Gallstones in young adults

CASE ANALYSIS

CLINIC

Gallstones AN ANALYSIS

in Young

OF 178 PATIENTS

UNDER

Adults

THIRTY

YEARS

OF AGE

RICHARDG. FOSBURG,* LCDR, MC, USN, Pbiladelpbia, Pennsylvania PhiIadeIphia, Pennsylvania, during the six year period from January 1955 to January 1961, were reviewed. OnIy those patients in whom roentgenograms reveaIed evidence of gaIIbIadder disease or in whom pathoIogic examination after operation proved the existence of choIeIithiasis were seIected for study. For the purpose of comparison, patients under thirty years of age were arbitrariIy cIassihed as young aduIts. Of the 681 admissions reviewed 582 fuIfiIIed the criteria selected for study; of these, 178 (30.6 per cent) were under thirty years of age. That more patients have been encountered in the younger age groups than generaIIy seen in the average hospital practice is a reffection of the nature of the population presenting to a Iarge military hospital. Many of the female patients cared for are the dependents of young adults in the Armed Forces and are seen during the chiIdbearing age. The maIe popuIation, despite initia1 screening and induction requirements, represents a greater concentration of young men than wouId be encountered in a civilian community. Because of the bias introduced by this preseIection the reported resuIts from severa other Iarge hospitaIs have been utiIized in the comparisons that foIIow. TabIe I summarizes the breakdown of the cIinica1 material. There were 485 patients treated surgicaIIy and ninety-seven patients treated medicahy. Of the 485 patients who underwent operation, 150 (30.9 per cent) were under thirty years of age. The twenty-eight medical patients under thirty years of age were encountered during the Iast year of the

From tbe Department of Surgery, United States Naval Hospital, Pbiladelpbia, Pennsylvania. Tbe opinions or assertions contained berein are tbe private ones of tbe autbor and are not to be construed as oficial or reflecting tbe view of tbe Navy Department or tbe Naval Service at large.

HE FREQUENCY Of galIStOneS in young aduIts continues to be unappreciated. As Iate as 1959 reports have appeared emphasizing the unusua1 nature of cholelithiasis in the second and third decades of life. The concept of gaIIstones as a disease in patients over forty years of age persists despite the fact that from 4 to 20 per cent of reported series of choIecystectomies are in patients under thirty years of age. A review of the EngIish Iiterature reveaIs few studies of significant size which deaI specificaIIy with choIeIithiasis in young adults. If improvement is to continue in the reduction of the morbidity and mortaIity associated with choIeIithiasis, earlier diagnosis is essentia1. In an attempt to eIucidate certain factors which might aid in the earlier diagnosis of these patients an anaIysis was made between 178 patients under thirty years of age with 404 patients over thirty years of age. SeveraI reported series of choIecystectomies were aIso reviewed and the findings correIated with those of the present study. The results of this anaIysis constitute the basis for this report.

T

CLINICAL DATA All patients admitted for disease of the biliary tract to the U. S. NavaI Hospital,

* Present address: USS Independence(CVA-62) c/o FIeet Post Of&e, New York, New York. American

Journal

of Surpry.

