shouId be removed in a11 cases in lind the galI-bIadder aImost normaI, retainwhich it was diseased, regardIess of the ing much of its norma bIue coIor, and a11 presence or absence of stones. This same year brought the introduction of the Graits smoothness and suppIeness. These are the cases it is most essential to recognize, ham-CoIe test’0 which, it was then hoped, for in them also the removal of the galIwouId soIve the problem of poor results in bladder is the onIy course of treatment non-calculous chronic cholecystitis. Since this time, roentgenoIogists and surgeons IikeIy to be attended by Iasting success.” However, Finney,” in I g I 3, called attenhave found that it is unreIiable as a diagtion to a dilatation of the lirst part of the nostic aid. duodenum inconstantly coupIed with panThe question of the type of operation, creatic changes and associated with atony choIecystectomy or cholecystostomy, seems and thinning of the stomach and duodenal to have been settIed in favor of cholewalls, occurring in patients with a neurotic cystectomy. W. J. Mayo,22 in 1914, stated taint, aImost invariabIy giving rise to a that simpIe drainage would not cure the symptom compIex which couId not be majority of patients, and choIecystectomy, explained by any demonstrable lesion of now the ruIe, did not give perfect results the gaIl-bladder or adjacent organs. In as yet. Mentzer,23 at the Mayo CIinic trying to account for faihrres in galI-bIad(rg28), showed that 55.7 per cent of gallder surgery, he said, “Failure to do the bIadder operations in rgo6 were chole-

New SERIES VOL. XLI. No.

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Brown-Non-Calculous

cystostomies, whereas in 1926 only 4.3 per cent were operations of this type. Other surgeons who have accepted choIecystectomy as the procedure of choice are Hitzrot 24Deaver 25Lahey,26 MuIIer,z’ ConneII,z8 cowIer,29 Highsmith3O Pfeiffer31 and others. There are very few advocates for cholecystostomy left. The time when a choIecystectomy shouId be done is not so easily settIed. Muher feIt that in supposed cases of chronic cholecystitis with atypica1 symptoms, and especiaIIy where there was a norma choIecystogram or a faint shadow and poor emptying, one shouId hesitate to advise operation unti1 a11 means had been exhausted in Iocating a possibIe Iesion outside of the biIiary tract, or unti1 satisfied that the patient was not in the dyskinesia group. In other words, he pIeaded for a most complete differentia1 diagnosis. Pfeiffer31 found that the mortaIity in surgery for biliary tract disease ran directIy paraIIe1 to the age and the condition of the patient and the extent and severity of the pathoIogic invoIvement. He stated that the Iow mortaIity at the earIy ages and in the absence of high grade Iesions placed a heavy responsibiIity upon those who temporized with active and recurring pathologic processes. AIvarezm found at operation that many of the gaII-bIadders were thin waIIed and norma in appearance, but in order to reIieve the patient, the organ had to be removed on the strength of the good history, suggestive physical and roentgenographic findings, the presence of Iarge gIands on the cystic duct with adhesions in this region, and perihepatitis. Deaver and Bortz25 emphasized that earIy operation on patients with recent disease wouId produce the most satisfactory results. These ideas coincided with Lahey’9 opinion that the gaII-bIadder shouId be removed if there were adequate symptoms unreIieved by treatment, irrespective of the norma appearance of the externa1 waIIs. ConneI128 beIieved that, in order to reduce the percentage of unsatisfactory resuIts, it

GaII-Bladder

Americanhurnd d surgery 24 I

must be noted that “surgery is a means to an end and not an end in itself.” He added that if one operated upon cIinica1 symptoms aIone with the usua1 signs of pathoIogy absent, there was danger of performing an unnecessary and therefore a harmfu1 operation; on the other hand to wait might permit an intercurrent pathoIogy in neighboring viscera which would consequently diminish the chances of a permanent cure. Young32 beIieved the onIy justification for an operation was the estabIishment of a diagnosis by cIinica1 and Iaboratory means. Once this diagnosis was made, the galIbIadder should be removed regardless of the amount of pathology present. From his study Mentzer 23 beIieved the onIy justification for remova of a norma appearing gaII-bIadder was the prominence of pain in the patients with gaII-bIadder distress. He feIt that operation shouId not be performed in a11 cases of choIesterosis because some might remain for years without any progression in the disease process. He concluded that a11 patients with chronic cholecystitis shouId be given the benefit of medical therapy before surgery was attempted. Highsmith30 stated that tenderness at Murphy’s point was an important sign and shouId be present before operation was decided upon. Mason and Blackford found that one-third of the cases of chronic choIecystitis couId be successfuIIy treated along medica Iines. FowIer,29 in his study, advocated earIy choIecystectomy because chronic inffammation of the gaII-bIadder was progressive. He stated that “more or less constant pain is practicaIIy aIways a symptom of chronic inflammation, but chronic inffammation does not aIways give pain.” Guthrie34 feeIs that this group of galI-bIadder diseases is the most treacherous to handIe. He is an advocate of very carefu1 seIection of cases before operation is attempted. ObviousIy, from these opinions of Ieading surgeons, one may concIude that the indications and the time to operate have not been settIed by any definite criteria.

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The diversity of opinion onIy makes for increased uncertainty in this phase of gaII-bIadder surgery. The duodenobihary drainage, as conceived by Lyon35 in rgrg, has Ied to a great dear of enthusiasm in the study of this subject. Lyon deveIoped his technique in this procedure to the extent of cIaiming it to be of diagnostic vaIue. The use of it has Ied to an endIess controversy, but the controversy has Ied to a great deaI of research and interest in this phase of galIbIadder disease. Nevertheless, AIvarez? and his co-workers have conchrded that as a diagnostic procedure, it is not worth the time spent. At the Guthrie CIinic, its use has come to be confined entireIy to its apphcation as a medica therapeutic procedure in cases that cannot be accepted for surgery. The subject of pathoIogy of the gaIIbIadder in chronic non-caIcuIous cholecystitis has received much study. Graham36 and Mackey 37 have prepared a cIassification which appears to be much in use, in&ding four groups of cases. I. The first group in&ides minima1 Iesions, in which the gaII-bIadder waIIs are not greatIy thickened and in which there is concentrated biIe. The mucous membrane is not disturbed, but there is some infdtration of Iymphocytes into the waI1. 2. Chronic catarrha1 choIecystitis marks the second group. There is edema of the mucous membrane, with bile contents Iess concentrated and some Iymphocytic concentration in the outer coats. 3. The third group is one of chronic fibrous choIecystitis, having for its characteristics a degenerate mucosa and thickened fibrosed outer Iayers of the wall. 4. ChoIesterosis, or strawberry galI-bIadder, is the Iast division, with a predominant picture of deposits of choIestero1 esters and neutral fats in the crypts of the mucous membrane. In addition to these pathoIogic features, AIvarez% found Iiving bacteria in the waII of 57 per cent of non-calculous gaIl-bladders. In respect to these findings BIaIock21 obtained positive resuIts in 58 per cent of

