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Fewer deaths from gall-bladder disease
is the leading independent surgical Journal. It publishes many papers read before the outstanding Surgical Societies, but it is not “the official organ” of any organization. Every manuscript is selected by the editors, as worthy of publication-nothing is published because “it was read at the meeting.” Copyright,
NEW SERIES,
VOL. XXXIV
EDITORIAL BOARD Tnu?.mm SCOTTWaror ))(LwI-ark D. C. Balfour Rahcstcr, Mmn. Carl Beck Chlcngo ?+w Tmk Gee. R. Brighton Meredith F. Camplxll New York Chicago JamesT.Cae Isidore Cohn &w Orknnr New ror!i Bradley L. Coley Ann A&w P. A. Caller George W Crile Ck&nd Boston E. C. Cutler Las Angeks R.V.Day Cbarlea A. Blaberg New T-4 Herbat C. Pett Br4lyn Chicego C.R.G.Porrater H. Dawmm Furnina New -l-4 Phibdelphia J.H.Gibbcm Emil Goetuh B74lw Charles A, Gordon &mklw Donald Gurhrie seyrc, Pa. Kawas City A. E. Her&x Denoir Louis J. Him&man James M. Hitzrot Nw -fork Frederick C. H&en New T-4 Err& F Holman San Fmuisa J. A. Hyama NW 7-04 Madisa R.H.Jackum John E. Jennings &rwklYWarhingtnn. D.C. W. L. Keller Bakiminc H.A.Kelly T. J. I&win NW r4 7-+ rmk Arthur Krih wcw r04 A. V .S. Lamberr Maurice Lznz
1936, by THE AMERICAN JOURNAL or
NC~ r0+
H.H.M.Lyle nlc~ 7-04 Jerome M . Lynch em r0rh Urban Mae8 I&w Grkanr Harrison S. h4artlmd Newa4 R. Matas F&a Orkmnr Detroit Roy D. McClure H. C. N&iger San Francisco C. R. O’Crowley NetLurk Louis E. Pbaneuf l3oston Eugene H. Pool ww rd, Douglas Quick NW 7-d N.P.Ratbbun BloO!+ H. A. Royster Rakigh Hmry S. Ruth Phibaclphicl ‘Tcmpk A.C.Smtt St. Louis M.G.Sdig 7qecu,rmk J .Bmtley Bwiu H. J. Stander ~w r0lh Sank George w .swift B&imLve Grant E. Ward San Francisco 1. H. Wmker
NOVEMBER,
SURGERY.
1936
INC.
No.
EDITORIAL FEWER
DEATHS
T
FROM DISEASE
GALLeBLADDER
HE Metropolitan Life Insurance Company in its November, 1935, bulletin states that gall-bladder diseases, next to appendicitis, are the most frequent surgica1 conditions of a serious nature and that there has been no improvement in the death rate in the last twenty-four years. During the last decade notabIe advances have been made in the surgica1 care of these cases, especiaIIy in the preoperative 2nd postoperative treatment. Why has there been this faiIure to transIate better surgery into better mortahty? I think that it is Iargely due to the fact that our profession as a iwhole stiI1 adheres to a policy of watchful waiting. Most 1surgeons postpone operation in cases of acute choIecystitis and hope that the inflammation wiI1 subside, despite the evidence that has accumuIated against this practice. As a resuIt of this attitude of the surgeon, the famiIy physician who is first called, counseIs deIay. He rightly reasons that he might as we11 do the watching at home and save the patient the expense of having the watching done by a surgeon in a hospital. In chronic choIecystitis and ChoIeIithiasis, aIso, there seems to be a feeling that there is no hurry as a year or two will make no difference. The gastroenteroIogist is wiIIing, in many instances, to take his turn with his professiona brethren in standing watch over the gaII-bIadder patient. That procrastination is often the order of the day, seems to be shown by the advertisements of a recent book on gall-bladder disease which is said to incIude dozens of actua1 prescriptions proved in daiIy practice. Can it be possibIe that dozens of prescriptions are necessary for the proper care of these cases? There are a few important facts that should be brought forcibIy to the attention of the profession and the Iaity. EIiason says that earIy diagnosis to-day is showing that I99
2
200
American
Journal
of Surgery
EditoriaI