Volume 106. July 1963

82

GaIIstones in Young AduIts study, and the majority undergone operation. CLINICAL

have

subsequentIy IN

ANALYSIS

Age and Sex. There were 234 men and 348 women in the total series, a ratio of I : 1.5. In the group under thirty years of age there were twenty-seven men and 15 I women, a ratio of I :5.6. In the decade ten to nineteen years there were three men and thirty-three women and in the decade twenty to twentynine years there were twenty-four men and I 18 women. The youngest man was eighteen and the youngest girI fifteen years of age. The oIdest man was eighty-one and the oIdest woman was eighty-five years of age. Acute Versus Chronic Cbolecystitis. Of the 582 cases, 159 (27.3 per cent) patients presented with acute choIecystitis and 423 (72.7 per cent) entered the hospital with the diagnosis of chronic choIecystitis or some unreIated diagnosis. Acute choIecystitis was the presenting iIIness in 42 per cent of the patients under thirty years of age as compared to 21 per cent of those patients over thirty years of age. In the decade ten to nineteen years, twenty-nine of thirty-six patients (80 per cent) presented with acute choIecystitis. In the decade twenty to twenty-nine years, forty-five of 142 patients (31.7 per cent) presented with acute choIecystitis. In the subsequent three decades Iess than 20 per cent of the patients presented with acute choIecystitis; however, the incidence increased markedIy in the eIderIy. The increased incidence of severe attacks of acute choIecystitis in the younger patients stands in marked contrast to the tota series. The reported incidence of acute choIecystitis in other series varies from 5 to 20 per cent. In CoIcock’s and McManus [I] series there was a 5.3 per cent incidence of acute cholecystitis, Bearse [2] reported 13 per cent, BorIand and Jaehning [3] 13 per cent, Ignatius and Madding [4] 15.6 per cent, WaIIace and AIIen [5] 18.3 per cent, and Sethi [6] found an incidence of 17.3 per cent. Pain. The most common symptom encountered was epigastric pain or in the right upper quadrant. Eighty-six per cent of a11 patients experienced pain in the right upper quadrant sometime during their hospitalization, although it was the presenting compIaint in onIy 67 per cent. Radiation of pain to the back, scapula, or shouIder top was noted in

TABLE I 681 TOTALADMISSIONS FOR DISEASEOF THE BILIARYTRACT582 PATIENTSFULFILLED THE CRITERIASELECTEDFOR STUDY

Under Thirty Years of Age,

Operative.

I50

178 OverThirty

Medical, 28

Operative,

Years of Age. 404

335

Medical, 69 --____

Men

Women

Men

Women

__-____ +5

Men

Women

125

z

16

154

Men

Women

_-__

-___

181

53

16

19 per cent of the patients, but was present more frequentIy in the younger group, 32 per cent versus 13 per cent. In the younger group of patients the pain was surprisingly different when compared to the older patients. The pain was Iimited to the epigastrium in 48 per cent of the young aduIts. Sparkman [7] reported that 45 per cent of his twenty-three patients under thirty years of age had pain Iimited to the epigastrium. A frequent compIaint was the inability to take a deep breath and because of this many patients were initially thought to have puImonary or diaphragmatic inffammations. Radiation of pain through to the back aIso occurred more frequently in the younger patients, 51 per cent versus 27 per cent, in those experiencing such radiation. Shoulder top pain was present in both groups about equaIIy when present (16 per cent). NocturnaI attacks were reIated by 37 per cent of the younger age group. Sparkman [7] noted this complaint in 30 per cent of his patients and cites Ravdin as directing attention to this occurrence in 195 I. It has been postuIated that recumbency aIIows a smaI1 stone to settle in the cystic duct with resuItant obstruction. Miscellaneous. Fatty food intolerance or a history of attacks in reIation to meaIs was encountered in 40 per cent of the patients. In onIy 20 per cent of the young adults couId such a history be eIicited. As the age of the patient increased this complaint was noted more frequentIy and was present in 70 per cent of the patients sixty years of age or over. In many of the older patients this may we11 reflect a genera1 dietary intoIerance. The absence of this compIaint, however, was responsible for the initial excIusion of biliary tract disease in many patients. Complaints of dyspepsia, eructation and AatuIence were rare in the younger group of 83