GaII-BIadder

AUGUST, 1938

a11 cuhures. BaciIIus cob was predominant and bacihus typhosus ranked second in occurrence. Incidently, BIaIock found that 28 per cent of the patients had a history typhoid fever, the greater percentage of them occurring in acaIcuIous cases. NickeI and Judd38 found 71 per cent of strawberry gaII-bIadder and the majority of a11 chronic choIecystitis cases were sterile. Deaver and Bortz26 wrote that 3.5 per cent of patients with non-caIcuIous galI-bladder disease have liver invoIvement and 1.2 per cent have pancreas invoIvement. WiIkie46 showed that intramura1 gaII-bIadder Iesions in choIecystitis precede the common Iiver changes in that disease. PathoIogists do not agree on what constitutes a normaI gaII-bIadder. It has even been estimated that 30 to 50 per cent of the ad& population over 30 years of age have chronic choIecystitis, which is the foundation for the often-heard statement that most digestive disturbances are due to chronic gaII-bIadder disease. However, no figures are avaiIabIe as to what percentage of those with supposed chronic disease show symptoms. Autopsy records co&-m the fact that many patients with gaII-bIadder disease never have symptoms. Since these situations exist in reahty, the question may be asked, “What is added to chronic gaII-bIadder disease to produce the symptoms?” This, however, is a question yet to be answered. CLINICAL

STUDY

This study consists of a survey of records and fohow-up on 346 cases of non-caIcuIous chronic cholecystitis. Of this number 356 were femaIes and go were maIes. The average age for the whore group was 41.06 years. The average age for a11 femaIes was 41.55 years, whiIe that of the married femaIes was 43.53 years, and of the singIe femaIes was 34.77 years. There were 2 18 married femaIes and 38 singIe females. It wiII be noted that the average age of the married group of femaIes was aImost ten years greater than of the singIe group. The average age of maIe patients was 39.66

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NEW SERVESVOL. XLI, No. 2

years. Comparatively, the maIes tended to be sIightIy younger than the femaIes at the time they came to operation. The ratio of femaIe to maIe was 2.84 to I. (Table I.) TABLE AGE

I

GROUPING

It wiI1 be noted that 39.9 per cent of the women and 28.8 per cent of the men feI1 into the 30-40 year age group-the incidence of disease was greatest for both maIes and femaIes in this decade of Iife. Two hundred and thirty-eight females (93 per cent) and 83 maIes, or g2 per cent, were between the ages of 20 and 60. In totals, 321 cases or 92.7 per cent, were operated in this period of their Iives. The oIdest patient was 76 years of age and the youngest 14. The compIaints of the patients were somewhat varied. The occurrence of the symptoms is given in Table II. The most commonIy given symptoms are included in this Iist whiIe the Iess common symptoms wil1 be mentioned in narration. TABLE OCCURRENCE

II

OF SYMPTOMS

Symptoms

No record of symptoms ......... Pain in epigastrium. ........... Pain in right upper abdomen. .. Nausea ....................... Vomiting. ..................... Fulness or distress after food. ... Constipation. ................. Flatulence ..................... Belching. ..................... Indigestion. ................... Pain in back or right shouIder. Pain in right Iower quadrant. Loss of weight ................. ReIief by soda. ................ Relief by food. ................ Loss of appetite ................ Jaundice. .....................

Occurrence

Per Cent of Cases

5.8

20

46.6

‘52 117

35.9

143 126

43.8 38.6 X9.3

63 145

44.4

139

40.0

78

20.0

42

12.8

76 26

23.0 8.0

25 23

7.6

1

7-o

19 22

C:” 7

I4

4.3

Gall-BIadder

A merican hd

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surgery 243

Percentages caIcuIated on the basis of 326 avaiIabIe histories. Patients complaining of pain in the upper abdomen comprised 82.5 per cent. Nausea, vomiting, constipation, Aatulence and pain in the shouIder and back were other common symptoms. The patients giving a history of reIief by soda and food were suspected of having peptic uIcers, but none were demonstrabIe at operation. Of the patients complaining of pain, onIy eight gave a history of pain of coIicky character. Some gave a history of weight Ioss, but this was expIained in most instances by the vomiting or by the fear of eating and arousing further severe distress. It was found that onIy 123 patients had tenderness in the right upper abdomen upon paIpation; twenty-seven had the tenderness in the epigastric region. There were eight patients with tenderness in the right Iower quadrant and two with the tenderness in the Ieft lower abdomen. One compIained of tenderness over the cecum whiIe two cIaimed tenderness about the umbiIicus, and two tenderness over the right kidney. By comparison, it is apparent that the physica findings do not coincide aIways with the symptomatoIogy of the patients. The duration of symptoms before patients came to the cIinic for study and treatment was recorded. There were 174 patients who had had their symptoms for over one year; the average time for this group was 6.6 years. Forty-five had had their symptoms for Iess than one year, with an average time of 3.9 months. Fourteen had had symptoms for 2.5 weeks prior to admission to the hospita1, whiIe three patients gave the duration of symptoms as Iess than one week, averaging 3.3 days. There were twenty-seven patients who were less definite about the Iength of time of their ihness; twenty-two gave the time as years, four as months, while one stated that the symptoms had been present for her lifetime. It is evident from these findings that patients with a symptom compIex which

