—The general subject of cholelithiasis and its associated lesions constitutes an important topic in the so-called “border-land” between medicine and surgery, where views and advice regarding prognosis and treatment will depend on the experience and the training of the medical attendant. Surgeons now recognize, and physicians are being gradually converted to their view, that gallstone disease is essentially a surgical disease, i. e., one to be combated by surgical intervention. While it is not to be gainsaid that many patients live and die with gallstones who are never conscious of their presence, and while others who have had serious attacks live to die of some other disease, nevertheless the general statement may be boldly made and easily defended, that when the disease is well marked and when patients suffer more or less constantly from it the only successful method of treatment is the surgical, and that, in other words, operation offers the only prospect of permanent relief. Regarding its associated dangers it may be said that danger comes from delay rather than from operation, and that here, as with many other conditions, patients often wait too long, partly from lack of proper advice, partly from timidity, and that a septic and moribund patient, allowed to become so for lack of earlier application of the resources of surgery, is a reflection on the one who waits rather than on the surgeon, who, endeavoring to save, still unfortunately loses his patient.
This is not the place to discuss non-operative measures—i. e., medicinal and dietetic treatment—valuable as they may be in certain cases. Most of the drugs which are supposed to be effective in their power of solution of gallstones or of facilitating their escape are disappointing, and at best are vague and uncertain in their action. The hydrotherapeutic treatment, such as carried out, for instance, at Carlsbad, will do good in many cases, especially for those who have been indulgent in their appetites and careless in their habits. Cases of any description not too far advanced would be benefited by a careful regimen of this character, but that Carlsbad or any other waters will certainly cure cholelithiasis is now absolutely disproved. As a preparation for operation a sojourn at some such place may be advised; as a substitute for it, never. Large doses of glycerin (50 to 150 Cc.) often temporarily relieve the pain of biliary colic.
In general, then, it may be said that cases which give a history of recurring attacks of biliary colic, with or without recurrent jaundice, and with those varied concomitant symptoms which are usually grouped under the term “indigestion,” in which there is definite tenderness over the region of the gall-bladder, with or without muscle spasm, and with the other referred pains so often present in this condition, should be regarded as legitimately surgical, where operation is more than justifiable and usually decidedly advisable, even too often imperative. The same is true of those cases of distended gall-bladder with obstruction of the duct where perhaps no calculi are present, but where the patient suffers in much the same way as though they were present. Biliary drainage is equally called for, and the presence or absence of calculi is but a minor feature upon which too much stress should not be laid nor too much disappointment expressed if they be not found.
Many cases of chronic cholelithiasis have become more or less toxemic, as well as cholemic. It is a well-recognized fact that cholemic patients are more likely to cause inconvenience to the surgeon from free hemorrhage or persistent oozing, because of the slowness with which coagulation of their blood takes place. When time is afforded for preparation it is of great value in these cases to administer calcium chloride, of which several doses may be given each day, in considerable water, the former varying in amount from 1 to 2 Gm. When time suffices, too, it is always of value to prepare these patients for the operation by measures already discussed, improving their elimination, reducing the degree of their toxemia, and fortifying their circulatory systems by well-known measures. The value of such preparation is perhaps more apparent in such instances than in most others. On the other hand, many cases calling for operation are almost as imperative as those of acute appendicitis, where every hour’s delay is to the disadvantage of the individual. The operations which are practised upon the biliary tract will all be discussed together in a section by themselves.
TUMORS OF THE GALL-BLADDER.
This expression refers rather to actual neoplasms of the gall-bladder itself than to distention of the sac by which an intra-abdominal tumor may be formed. The latter subject may be dismissed with the mere statement that the gall-bladder may become distended with bile, with mucus, with pus, with concretions, or with the products of such disease as echinococcus, actinomycosis, etc. In this way it may be so much enlarged as to be easily felt through the abdominal walls or to be even mistaken for other conditions. In the latter case it may have to be differentiated between such a condition and a movable right kidney, a tumor of the kidney itself or of its capsule, as well as from tumors of the stomach, especially the pylorus, of the liver, or of the intestine and from the enlargement of the right lobe which often accompanies cholelithiasis, or from fecal impaction. It would be best to abstain from the use of the aspirating needle in these cases, as more harm might be done by the escape into the abdomen of deleterious fluid than would be atoned for by the information which the procedure would afford. Even when the abdomen is open the gall-bladder should rarely be punctured in this manner, unless one is prepared at the same time to open it and drain. In other words, there is less risk about a small exploratory incision than in puncture.
Nearly all varieties of malignant and many of benign tumors have been reported as occurring in this location. It will be sufficient in this place, however, to say that cancer of the gall-bladder, which, of course, may extend in various directions, is by no means an uncommon affection, and is usually a complication of gallstones. In fact, it may be doubted whether primary cancer of the gall-bladder ever occurs in the absence of such a source of irritation. These cancers vary in type between the round-cell and the squamous, most of them, however, being of the former character. Although Musser has put the percentage at 65 and Zenker as high as 85 of instances where gallstones are found within cancerous gall-bladders, it does not follow that the above statement may not be true regarding their almost universal association and causal relation, for any gall-bladder found empty at a given time may at some other time have contained a calculus. This frequent association is justly among the valid arguments which surgeons may now use in making a plea for earlier operation, and for making it a more standard procedure.
Cancer may be suspected in cases of progressive and unintermittent jaundice, especially when there can be felt in the region of the gall-bladder a distinct tumor or an enlargement of the liver. Pain is a frequent but by no means a constant or reliable symptom. As the disease spreads the adjoining textures will become matted together, and a low grade of local peritonitis may still further cement them into a mass which will occupy a considerable portion of the upper part of the abdomen.
But few cancers of the gall-bladder which are so apparent as to be recognized without exploration can be considered as still amenable to surgery, which for them can hold out but little prospect save perhaps a temporary relief by biliary drainage. It is the cases in their earlier stages, when the condition is made out by exploration, and by it alone, which still afford prospects of more or less permanent relief. The very impossibility of detecting the condition in these earlier stages without exploration affords one of the strongest arguments for such a procedure in every vague case of the kind. That cases of this character are not necessarily hopeless is instanced by an experience of my own, where on opening the abdomen of a large and fleshy woman I found a distinctly cancerous gall-bladder containing two large calculi, and removed the entire mass, with a considerable portion of the surrounding hepatic tissue, the removal being effected with the actual cautery. At present date of writing, nearly six years after the operation, the patient is apparently perfectly well and doing her own housework.