Fosburg patients being noted in onIy 12 per cent. Bearse [z] reported that such symptoms were one-fourth as common in patients under thirty in his study. In comparison these compIaints were present in nearIy 60 per cent of the older patients. Colcock and McManus [r] and Adams and Stranaham [8] reported these symptoms were present in 64 per cent of patients in their studies. Jaundice. In the entire series sixty-three patients (10.8 per cent) had jaundice at the time of admission. This compares favorabIy with the incidence of 12.4 per cent reported by Sethi [6], 18.8 per cent reported by CoIcock and McManus [I], 13 per cent by Bearse [2], I 7 per cent by Lester [9], and the 15 per cent reported by both Waiters, Gray and PriestIy [IO], and McEachern and Sullivan [II]. In patients with acute choIecystitis and jaundice there was IittIe difference between the two age groups. Of the forty-two patients with acute choIecystitis with jaundice in the entire series (26.4 per cent of a11 patients with acute choIecystitis) there were twenty-two patients (29.7 per cent) in the age group under thirty and twenty patients (23.5 per cent) over thirty years of age. No patients under thirty years of age presented with chronic cholecystitis and jaundice; however, twenty-one patients (6.6 per cent) of those over thirty years of age, with chronic choIecystitis, had jaundice. Associated Disease. The attempts to associate other diseases in a causa1 reIationship to choIeIithiasis has proved uniformIy unsuccessfu1. Many observers have noted a reIativeIy high incidence of gaIIstones in diabetics. Lieber [12] in an anaIysis of over 1,200 persons with diabetes reported that 30.2 per cent had gaIIstones aIthough he had no expIanation for these findings. Robertson [13] was unabIe to find a singIe author who supported the possibiIity that diabetes favors the formation of gaIIstones. Newman and Northrup [14] suggest that the eIevated serum Iipoid which often accompanies diabetes may stiI1 be of significance. Diabetes meIIitus was encountered in only one patient under thirty years of age (0.5 per cent) as compared to 8.4 per cent of the patients over thirty. The incidence of peptic uIcer disease in those under thirty was 3.3 per cent and 5.3 per cent in those over thirty year: of age. There is no evidence that peptic uIcer disease affects the incidence of cholelithiasis. The discovery of

multipIe diseases of the gastrointestina1 tract is reIated to the diagnostic studies performed as part of the evaIuation of such patients. The association of choIeIithiasis, diverticuIosis and hiatus hernia was not encountered in those under thirty, but was seen in 9 per cent of those over thirty years of age. However, this triad was not Iooked for in every patient and the actuaI incidence might be considerabIy higher. Any attempt to correlate obesity with galIstones is fraught with hazard since it is impossibIe to determine the weight of the patient at the time gaIlstones form as compared to the time when they become symptomatic. For completeness, however, 13.3 per cent of the patients under thirty were obese (IO per cent above standard weight) as contrasted to 30.9 per cent of those over thirty years of age. Operative Data. Of the 485 patients undergoing choIecystectomy, 150 (30.9 per cent) were under thirty years of age. Of those operated upon for acute choIecystitis, twenty-eight (18.7 per cent) were under thirty years of age and forty-three (12.8 per cent) were over thirty. There were no deaths in the younger group. The operative mortaIity in those over thirty was 2.7 per cent and the mortaIity for the entire series was 1.8 per cent. The common duct was expIored in twentynine (19.3 per cent) patients under thirty and ninety-eight (29.2 per cent) in those over thirty. Of those explored, stones were found in the common duct in six (20.7 per cent) of the patients under thirty and forty-six (46.9 per cent) of those over thirty. AI1 sixty-three patients who had jaundice during their hospitalization had common duct exploration. Acute choIecystitis with jaundice was seen in fortytwo patients and seventeen (40.5 per cent) were found to have common duct stones. In the group under thirty years of age, six of twentytwo patients (27.3 per cent) had common duct stones; in those over thirty years, eleven of twenty patients (55 per cent) had common duct stones. The twenty-one patients with chronic choIecystitis and jaundice a11 had common duct stones; none were under thirty years of age. Fourteen patients (4.2 per cent) in the group over thirty had common duct stones without cIinica1 jaundice. The incidence of common duct stones in the tota series was 10.7 per cent. A tota of thirty-one different postoperative