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may be interpreted as gaII-bIadder disease tend to procrastinate in seeking medica care. Perhaps this reIieves the doctors of some of the bIame for the large percentage of unsatisfactory results which reputedIy exist in this branch of surgery. It has been stated by a number of authorities that the resuIts depend somewhat on the Iength of time the symptoms of the patient have been in existence; proIonged duration of symptoms and disease tends to Iead to irreparabIe damage to the Iiver and pancreas. Laboratory work, except for the urine examinations, on patients with apparent gaII-bIadder disease is aIso summarized. There were fifty-six patients who had Wassermann tests done; of these, fifty-five were negative and one male reacted 3 pIus. Of the 148 patients having the Kahn test performed, 147 were negative whiIe one femaIe gave a 4 pIus reaction. These two patients were given antiIuetic treatment. In seventy-three patients a Rehfuss test was performed. There were sixty-five with norma stomach acids; two had high hydrochIoric and tota acids (HCI of I 10-104) ; two had Iow hydrochIoric acid (IO- IO) and four of the group showed an absence of hydrochIoric acid. These figures do not bear out those found in the Iiterature, as some authors have found that as high as 23 per cent of these patients have an achIorhydria. The bIood work, in the main, consisted of white bIood ceI1 counts and differentia1 counts. Of the tota 346 patients, there were 230 who had 240 counts. The average white bIood ceII count was found to be 8, I 70, with an average differential of 68 per cent poIymorphonuclear leucocytes and 32 per cent (by subtraction) Iymphocytes. The highest count was 3 1,300 with a differentia1 of g6 per cent poIys and 4 per cent Iymphocytes. The Iowest count was 4,000 (of which there were severaI), with differentia1 of 66 per cent polys and 34 per cent lymphocytes. There was no record on I 16 cases. It is evident from these figures that the bIood counts do not offer much of diagnostic vaIue in these cases.

GalI-BIadder OPERATIVE

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1938

IMMEDIATE

POSTOPERATIVE

STUDIES

Of the 346 patients included in this series, there were 320 upon whom a cholecystectomy was performed; nine aIso had a choledochotomy. The remaining twentysix patients had choIecystostomies. An appendectomy was a secondary procedure in I86 cases. The pathoIogic diagnosis of appendices incIuded four cases of acute appendicitis; nine subacute; rag chronic; and Iifty-nine described as normal. Eighteen of the infected specimens contained fecaliths. The operative fmdings in reIation to the appendix showed thirty with marked adhesions, four with a Lane’s kink, and fifteen described as retroceca1. From these findings, one cannot but suspect that the appendix was responsibIe for some of the symptoms, aIthough Mackey3’ was not abIe to show that the remova of diseased appendices played any part in the end resuIts of surgery of the gaII-bIadder disease. Other secondary operations performed at the time of the primary operation were : one jejunostomy, three ventraI hernia repairs, four inguina1 hernia repairs, one repair of epigastric hernia, one umbiIica1 hernia repair, one pyIorosphincterectomy for hypertrophic pyIoric sphincter, one oijphorectomy and one saIpingo-oophorectomy. TABLE PERICHOLECYSTIC

Operative

III DISEASE

Findings

Pericholecystic adhesions. . . . . Hepatitis.. . . . ... . Pancreatitis. . .. . . . Cirrhosis of liver.. .. . ... EnIarged glands of biliary tract. Infected or diIated common duct.

Number of Patients

I99

Percentage of TotaI

60

24

57.3 17.3 6.9

4

18.2

1.1

IO

2.9

The operative findings outside the gaIIbladder and its ducts are listed in Table III.

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The 57.5 per cent of perichoIecystic adhesions is Iess than is commonIy quoted in the Iiterature, as high as 75 per cent having been reported by some authors. AIthough hepatitis has been shown to be a constant companion of gaILbladder disease, only 17.3 per cent of the series were described as having it. Pancreatitis and cirrhosis of the liver were Iess frequent in this series than had been expected from a reading of the Iiterature. It is rather surprising to fmd that onIy 18.2 per cent of these cases were described as having gIands aIong the biIiary tract. Other findings in the abdomen not incIuded in TabIe III are: pregnancy, two; hypertrophic pyioric sphincter, one; pylorospasm, one; retroversion of uterus, two; hydronephrosis one; gastroptosis, one; diIatation of stomach, one; fibroid of uterus, two; heaIed duodena1 uIcer, one and sIiding hernia, one. These extra-biIiary findings couId undoubtedIy account for some of the symptoms. Mackey3’ reported a mortality of 3 per cent in 264 stoneless cases. The mortaIity in the present series of 346 cases was 2.6 per cent; a11 nine deaths occurred in the choIecystectomy group. When the mortality is caIcuIated on the basis of 320 cholecystectomies, the rate becomes 2.8 per cent. The age of the patient and the cause of death are Iisted as foIIows: Mrs. J. M., 61, intestinal obstruction. Mrs. A. E., 54, cardiac death. Mrs. C. W., 65, pulmonary embolism. Mr. J. S., 40, following jejunostomy for iIeus, seven days postoperative. Mr. F. S., 51, Iobar pneumonia. Mr. F. D., 50, chronic myocarditis. Mrs. P. H., 32, pulmonary emboIism-seven days postoperative. Mrs. F. C., 54, cardiac disease-one day postoperative. Mrs. S. S., 49, choIangitis and gastric mesenteric iIeus, 7 days postoperative.

There were no deaths from peritonitis. It wouId seem that none of these deaths couId have been prevented. Some writers in the literature have given peritonitis as one of the common causes of death in operative gaII-bIadder cases.