36 per cent of patients with gallstones are under thirty-nine years of age. Goldish and GiIIespie have shown that of those who die after gall-bIadder operations the average age is ten years oIder than those who Iive. Bashein anaIyzed I 58 operations and found that those with one or two attacks onIy showed a mortaIity of 3 per cent while those with more than two attacks showed a mortality of 8.7 per cent or nearIy three times. The Metropohtan Life Insurance Company’s figures show that beginning with the age of twenty years the death rate from galI-bIadder diseases becomes appreciabIe and increases rapidIy thereafter to the end of life. Touroff, of the Mt. Sinai HospitaI, anaIyzed 75 cases of proved acute choIecystitis. A poIicy of deIay was pursued, waiting for the inflammation to subside before operation was finaIIy performed. He remarks “Advanced grades of inflammation may exist in the complete absence of cIinica1 signs and symptoms.” In about one-third, pus or gangrene was present at operation. A rosier picture is painted by Pratt from Wayne Babcock’s cIinic who reported a11 the operations for acute suppurative and gangrenous cholecystitis covering a period of thirteen months. There were no deaths when the operation was performed within forty-eight hours of the onset of symptoms. Twenty-three patients were operated within twenty-four hours of admission to the hospita1 and a11 recovered. Perforation of the gaI1 bIadder is not uncommon but it is seIdom diagnosed even
NOVEMBER, 1936
by surgeons of Iarge experience. A carefu1 survey of the causes of death in any Iarge clinic wiI1 show that the basic reason in practicaIIy every case is delay, sometimes over a period of years and sometimes onIy for a few days. The death certificate may say pneumonia or myocarditis but these are onIy secondary to inanition and poor resistance to infection from proIonged gaIIbIadder disease. Death seIdom occurs in younger peopIe operated earIy in the course of their disease. I quote again from the MetropoIitan buIIetin In expert hands to-day the operative mortaIity is very Iow. Permanent. recovery results in most cases. In one group of patients who were traced a year or more after operation for remova of the gaII bIadder, more than 85 per cent reported compIete reIief, and most of the others reported pa&a1 reIief. In a simiIar group of patients traced from twenty-two to twehtyfive years after operation, the Iong term resu1t.s were found to be satisfactory in more than 80 per cent of the cases.
UndoubtedIy these resuIts couId be improved by our more accurate methods of diagnosis and by more prompt operation. Where is there a more fruitful fieId for a campaign of education than this? PhiIadeIphia recentIy had a specia1 drive to Iower the mortaIity in appendicitis. Which one of our societies wiI1 be the first to make a determined effort to secure operation earIy in the disease for those suffering from definite, carefuIIy diagnosed gaIl-bIadder disease? The resuIts wiI1 ampIy repay those who can accompIish this.
HENRY F.
GRAHAM.
Subscribers to THE AMERICAN JOURNAL OF SURGERYvisiting New York City are invited to make the ojjice of the publishers (The American Journal of Surgery, Inc., 49 West 45th Street, New To7k) their headquarters. Mail, backages 07 bundles may be addressed in our care. Hotel reser’ vations will gladly be made for those advising us in advance; kindly notify us in detail as to requirements and prices.
NEW SERIES,
VOL. XXXIV
EDITORIAL BOARD Tnu?.mm SCOTTWaror ))(LwI-ark D. C. Balfour Rahcstcr, Mmn. Carl Beck Chlcngo ?+w Tmk Gee. R. Brighton Meredith F. Camplxll New York Chicago JamesT.Cae Isidore Cohn &w Orknnr New ror!i Bradley L. Coley Ann A&w P. A. Caller George W Crile Ck&nd Boston E. C. Cutler Las Angeks R.V.Day Cbarlea A. Blaberg New T-4 Herbat C. Pett Br4lyn Chicego C.R.G.Porrater H. Dawmm Furnina New -l-4 Phibdelphia J.H.Gibbcm Emil Goetuh B74lw Charles A, Gordon &mklw Donald Gurhrie seyrc, Pa. Kawas City A. E. Her&x Denoir Louis J. Him&man James M. Hitzrot Nw -fork Frederick C. H&en New T-4 Err& F Holman San Fmuisa J. A. Hyama NW 7-04 Madisa R.H.Jackum John E. Jennings &rwklYWarhingtnn. D.C. W. L. Keller Bakiminc H.A.Kelly T. J. I&win NW r4 7-+ rmk Arthur Krih wcw r04 A. V .S. Lamberr Maurice Lznz
1936, by THE AMERICAN JOURNAL or
NC~ r0+
H.H.M.Lyle nlc~ 7-04 Jerome M . Lynch em r0rh Urban Mae8 I&w Grkanr Harrison S. h4artlmd Newa4 R. Matas F&a Orkmnr Detroit Roy D. McClure H. C. N&iger San Francisco C. R. O’Crowley NetLurk Louis E. Pbaneuf l3oston Eugene H. Pool ww rd, Douglas Quick NW 7-d N.P.Ratbbun BloO!+ H. A. Royster Rakigh Hmry S. Ruth Phibaclphicl ‘Tcmpk A.C.Smtt St. Louis M.G.Sdig 7qecu,rmk J .Bmtley Bwiu H. J. Stander ~w r0lh Sank George w .swift B&imLve Grant E. Ward San Francisco 1. H. Wmker
NOVEMBER,
SURGERY.
1936
INC.
No.