GaIIstones

in Young

AduIts

TABLE II FREQUENCY OF GALLSTONES IN -

PATIENTS

-

Year

Author

UNDER

THIRTY

-

-

Under Twenty Years of Age

TotaI

YEARS

OF AGE

-

T Under Thirty Years of Age

Per cent

Chronic

!._

Blalock[3r] ................................. Eliason [32]. ................................ Bearse and Fergeson [z]. ....................... Biskind and Pevaroff 1171.. .................... Smith [33].................................... Adams and Stranahan [8]. ..................... Dunphy and Ross [34]. ....................... Gaster [35].. ................................. G&n and Smith [16]. ........................ Colcock and McManus [r]. .................... Becker, PoweIl and Turner [36]. Sparkman [7]. ................................ Johnson and Close (371. ....................... McEachern and SulIivan [I I]. .................. Byrne [$+I................................... Smith 139).............................. Pearce [4o]. ................................. Pearcelgo] ................................... Sethi[6] ................................... Weckesser [41]. ..............................

i1924 1927 1941 ’ 942 ‘945 1947 ‘949 ‘950 1954 ‘955 ‘957 1957 ‘957 ‘959 ‘959 1959 1960 1969 1961 1961 1962

.....

Fosburg .....................................

Acute or

I‘er cent

724 128 232 746 332 1104 134 533 245 1356 I 060 I00 103 155 134 148 172 395 274 3085 485 11645

11 I

1.5 0.8

:

0.6 0.5

110*

i

-

21

76* II

-

24 35* 74* 142* 23* 17 17 6

8 3 19

3.3 0.2 1.8

I 3

0.9 1.9

3

2.0

21

28 32

0.9 6.6

9 28 38 276 ‘50

117

1.0

._

TotaI ......................................

100 13 48

-

_-

--

AK AK AK AK A?C A?C AK AK A$C A A ; A AK ; A A/C AK 1 A/C I

10.6

1239 -

13.8 IO. I 20.6 14.7 6.3 6.9 8.2 4.5 14.4 5.4 13.4 23.0 16.5 10.9 4.5 14.2 5.2 7.’ 5.8 8.9 30.9

-

* Includes patients thirty years of age.

TABLE III I N THIS ANA DIFFERENCES ELUCIDATED

complications were seen in the entire group for a morbidity rate of 18.2 per cent. Complications were encountered in twelve of 150 patients under thirty years of age for a morbidity rate of 8 per cent as contrasted to seventy-six of 335 patients over thirty or 22.6 per cent. Of these compiications wound infection was the most common foIlowed by ateIectasis and pneumonia. Retained common duct stones occurred in three patients, al1 over thirty years of age, an incidence of 0.6 per cent in the total series. These results are similar to those of others and warrant no specia1 comment except to emphasize that a gratifyingIy Iow morbidity and no mortality is possibIe in young aduIts under the age of thirty years.

LYSIS

1

Under T Thirty Disease

Over Thirty Years of

Years of Age (Per cent) _--___

Acute ChoIecystitis.. .. .. Operated on for acute cholecystitis. Chronic cholecystitis. Pain limited to epigastrium Radiation of pain.. . . . . .. Radiation of pain to back. Radiation to shouIder top.. Nocturnal attacks.. Fatty food intolerance.. Dyspesia, eructation and flatulence. . . . . Acute choIecystitis with jaundice due to common duct stone. . Stones in common duct. Common duct expIored. Retained common duct stones Operative mortality. . . Postoperative morbidity rate.

COMMENTS The frequency of gaIIstones in patients under thirty years of age has been summarized in TabIe II from several coIIected series of cholecystectomies in which the age was specificahy stated. TabIe III summarizes the differences 85

-

-

Age (Per cent)

42.0

21.0

18.7 58.0 48.0 32.0 51.0 16.0 37.0 20.0

12.8 79.0 10.0 13.0 27.0 16.0 17.0 60.0

i

12.0

60.0

27.3 20.7 19.3 0.0 0.0 8.0

55.0 46.9 29.2 0.6 2.7 22.6

-

Fosburg 17 16 15 14

,X

13 12 I1 10

9

FIG. I. Age distribution of 178 patients under thirty years of age. Note: X = femaIe patients and 0 = male patients.