GaII-BIadder

CLASSIFICATION USED

Ame&an

JOUI~

of surgery

OF GALL-BLADDER IN THIS

245

DISEASE

ANALYSIS

The cIassification of the gaII-bIadder disease was made from the gross description of specimen since no record of microscopic study was recorded. The first group was the sIightIy pathoIogic to norma gaII-bIadder. In this group, the galI-bladder waI1 was described to be of normal thickness, the suppIeness and coIor of the organ were retained, and the mucous membrane was intact and norma in appearance. The second group was identified by the term chronic choIecystitis and the gross description incIuded sIight to moderate thickening of the waI1, the coIor varied from gray to white depending on the amount of scarring, and the mucous membrane was thickened and edematous. The Iast group was designated as choIesterosis. The coIor of the organ was practicaIIy normaI; the thickness of the waI1 was IittIe changed, and the mucous membrane was reddened and contained pIacques or crystaIs, visibIe to the eye, of choIestero1 deposits. There were no specimen descriptions of the chronic fibrous group. RELATION

OF

ROENTGENOGRAPHIC

PATHOLOGIC

AND

FINDINGS

In this series, there were 166 choIecystographic tests on 166 patients, 105 done by the intravenous method and 61 by accepted ora methods. The interpretations of the choIecystographic findings were used for study. “ Norma1 function ” indicates the IiIIing and emptying of the galI-bIadder in physiologic manner. “DeIayed function” means that fiIIing may or may not have been prompt whiIe emptying was aIways delayed, and visualization was good. In the “faint shadow” group the concentration of dye was so sIight that visuaIization was unsatisfactory and in the “no shadow” group there was no concentration of dye. (Table IV.)

246 A me&an JournaI of Surgery Brown-Non-CaIcuIous TABLE RELATION

OF

Iv

ROENTGENOGRAPHIC

TO

PATHOLOGIC

FINDINGS

PathCholecystographic

Response

ology

Slight to Normal

Chronic Cholecystitis

Cholesterosis (Strawberry)

Total Per No. of Cent Readof ings Total --

Normal

function.

Delayed function.. Faint shadow. No shadow..

Totals..

2 +I

32

19.2

84

50.6

3 z

16 34

9.6 II.0

166

100.4

38

i 94

44

These findings wouId appear to be significant in that a deIayed function was the commonest roentgenographic finding for a11 the cIasses of diseased gaI1 bIadders. PracticaIIy a11 of these readings occurred in the group which is the most pathoIogic of the three classes of lesions. Even though there were eighteen normal readings in this most pathoIogic group, aImost twice as many others gave no shadow or an unsatisfactory faint shadow. It has been stated that the strawberry gaII-bIadder is abIe to concentrate dye sufficient for VisuaIization; this is borne out by thirtyone out of forty-four readings satisfactory for VisuaIization. AIso, it wiI1 be seen that twenty-three out of twenty-eight readings in the sIightIy pathoIogic to norma group gave good visualization. It wouId seem fair, from this correlation of data, to conclude that a reading of “normal function ” should mean a non-operative galI-bIadder, whiIe readings of “delayed function,” “ faint shadow ” (unsatisfactory visuaIization), and “no shadow” shouId indicate a pathoIogic gaII-bIadder amenabIe to surgery. RELATION TO

OF ROENTGENOGRAPHIC PERICHOLECYSTIC

FINDINGS

DISEASE

It wouId seem IikeIy that the presence of disease about the galI-bIadder as represented by adhesions and in adjacent organs wouId have some significant effect on the galI-bIadder function. That the liver must be abIe to excrete the dye is definiteIy known. Adhesions about the gaII-bIadder

GalI-BIadder

AUGUST, 1~8

couId prevent emptying of the organ by obstructing or binding the organ to the extent of neutraIizing its contractile powers required for evacuation. Also the presence of adhesions might represent a more advanced stage of the disease-the inff ammatory reaction having gotten beyond the confines of the gaII-bIadder. DirectIy, it is not IikeIy that pancreatic invoIvement wouId effect the concentrating capacity of the gaILbladder, but it aIso represents a progression of the disease outside the biIiary tract. With these possibiIities in mind, Table v has been prepared. TABLE RELATION

OF

v

ROENTGENOGRAPHIC

PERICHOLECYSTIC

FINDINGS

TO

DISEASE

NO

Pericholecystic Disease

v

18

Normal function. Delayed function.. Faint shadow.. No shadow..

Total..

6

35 II

3 3

15 _/

pg

4 5 1 4

12 1

34

1

14

1

0 0 I 7.

10

3

45

16 3 16

The case with the invoIvement of the adjacent tissues and organs gave a smaI1 percentage of norma choiecystographic readings. The “delayed function” interpretation was highest in a11 groups except in the three cases of cirrhosis in which the shadow was unsatisfactory or absent. Over one-haIf of the cases with adhesions gave a “deIayed function.” This wouId seem signihcant in indicating more advanced pathoIogy. In the hepatitis group there were twenty-two out of thirty&e cases showing deIayed reactions. The distribution of findings in the pancreatitis group was so even that no deductions were possibIe. In the group with no perichoIecystic disease the spread of roentgenographic findings was so uniform that no concIusions couId be made. In this group of cases, the amount of pathoIogy in the gaII-bIadder was whoIIy responsibIe for the radiographic response.

NEW SERIES VOL. XLI, No. 2

FOLLOW-UP

RESULTS

Brown-Non-CaIcuIous AND

STUDIES

At the beginning of this foIIow-up study there were 346 patients. The earIiest cases were operated on beginning January I, 1921. The Iatest patients were incIuded to JuIy 1936, giving a foIIow-up period of at Ieast six months from the date of operation. There were seven cases folIowed less than one year, but a11 others were seen for one to fifteen years postoperativeIy. Most of the foIIow-up resuIts were obtained by mai1, whiIe a few were questioned and examined at the Guthrie Clinic. The Ietters sent to a11patients were made as simpIe as possibIe. A statement of our purpose in seeking repIies was made in the introductory paragraph and three easiIy understandabIe questions were incIuded in the Ietter. The questions were: I. Have you had permanent relief of your symptoms? 2. If not, describe the symptoms you have had. 3. When did these symptoms recur foIIowing the operation? Question 2 Ieaves the patients to their own resources in describing or enumeratingtheir symptoms. InstinctiveIy, the patients describe the symptoms that are most annoying to them, and in our experience, most of them were capabIe of expIaining the exact feeIings. The third question was designed to bring out whether the symptoms continued from the time of operation or recurred some months or years Iater. The replies were anaIyzed as criticaIIy and as fairly as possibIe. Of the 346 cases there were twenty-six choIecystostomies, and the remaining 320 were a11choIecystectomies. Of the 320 cases of choIecystectomy onIy nine had choIedochotomies. The choIecystostomy group wiI1 be dismissed by simpIy giving the follow-up resuIts without further analysis, as shown in TabIe VI. Permanent reIief means a positive cure, i.e., the patients compIain of no symptoms. The improved Grade I group is composed of those patients with no pain but having

GaII-Bladder

American Journal of Surgery

247

some occasiona miId indigestion of the same type as compIained of before operation. Grade II improvement includes those patients who compIain of some miId TABLE VI Degree of Relief of Symptoms

Permanent relief. Improved (Grade I). Improved (Grade II). No reIief.. . No return..