EDITORIAL FEWER
DEATHS
T
FROM DISEASE
GALLeBLADDER
HE Metropolitan Life Insurance Company in its November, 1935, bulletin states that gall-bladder diseases, next to appendicitis, are the most frequent surgica1 conditions of a serious nature and that there has been no improvement in the death rate in the last twenty-four years. During the last decade notabIe advances have been made in the surgica1 care of these cases, especiaIIy in the preoperative 2nd postoperative treatment. Why has there been this faiIure to transIate better surgery into better mortahty? I think that it is Iargely due to the fact that our profession as a iwhole stiI1 adheres to a policy of watchful waiting. Most 1surgeons postpone operation in cases of acute choIecystitis and hope that the inflammation wiI1 subside, despite the evidence that has accumuIated against this practice. As a resuIt of this attitude of the surgeon, the famiIy physician who is first called, counseIs deIay. He rightly reasons that he might as we11 do the watching at home and save the patient the expense of having the watching done by a surgeon in a hospital. In chronic choIecystitis and ChoIeIithiasis, aIso, there seems to be a feeling that there is no hurry as a year or two will make no difference. The gastroenteroIogist is wiIIing, in many instances, to take his turn with his professiona brethren in standing watch over the gaII-bIadder patient. That procrastination is often the order of the day, seems to be shown by the advertisements of a recent book on gall-bladder disease which is said to incIude dozens of actua1 prescriptions proved in daiIy practice. Can it be possibIe that dozens of prescriptions are necessary for the proper care of these cases? There are a few important facts that should be brought forcibIy to the attention of the profession and the Iaity. EIiason says that earIy diagnosis to-day is showing that I99
2
200
American
Journal
of Surgery
EditoriaI
36 per cent of patients with gallstones are under thirty-nine years of age. Goldish and GiIIespie have shown that of those who die after gall-bIadder operations the average age is ten years oIder than those who Iive. Bashein anaIyzed I 58 operations and found that those with one or two attacks onIy showed a mortaIity of 3 per cent while those with more than two attacks showed a mortality of 8.7 per cent or nearIy three times. The Metropohtan Life Insurance Company’s figures show that beginning with the age of twenty years the death rate from galI-bIadder diseases becomes appreciabIe and increases rapidIy thereafter to the end of life. Touroff, of the Mt. Sinai HospitaI, anaIyzed 75 cases of proved acute choIecystitis. A poIicy of deIay was pursued, waiting for the inflammation to subside before operation was finaIIy performed. He remarks “Advanced grades of inflammation may exist in the complete absence of cIinica1 signs and symptoms.” In about one-third, pus or gangrene was present at operation. A rosier picture is painted by Pratt from Wayne Babcock’s cIinic who reported a11 the operations for acute suppurative and gangrenous cholecystitis covering a period of thirteen months. There were no deaths when the operation was performed within forty-eight hours of the onset of symptoms. Twenty-three patients were operated within twenty-four hours of admission to the hospita1 and a11 recovered. Perforation of the gaI1 bIadder is not uncommon but it is seIdom diagnosed even
NOVEMBER, 1936
by surgeons of Iarge experience. A carefu1 survey of the causes of death in any Iarge clinic wiI1 show that the basic reason in practicaIIy every case is delay, sometimes over a period of years and sometimes onIy for a few days. The death certificate may say pneumonia or myocarditis but these are onIy secondary to inanition and poor resistance to infection from proIonged gaIIbIadder disease. Death seIdom occurs in younger peopIe operated earIy in the course of their disease. I quote again from the MetropoIitan buIIetin In expert hands to-day the operative mortaIity is very Iow. Permanent. recovery results in most cases. In one group of patients who were traced a year or more after operation for remova of the gaII bIadder, more than 85 per cent reported compIete reIief, and most of the others reported pa&a1 reIief. In a simiIar group of patients traced from twenty-two to twehtyfive years after operation, the Iong term resu1t.s were found to be satisfactory in more than 80 per cent of the cases.
UndoubtedIy these resuIts couId be improved by our more accurate methods of diagnosis and by more prompt operation. Where is there a more fruitful fieId for a campaign of education than this? PhiIadeIphia recentIy had a specia1 drive to Iower the mortaIity in appendicitis. Which one of our societies wiI1 be the first to make a determined effort to secure operation earIy in the disease for those suffering from definite, carefuIIy diagnosed gaIl-bIadder disease? The resuIts wiI1 ampIy repay those who can accompIish this.
HENRY F.
GRAHAM.
Subscribers to THE AMERICAN JOURNAL OF SURGERYvisiting New York City are invited to make the ojjice of the publishers (The American Journal of Surgery, Inc., 49 West 45th Street, New To7k) their headquarters. Mail, backages 07 bundles may be addressed in our care. Hotel reser’ vations will gladly be made for those advising us in advance; kindly notify us in detail as to requirements and prices.