8 7 6 5 4 3 2 1

/O

P,o/o\ o/O /O “\,P-“0

0

15 16 17 1.819

20

21

22

23

21~ 25

26 27 28

29

AGEIN-

twenty-one to thirty years, and 39 per cent were under forty years of age. Griflin and Smith [16] found 14.4 per cent of patients in a study of 245 cases to be thirty years of age or Iess. Biskind and Pevaroff [17] reported that IIO (18 per cent) of 612 women who underwent choIecystectomy in their series were between sixteen and thirty years of age. AIthough the first case of gaIlstones in a chiId was reported by Gibson in 1722, according to Potter [r8], Iess than 500 cases under fifteen years of age have subsequentIy been reported as evidence by the reviews of UIin, NosaI and Martin [Ig] and SeiIer [20]. In 1910 Reuben Peterson reported on sixteen patients between twenty and thirty years of age in whom pregnancy or the puerperium were complicated by gaIIstones and cites Vineberg’s [22] report of 1905 as being one of the first to caI1 attention to this compIication. CoIe [23]

eIucidated in this anaIysis. It has been a we11 documented fact that the incidence of gaIIstones increases with age. The majority of studies deaIing with biIiary tract disease have found the greatest incidence in the fifth or sixth decade. This finding has been substantiated both by cIinica1 and autopsy anaIyses. AIthough Deaver [15]was responsibIe for the phrase “fair, fat, and forty” as being descriptive of the typica patient with biIiary tract disease, he aIso emphasized the occurrence of gaIIstones in the younger age groups. He and Ashhurst [42] reported 14.5 per cent of his persona1 series of choIecystectomies were in patients in the third decade of Iife. Bearse [2] reported on a group of 232 patients in which 20 per cent were thirty years of age or Iess. Sparkman [7] reporting on 100 consecutive cases of choIecystectomy in women found 23 per cent were in the decade

86

GaIIstones

in Young

reported twenty-one cases in persons under thirty years, Gerwig and Thistlethwaite [24] reported ten women under age thirty, Pearson [25] reported seven cases in patients under thirty-two years, and BeaconsfieId and Jacobson [26] reported on three cases in teen-agers. The age distribution of the 178 patients in this report is shown in Figure I. The autopsy incidence of gahstones under thirty years of age is smaI1. In a series of 9,531 autopsies with an incidence of 8.4 per cent choIeIithiasis, Gross [27] found fifteen cases in patients under thirty years representing 0.019 per cent of those with gahstones. Lieber [12] in an anaIysis of 34,666 autopsies faiIed to find any gallstones in 4,887 autopsies under twenty years of age. He reported that the incidence in autopsy materia1 for the decade twenty to thirty years was 0.9 per cent for white men, 4.2 per cent for white women, 2.0 per cent for Negro women, and 5.2 per cent for Negro men. In a simiIar study by Cunningham and Hardenbergh [28] of 6,185 autopsies with an incidence of 5.51 per cent choIeIithiasis, the incidence was 1.7 per cent in white men, 6.75 per cent in white women, 0.5 per cent in Negro men, and 6.28 per cent in Negro women in the age group twenty-one to forty years. Newman and Northrup [r4], aIso, with autopsy materia1 noted a progressive rise in the frequency of gaIIstones in both sexes and a11 races after the age of twenty. In the period from birth to nineteen years they reported an incidence of 0.1 per cent, but in the decade twenty to twenty-nine years the incidence was 5 per cent in white women, I per cent in white men, 0.2 per cent in Negro men, and 2 per cent in Negro women. KozoII, Dwyer and Meyer [29] in a review of 29,618 autopsies with an incidence of choIeIithiasis of 6.3 per cent onIy found four cases of choIeIithiasis in the decade zero to nine years, aIthough this age group represented 28.2 per cent of the tota autopsies reviewed. In the decade ten to nineteen years which represented only 2.9 per cent of a11 autopsies they found five cases, and thirty cases in the decade twenty to twenty-nine years which represented 4.8 per cent of the tota autopsies. Torvik and Hoivik [30] faiIed to find any gahstones in patients beIow twenty years of age in I 1,129 autopsies in Sweden, but encountered a progressive increased incidence after twenty years of age simiIar to the findings of those cited previousIy.