No. of Cases

Per Cent of TotaI

9 3

34.6 11.5

:

‘4.3 23.0

4 26

15.3 99.7

epigastric or right upper quadrant distress and some digestive symptoms a11 of which are less severe than before operation. The no reIief group are those patients whose symptoms have not been changed by the operation or were made worse. “No return ” means that the patients negIected or refused to answer, and incIudes aIso those who could not be located. Less than 50 per cent of the tota number were cured by choIecystostomy, but the tota of cured and improved combined was 61.4 per cent. Although this series of cholecystostomies is smaI1, it bears out the commonIy accepted opinion that this procedure is unsatisfactory in non-caIcuIous chronic gaII-bIadder disease. The foIIow-up resuIts for the 320 cases of cholecystectomy are listed beIow in a manner simiIar to that for choIecystostomy. (TabIe VII.) There were 275 patients who answered our letters, and this number has been used in caIcuIating percentages. TabIe VII shows that 70.8 per cent of the 275 cases accounted for were cured or improved. The 25 per cent of patients with no relief coincides with the resuIts of studies of a number of other authors. The two deaths Iisted separateIy are patients whose reIatives answered the queries but simply stated that the patients had died severa years after operation without giv-

248

A mericanJournal of Surgery

Brown-Non-CaIcuIous

ing any statement as to cause of death or the symptoms before death. The immediate postoperative deaths were 3.6 per cent of the tota number of patients accounted for. TABLE

VII

No. of I ‘er Cent I‘atient5 i ,>f Total

Degree of Relief after ChoIecystectomy

109 48

39.6

17.3

13.8

5

25.0

2

1

0.7

9

/_

cures (55 per cent) in this group. However, there were more than doubIe the number of cases of no reIief in this group as in the choIesterosis group and sIightIy-pathologic-to-normal group. The tota of compIete and partial relief in patients with definite chronic ChoIecystitis was 107, or 40.5 per cent. There were thirteen cases of no reIief in the sIightIy-pathologic-tonorma group, whiIe the number of cures was only sixteen. It is surprising that there were nearIy 30 per cent of cures in the choIesterosis group. It is evident that surgery does its greatest good in the more advanced gaII-bIadder disease.

3.6

275

1

100.0

RELATION

OF

TO

The true death rate has been previousIy discussed. The tota replies on al1 cases represented 82.9 per cent. RELATION

OF

FOLLOW-UP

DEGREE

OF

RESULTS

AND

PATHOLOGY

The degree of advancement of the pathoIogic lesion of the galI-bIadder has been accepted as a factor in determining the amount of reIief obtained. In other words, the more advanced the pathoIogy of the gaII-bIadder, the greater shouId be the percentage of relief. The resuIts as aIIocated in Table VIII seem to indicate the veracity of this assumption. RELATION

AUGUST, 1938

-1

___Permanent relief.. . . Improved Grade I.. Improved Grade II. . No relief.. . Deathspre-mortem condition unknown........................ Postoperative deaths.

GaII-BIadder

PERICHOLECYSTIC

END

RESULTS

DISEASE OF

CHOLECYSTECTOMY

In going over the case records, many cases, at operation, were described as having adhesions, pancreatitis, hepatitis, cirrhosis or gIands aIong the ducts of the biIiary tract. The frequency of these raised the question as to what inffuence these findings couId have on the end rest&s. Table IX is a composite of the correlation. Some cases had more than one of these perichoIecystic invoIvements, but are credited in the coIumn of each. TABLE IX RELATION OF PERICHOLECYSTIC DISEASE TO END RESULTS IN

CHOLECYSTECTOMY

TABLE VIII OF END RESULTS TO DEGREE OF PATHOLOGY

Permanent relief.......... Improved (Grade I). ...... Improved (Grade No relief.

II). .....

................

Total ..................

16 :

Permanent relief., Improved (Grade I). Improved(Graderr)...... No relief..

61

32 II

28

199 48

13

18

12

41

15

z

46

148

79

264

--

There were 264 patients whose degree of reIief of symptoms was used in this survey. The greater number of patients feI1 in the “chronic cholecystitis” group pathoIogicaIIy, which represents the most advanced Iesion grossIy. There were sixty-one

74 29

18

21

1’:

40 -----

9

164

47

Total.. I

I

II 6 4 0

1

21 I

24 IZ 7

: I

ID

4 I

53 I

Seventy-four of the patients, or 45 per cent, who had adhesions and gave foIIow-up resuIts, were permanentIy cured by the operation. The cured and improved in this group amounted to 124 out of 164, or 75 per cent. Of those with hepatitis eighteen, or 38 per cent, were cured, whiIe the cured and improved combined

New

SERIES VOL. XLI.

No.

Brown-Non-Calculous

z

amounted to 80 per cent of the forty-seven cases. Of those having pancreatitis, about 50 per cent were cured, but all were either cured or improved by the operation. The scarcity of patients with cirrhosis made the analysis of this group unimportant. The largest number of those patients described as having enlarged glands along the biliary ducts were cured; forty-three out of fifty-three patients were either cured or improved. These figures would indicate that the best results can be expected from surgery when the disease is advanced beyond the gall-bladder walls. RELATION TO

OF

END

RESULTS

ROENTGENOGRAPHIC

There were Graham-Cole questionnaire. sults with the tion is included

OF

ENDRESULTS

OF

I

I

15

.

3 7 7

_,.

Total..

. .

.

32

SURGERY

TO

FINDINGS I

/ Normal j Ddayedl Function Functmn

of Relief

Permanent relief.. Improved (Grade I) Improved (Grade II). No relief.

FINDINGS

x

RADIOGRAPHIC

Degree

SURGERY

155 patients who had the test and replied to the The correlation of the reroentgenographic interpretain Table x. TABLE

RELATION

OF

-~

I Faint Shadow

6

24 16 10

3 2

19

3

69

14

/

No Shadow

13 i *Cl 31

The spread of cases in the various groups was rather uniform, but the greatest number of patients fell in the delayed function group. Of the sixty-nine cases in this group, fifty of them were improved or cured-approximately 72 per cent. This would indicate that the patients showing a delayed function roentgenologically gave the best results in surgery. Since delayed function might indicate a more advanced pathologic process, this finding coincided with the greater number of cures and improvements in patients with adhesions, hepatitis and other extra-bihary disease involvement.

Gall-Bladder

A me&an

RELATION

OF

Journal of Surgery

END-RESULTS

SYMPTOMATOLOGY CHOLECYSTECTOMY

249

TO

IN PATIENTS

There were 2 18 cases in which cholecystectomy was done. This group included only those cases in which an adequate history was recorded and those who answered the follow-up queries. (Table XI.) TABLE RELATION

OF

END

PerSymptoms

Upper abdominal pain or distress. Nausea.. V Constipation.. Flatulence. Pain in shoulder or back. Epigastric tenderne*s.

omtrng.

.

manent Relic

XI

RESULTS

TO

-

SYMPTOMS Per Cent :ured ,* Imroved

Imrove‘

hdc 1)

I28 12 8 14 15

73 58 65 72 72

16

4

58

47

I?.

71

93 39 35 40 43

-

-

There were 2 18 cases with upper abdominal pain or distress and of these 160, or 73 per cent, were cured. Of those complaining of nausea, g7 in a11 out of the group of 2 18, 58 per cent were cured or improved. There were 83 with vomiting with 65 per cent cured or improved; IO I had constipation and 72 (72 per cent) were permanently relieved or improved. There were 105 with flatulence, of whom 76 (72 per cent) were improved or perThose having pain manently relieved. radiating to the back and right shoulder were only 58 per cent cured or improved. From the standpoint of physical findings, the most important and commonest was tenderness in the upper abdomen either in right upper quadrant or the epigastrium; there were gg of the 218 with this finding. Of this group, 71 per cent were cured or improved. When it is remembered that 70.8 per cent of the whole group of cholecystectomies were cured or improved, it wouId appear from the simiIar percentages of results for individua1 cardinal symptoms that there is a definite relationship of

Brown-Non-CaIcuIous

A m&can Journal of Surgery

230

symptomatoIogy and the end-rest&s to be expected in any given case. In those cases with upper abdominal pain or distress, constipation, AatuIence and epigastric tenderness, the surgeon has approximateIy a 75 per cent chance of curing or giving the patient some reIief. SUMMARY

OF

DEATHS

SINCE

OPERATION

ExcIuding immediate postoperative deaths, discussed in another section, there were fourteen deaths reported in the foIIow up survey. (TabIe XII.)& TABLE Name

Mr.

W. A.

State of ReIief

Age

. . .

.

.

50

Mrs.P.B ..,._..._.___. Mrs.T.B.. ................. Mr. H. C. ................... Mrs. J. F., ..................

57 59 48 66

Mrs.0.H.. ................. Mrs. W. H. ................. Mr. H. H. ...................

56 35 28

Mr.W.J

76

..,........._...,_..

Mrs.E.J .................... Mrs.L.N.. ................. Mr. G. P .................... Mrs. A.!!.. ................. Mrs. F. W. ..................

68 38 :: 53

No relief No relief No relief Imp. G. II No relief No reIief Not given Cured No reIief Cured Imp. Cr. 1 Not given No relief [mp. Gr. II

GaII-BIadder

AUGUST,

1938

other authors. An attempt has been made to summarize these results in tabular form so that the readers may gain at a gIance the unsoIved probIem of gaII-bIadder disease. In TabIe XIII the results are summarized, covering a period of twenty-five years. The number after the author’s name is the bibliographic guide to the source of the resuIts. It is of interest to compare the findings of Stanton in rgi I and 1932. Most of the operations were choIecystostomies in 191 I, and there were 46 percent cures; in 1932; XII Date Operated

1923 I925 ‘923 8-19-29 6-13-29 I925 I927 ‘924 I I-2-34 ‘923 1921 lo-1931 8-30-35 I I -3-28

Date of Death

6-3-36 1930 *I923 f-14-32 6-7-33 I-29-30

6-1933 I-I-34 4-1936 I I-1932 I-I-37 E-12-34 I I-29-35 I932

Cause of Death

Not given Abscess (?) Not given Not given Cardiac disease Kidney disease Cancer of stomach Drowned Operation for adhesions at another hosp. Mass in left abdomen Not given Not given Not given Apoplexy

* I I days after returning

home.

In most instances death occurred a number of years after the galI-bladder operation. It is interesting to specuIate on what caused the death of Mrs. T. B. eIeven days after returning home. Since she was 5g years old, it wouId seem that apopIexy or puImonary emboIism wouId be most IikeIy to cause such a rapid termination. There appeared to be no cases in which the death could be attributed to the gaIIbladder operation. RESULTS WITH

FROM

THOSE

LITERATURE

OBTAINED

IN

COMPARED THIS

STUDY

Since the resuIts of surgery in stoneIess gaII-bladder disease form an important part of this thesis, it is essential to compare the resuIts of this study with those of

choIecystectomy predominated and the fina anaIysis showed 53 per cent cures. Thus, with a supposedIy better knowIedge of galI-bladder disease, its diagnosis and improved technique in surgery, there was a gain of only 7 per cent in cures. However, Stanton’s resuIts in 1932 were caIcuIated on a time basis; when he caIcuIated resuIts in the usua1 way, he found that sixty-seven out of ninety cases, or 74.5 per cent, made compIete recoveries. Listed under “per cent cured” in TabIe XIII, the figures of Alvarez incIuded the cases which were cured or improved. The cases of Deaver and Bortz incIuded both acute and chronic stoneTess gaII-bIadder. Their figures for cures wouId not be so high if onIy the chronic cases were considered. Out of