AduIts SUMMARY

The frequency of gahstones in young adults continues to be unappreciated. From four to twenty per cent of reported series of cholecystectomies are in patients under thirty years of age. In an anaIysis of 178 patients under thirty, 150 of whom underwent choIecystectomy, a considerabIe difference was apparent in the clinical picture of biIiary tract disease as compared to patients over thirty years of age. The sex ratio is one man to five women. The incidence of acute cholecystitis is three to four times greater in the young patient. Pain limited to the epigastrium and radiation of pain was far greater in young patients, thus adding confusion to the diagnosis. Fatty food intoIerante and complaints of dyspepsia, eructation and AatuIence are not common in young patients. The presence of associated disease is extremeIy uncommon. Patients under thirty years of age toIerate choIecystectomy with a gratifyingly low morbidity rate and no mortaIity. REFERENCES I. COLCOCK, B. P. and MCMANUS, J. E. Experience with 1356 cases of cholecystitis and choIelithiasis. Surg. Gynec. TVObst., IOI : 161, 1955. 2. BEARSE, C. Gallstones in patients under thirty years of age. New England J. Med., 225: 8, rg4r. 3. BORLAND, V. G. and JAEHNING, D. Acute choIecystitis: its surgical treatment: report of 108 cases. Surgery, 32: 581, 1952. 4. IGNATIUS, J. A. and MADDING, G. F. Biliary tract surgery in the aged patient. Gastroenterology, 34: 694, ‘958. 5. WALLACE, R. H. and ALLEN, A. W. Acute choIecystitis. Arch. Surg., 43: 762, 1941. 6. SETHI. R. A. SuraicaI management of acute choIecystitis. Arch. krg., 82: 3y66, 1961. 7. SPARKMAN, R. S. GaIlstones in young women. Ann. Surg., 145: 813, 1957. 8. ADAMS. R. and STRANAHAN, A. Cholecvstitis and choIelithiasis: analytica report of I 104 operative cases. Surg. Gynec. CTObst., 85 : 776, I 947. g. LESTER, L. J. Acute choIecystitis. Surgery, 21: 675, 1947. IO. WALTERS, W., GRAY, H. K. and PRIESTLEY, J. T. Annual report on surgery of the biliary system and pancreas for 1946. Proc. Sta$ Meet. Mayo Clin., 23: 40, 1948. II. MCEACHERN, C. G. and SULLIVAN, R. E. Acute cholecystitis. Arch. Surg., 78: 300, 1959. 12. LIEBER, M. M. The incidence of gaktones and their correIation with other diseases. Ann. Surg., 135: 394, ‘952. 13. ROBERTSON, H. E. The preponderance of gaIIstones in women: an etiologic study. Znternat. Abstr. Surg., 80: I, 1945. 14. NEWMAN, H. F. and NORTHRUP, J. D. The autopsy