Brown-Non-CaIcuIous

NHW Smrns VOL. XLI, No. z

Young’s I 15 cases there were fifteen with stones, which accounted for the increased cures in his series. The figures of Judd and PriestIey were averaged to obtain those in the tabIe. They had fifty cases upon

GaII-BIadder

A merican Journal of Surgery

23 I

findings of AIvarez, Mackey, Graham and Mackey, Stanton, Mason and BIackford, Highsmith and Hitzrot and ConneII appeared to be from the most critica anaIyses, hence they are probabIy the most

TABLE XIII COMPARISON

OF RESULTS

IN NON-CALCULOUS

-

Date

Author

No.

of Sasec

Cho.ecys tectomy

Cho-

tomy

-

CHRONIC

Per Per /Cent Cent ImCure
CHOLECYSTITIS

-

Per Cent No XeIief

Per Cen t Mor taIit, Y ‘_

_Stanton’*. ................... AIvarez et aI.*O. .............

_-

191 I

‘923

92 ?

9

65.5

‘7.5

5

76.2 00.0 63.0

22.0

I926

.

‘927

438

429

MulIe+. .................... OIch“‘.......................

42

. 1x5

37

Youngsa,

....................

ConneW*

....................

I928

30

8

Highsmithw. ................. Judd & PriestIey42. ...........

I931 ‘932

IO0

...

72

21

Stanton43.

I932

67

4I

Ross’4 .

ResuIts of this study..

1932 ‘934 ‘934

1936 1936

.

1937 -

.

22

5I 7

264 161

264 161

43 98

43 98

346

320 -

whom choIecystostomy was done, giving 62.9 per cent satisfactory resuIts and 26 per cent unsatisfactory resuIts; 12 per cent of these had to have reoperation. One case of choIecystostomy had aIso a choIedochostomy. There were twenty-one upon whom choIecystectomy was performed, with 85.7 per cent satisfactory and 14 per cent unsatisfactory resuIts. The figures of Shafer, which are listed in the table as cured, represent those cases cured or improved. The resuIts of ConneIl were averages for choIecystectomy and choIecystostomy. The

76. I 46.0

25.0

73.8

...

53.0

19.0 . .. .

I.7

This per cent cured includes those improved.

2.911

Includes acute and chronic non-calculous cases.

15.0

I.3

Total cases incIuded

23.8

.

11.0

.O

27.0 30.0

31.7 72.0

33.5

74.0

26

20.

34 with stone. Results are averages.

1Results

are averages. 1Calculated on time basis.

I

47.0

60.0 56.0 30.0

... ...

.

.

33.0

77.0 41.0

I927 1927 I928

Mason & Blackford33. Mackey”. . Graham & Mackeys. PfeiffeF. . Shafer=...............

46.0

7 ?

Hitzrot & CorneIP’. .......... Deaver & Bar@. ............

...................

Remarks

26.8 31.1

34.6 39.6

-

. .. . 17.0

.6

37.0 34.8

.O 4-I.

..

0

0

26.0

.

23.0 25.0

.i

:74 per cent incIudes cured imand proved. tZhofecystostomies. tZholecystectomies. -

standard. The resuIts of this present study compare favorably with the findings of these men. It is evident that choIecystectomy has been the choice among operative procedures. The mortaIity for the operations ranges from I to 6 per cent. When the resuIts are examined cIoseIy from the earIiest to the most recent, it is evident that there has not been a phenomenal improvement in the percentage of good results.

252

American

Journal

0f

surgery Brown-Non-CaIcuIous

DISCUSSION Many of the patients with unsatisfactory resuIts have been reExamined at this cIinic since operation. Four of this group have now been diagnosed as victims of some type of neurosis. Two have been given diagnoses of biIiary dyskinesia, and in one of these there is a definite achIorhydria. One patient has a pyIorospasm, while another has been shown to have a hydronephrosis with symptoms simulating a DietI’s crisis. One patient had a jejunostomy for margina uIcer three years after the choIecystectomy and had had a posterior gastroenterostomy for an uIcer six years before the choIecystectomy. One patient who cIaimed no reIief has now, six years postoperativeIy, delinite angina1 attacks. There are four cases who have been found to have an intercostal neuraIgia. Two of these patients have been examined in other cIinics and are suspected of having peptic uIcer. One patient has hypertension and another has ptosis of the stomach. When the character of Iater diagnoses is noted, the question comes to mind of how many conditions existed before the gaII-bIadder operation and were too earIy and not cIear cut enough to make a definite diagnosis. At any rate, these failures shouId stimuIate interest in the most compIete differentia1 diagnosis possibIe for a11 suspected galI-bIadder cases. As suggested by AIvarez, the surgeon should check up on his resuIts in order to gain this interest. Mason and Blackford were successfully able to treat medica1Iy one-third of their cases, and they showed that surgery in those cases which did not respond to medica therapy gave the best rest&s. Therefore, it is suggested that a compIete study be made of every patient, and that tria1 of a rigid medica program for a period of a few months to a year be instituted; aIso that a cIoser and Ionger fohow-up and supervision of postoperative care might do much to Iessen the disappointments in this branch of galI-bladder surgery.

GaII-BIadder

AUGUST,

1938

As to when the gaII-bIadder shouId be removed, there are those who argue that deIay in surgery lessens the chances of cure by virtue of the fact that the inffammatory disease tends to spread to adjacent that such a organs. Let it be granted tendency exists. However, from this present study, it has been shown that the majority of patients had their symptoms for over six years, and some were present for fifteen to twenty years or longer. The question, then, arises as to how much more damage wouId be done by a few months of medical therapy, during which time the patient could be reIieved or proven to be a definite surgica1 probIem. To this probIem of surgery, Lord Moynihan’s statement that the “progress in surgery is marked by the fewer number of operations performed” aptly applies. SUMMARY The data for this study were derived from 346 uncompIicated cases of non-caIcuIous chronic ChoIecystitis. The physioIogy of the galI-bladder in its modern conception and the principles of ChoIecystography have been reviewed. Surgery of the gaII-bIadder began as earIy as 1618, when Fabricius HiIdanus removed ga1Istones from a Iiving patient. In agog, Moynihan caIIed attention to the type of gaII-bladder disease now known as the strawberry galI-bIadder. Stanton, in rgr I, made a study of the resuIts in stoneIess gaIl-bIadder disease. ChoIecystectomy has been accepted as the operation of choice in this type of gaIlbIadder disease. The question as to when the gall-bIadder shouId be removed is unsettIed. Latest cIassification of pathoIogy in this disease has been discussed. CONCLUSIONSOF CLINICAL STUDY The average age for femaIes who were operated upon was 41.55 years, whiIe that of the males was 39.66 years. The ratio of femaIes to males was 2.84 to I. Most patients came to operation between the ages of 20 and 60 years.

NEW SERIESVOL.XLI, No. 2

Brown-Non-CaIcuIous

The symptoms of upper abdomina1 pain, nausea, vomiting, AatuIence, constipation and radiation of pain to the right shouIder or back were the commonest symptoms. The white blood ceI1 counts of noncaIcuIous chronic ChoIecystitis cases averaged 8,170, with average differentia1 of 68 per cent poIys and 32 Lymphocytes. The commonest manifestations of disease outside the gaII-bIadder were perichoIecystic adhesions (57.5 per cent) and hepatitis (I 7.3 per cent). MortaIity rate for 320 cholecystectomies was 2.8 per cent, whiIe the rate for twentysix choIecystostomies was zero. Cholecystographic response of deIayed function was commonest in a11 cIasses of Iesions. DeIayed function was the most in those cases with frequent response perichoIecystic diseases. FoIIow-up resuIts in twenty-six choIecystostomy cases showed 34.6 per cent cured, I I per cent improved (Grade I); 15.3 per cent improved (Grade II), and 23 per cent no reIief. Of 275 cases of choIecystectomy, there were 39.6 per cent cured; 17.3 per cent improved (Grade I), 13.8 per cent improved (Grade II), and 25 per cent no reIief. The Iargest number of cases was found in the patients with definite chronic ChoIecystitis and cholesterosis. The greatest number of cures and improvement was in the patients with adhesions about the galI-bIadder. Roentgenographically, the greatest number of satisfactory resuIts was in the deIayed function group. From the standpoint of symptoms, those patients with upper abdomina1 pain or distress were 73 per cent cured or improved. Summary of deaths after operation, not counting immediate postoperative deaths, is given. A comparison of resuIts of this study and those of the Iiterature shows that progress in this branch of gall-bIadder surgery has not improved to any marked degree from 19 I I to date.

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From this study, the conclusion is reached that patients with non-caIcuIous chronic ChoIecystitis shouId not be subjected to surgery unti1 a compIete differentia1 diagnosis is made and a period of rigid medica therapy is tried. A Ionger postoperative foIIow-up and supervision of care is recommended. REFERENCES I.

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‘9. GRAHAM, E. A. Hepatitis, a constant accompaniment of cholecystitis. Surg. Gynec. ti Obst., 26: 521-527 (May) rgr8. 20. ALVAREZ, W. C. I., MEYER, K. F., RUSK, G. Y., TAYLOR, F. B., and EATON, JESSIE. Present day problems in regard to gaIIbIadder infection. J. A. M. A., 81: 974-980 (Sept. 23) 1923. 21. BLALOCK, ALFRED. A statistical study of eight hundred and eighty-eight cases of biliary tract disease. Bull. Johns Hopkins Hosp., 35: 391-409 (Dec.) 1924; J. A. M. A., 83: 2057 (Dec. 27) 1924. 22. MAYO, W. J. Cholecystitis without stones or jaundice in relation to chronic pancreatitis. Am. J. M. SC., 147: 469, 1914. 23. MENTZER, S. H. The status of gallbladder surgery: based on a study of 14ooo specimens. J. A. M. A., go: 607-610 (Feb. 25) 1928. 24. HITZROT, J. M., and CORNELL, N. W. An analysis of four hundred and eighty-two gaIlbladder cases. Treated in the first surgica1 division of the New York Hospital. Ann. Surg., 84: 829-832 (Dec.) 1926. 25. DEAVER, J. B., and BORTZ, E. L. GaIIbIadder disease: a review of nine hundred and three cases. J. A. M. A., 88: 619-623. 26. LAHEY, F. H. Cholecystitis, cholesterol gallbladder and silent gall stones. Boston M. Ed S. J., 196: 677-681 (April 28) 1927. 27. MULLER, G. P. Non-calculous disease of the gallbladder. Pennsylvania M. J., 39: 857-860 (Aug.) ‘936. 28. CONNELL, F. G. Remote resuIts of biliary surgery. Ann. Surg., 87: 837-843 (June) 1928. 29. FOWLER, R. S. GaII-bladder disease: one thousand end results. Am. J. Surg., 22: 53-59 (Oct.) ‘933. 30. HIGHSMITH, J. D. Chronic cholecystitis without stones. Soutb. Med. CYSurg., vo1. 93, 1931.

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489-493 (April) 1936. 32. YOUNG, E. L., JR. The end resuIts of chronic cholecystitis. New England Surg. J., zg8: 729-734 (May 24) 1928. 33. MASON, J. T., and BLACKFORD,J. M. The conservative treatment of cholecystitis. J. A. M. A., gg: 891-893 (Sept. IO) 1932. 34. GUTHRIE, DONAU). Personal communication. 35. LYON, B. B. Diagnosis and treatment of disease of the gaIIbIadder and biliarv ducts. J. A. M. A., 73: g8o (Sept. 27) rgrg. 26. GRAHAM. E. A.. and MACKEY. W. A. A considera., tion of the stoneIess gaIIbIadder. J. A. M. A., 103: r4g7-r4gg (Nov. 17) 1934. 37. MACKEY, W. A. Cholecystitis without stone. Brit. J. Surg., 22: 274-295