Fosburg 30. TORVIK, A. and HOIVIK, B. Gallstones in an autopsy series. Acta cbir. scandinav., 120: 168, 1960. 31. BLALOCK, A. A statistica study of eight hundred and eightv-einht cases of biliarv tract disease. Bull. Jibis Hipkins Hosp., 35: ;gI, 1924. 32. ELIASON, E. L. and FERGUSON,L. K. Some results of surgery of the biIiary tract. Ann. Surg., 85: 565, 1927. 33. SMITH, B. C. Acute choIecystitis: the surgicaI treatment of 332 cases at the Presbyterian Hosrg32--I941 incIusive. Surg. pital, New York, Clin. N. Amer., 25: 285, 1945. 34. DUNPHY, J. E. and Ross, F. P. Studies in acute cholecystitis; surgical management and results. Surgery, 26: 539, 1949. 35. GASTER, J. Surgery of the biliary tract: a 5 year survey. Arch. Surg., 60: 21, 1950. 36. BECKER, W. F., POWELL, J. L. and TURNER, R. J. A cIinica1 study of 1,060 patients with acute cholecystitis. Surg. Gynec. ti Obst., 104: 491,

of galIstones. Internat. Abstr. Surg., 109: I, 1959. 15. DEAVER, J. B. The sequeIae of biliary tract infection. J. A. M. A., 95: 1641, 1930. 16. GRIFFIN, G. J. and SMITH, L. A. GaIlbladder disease in adolescents and young aduIts. J. A. M. A., incidence

154: 731, ‘954. 17. BISKIND, L. H. and PEVAROFF, H. H. GaIIbIadder disease and pregnancy. Obio M. J., 38: 1013, 1942. 18. POTTER, A. H. GaII-bIadder disease in young subjects. Surg. Gynec. u Obst., 46: 795. 1928. 19. ULIN, A. W., NOSAL, J. L. and MARTIN, W. L. Cholecystitis in childhood: associated obstructive jaundice. Surgery, 31: 312, 1952. 20. SEILER, I. GaIIbIadder disease in chiIdren. Am. J. Dis. Cbild., 99: 662, 1960. 21. PETERSON, R. Gallstones during pregnancy and the puerperium. Surg. Gynec. ti Obst., I I : I, 1910. 22. VINEBERG, H. N. Acute choIecystitis in the puerperium: report of two cases, choIecystotomy, recovery. M. Rec. @Ann., 67: 532, 1905. 23. COLE, F. R. GaIIbIadder disease in young women. New York J. Med., 56: 1808, 1956. 24. GERWIG, W. H., JR. and THISTLETHWAITE, J. R. ChoIecystitis and choIelithiasis in young women folIowing pregnancy. Surgery, 28: 983, 1950. 25. PEARSON, W. W. Cholelithiasis in young adults. Mississippi Doctor, 34: 189, 1959. 26. BEACONSFIELD, P. and JACOBSON, H. A. Cholelithiasis in the teenager. Illinois M. J., 113: 121,

1957. 37. JOHNSON, P. and CLOSE, M. B. Acute gaIIbIadder disease: experience with 103 consecutive cases. California Med., 87: 291, 1958. 38. BYRNE, J. J. Acute choIecystitis. Am. J. Surg., 97: 156, 1959. 39. SMITH, F. W. ChoIecystectomy: a critica anaIysis of a personal series. Am. Surgeon, 25: 801, 1959. 40. PEARCE, A. E. Acute choIecystitis: planned choIecystectomy at any time during the course of the disease. J. Internat. Coil. Surgeons, 33: I, 1960. 41. WECKESSER, E. C. Surgery of gaIIbIadder disease in Ohio: survey of 3,085 operations. Am. J. Surg., 102: 695, 1961. 42. DEAVER, J. B. and ASNHURST, A. C. Surgery of the Upper Abdomen. GaII-bladder, Liver, Pancreas, and Spleen, VOI. 2, p. 87. PhiIadeIphia, 1914. P. Blakiston’s Sons & Co.

v#-

27. GROSS, D. B. A statistica study of ChoIeIithiasis. J. Patb. fl Bact., 32: 503, 1929. 28. CUNNINGHAM, J. A. and HARDENBERGH, F. E. Comparative incidence of ChoIeIithiasis in Negro and white races. Arch. Int. Med., 97: 68, 1956. 29. KOZOLL, D. D., DWYER, G. and MEYER, K. A. PathoIogic correlation of gaIIstones. Arch. Surg., 79: 514, 1959.

88