CONDUCTED BY

WILLIAM TOD HELMUTH, M.D.,

GEORGE W. ROBERTS, PH.B., M.D.

GALL STONES AND DISEASES OF THE BILE DUCTS.*

THE

BY H. F. BIGGAR, M.D., LL.D.

Cleveland, Ohio.

HERE is no class of systemic diseases that more fully and richly repays the student than that chosen for this occasion. There is none that calls into keener exercise the knowledge of physiology, physiological chemistry, the laws of blood and nerve. supply, all in the abnormal as well as normal aspects, than this. Nor is there one, in either its medical or surgical views of successful treatment, that demands more rigid exactness of differentiation of mechanisms involved, or the means to be employed to secure satisfactory results, than the gall-bladder and ducts.

There is scant opportunity for a treatise on the subject, therefore I do not undertake it, but shall only give consideration to salient features, those lying in the way of the busy practitioner rather than in that of the specialist. And setting for myself a limit, let it be that of affections of the gall bladder and its ducts, and of these again, cholecystitis and cholangitis, inflammation of the cyst in one case and of the ducts in the other, and of a chief result, cholelithiasis.

It will also be observed that I do not confine such consideration to either medicine or surgery as such; for the one might forever find limitation falling short of cure, and the other deal only with a last fixed stage, a hopeless incident. It is not that I discourage medication—our best hope may lie there-nor decry operative measures in those cases demanding the knife; but I do plead for thorough and intelligent treatment of the same cases in their early stages with either medicines or the knife, or both in full view and easy reach.

With a warning that the surgeon's knife may be too frequently used, an eminent surgeon says: "The domains of medicine and of surgery can never be separated. It may fail to gratify the physician to see surgery obtain quickly and by a few strokes of the knife what medicine had failed to accomplish; but, on the other hand, has not the physician to stay, and with advantage, the hand of the surgeon? The immunity with which the most formidable operations are now performed has given a confidence-might I not say a recklessness

* Read before the American Institute of Homeopathy.

possibly which renders the staying hand of the physician of priceless value. Especially is this true when, as it sometimes happens, the inexperienced surgeon hurriedly resorts to a tentative operation to establish a diagnosis, where one more experienced would see no reason for the procedure. I have more than once observed the meddlesomeness of a surgeon to be in a direct ratio to the measure of his inexperience."

It is their duty to become intimately acquainted with causes and clinical history and physio-chemical variations in these diseases, and their differential and specific tissue changes, that insure the position of vantage.

There are some facts in the surgical history of cholelithiasis, or gall-stones, that are suggestive. The era of gall-bladder surgery began in 1879, when there were in England one hundred and seventy-two deaths. In 1889, after ten years' experience, there were four hundred and eighty-eight fatal cases. Kehr, of Halderstadt, who has performed more operations for gall-stones than any other operator, gives a series which shows that a certain per cent. demand re-operation, either from the "first operation not being complete or to a return of the disease." It is a well-known fact that after operations for the removal of biliary calculi other stones are frequently passed, and even after the removal of the gall-bladder stones have been found in the bile ducts. In adults one out of ten have gall-stones, of the old one out of every four; and four times as many women are affected as men. Only one out of every thirty

requires the knife.

It is concluded, therefore, that while in the simplest cases the mortality may be as low as one to three per cent., it is in complicated cases as high as five to thirty per cent. In the experience of Mayo Robson, a published series shows sixteen and six-tenths per cent. of recoveries.

In view of such a record, many of the cases being, without doubt, not in the class of last resort, we may carefully heed a remark of Treves, that "the operation for gall-stones is an excessive zeal on the part of some of our colleagues." At all events, we are impelled to return to a more searching review of the conditions the premonitions of which are gall-stone formation, and thus on to the radical cure of the diseases of which they are the expression, by medication.

What is a gall-stone? A crystalline, friable mass, composed of cholesterin, lime, iron, and various bile salts and resins, precipitated and caught up and bound together in a matrix of albuminousmaterial.

How formed? Irritation of the mucous surfaces of gall-bladder, hepatic, cystic, and common ducts, their obstruction by swelling or plugs of mucus causes retention of liver products, and therefore the precipitation of their solids with excess of cholesterin which, caught up as above described, become inspissated and solidified in the familiar concretions.

Their location, either as sand or larger stones, is in either duct or gall-bladder or ampulla of Vater, a dilatation of the common and pancreatic ducts at their entrance into the duodenum. Outside of the gall-bladder the cystic and common ducts are the most frequent locations of impacted stones. If there is permanent obstruction great distention occurs, and the more persistent the impaction the greater the liability to ulceration and possible perforation into the adjacent organs. The gall-bladder may be actually inflamed, when there is danger of occlusion of the cystic duct.

The causes are indigestion, intemperance and worry; and it is further predisposed by disproportionate amounts of fats and animal food. The beginnings of menstruation and pregnancy are prolific of these cases.

The diagnosis in simple cases is easy; but to differentiate in complicated or obscure cases may be very difficult. The shape, density, position, condition of superficial veins and intestinal canal, all demand consideration. One point I must not fail to notice: A distended, impacted gall-bladder can be distinctly felt between its normal position and the umbilicus; and here it swings as from a fixed point in the arc of a circle, convexity downwards. This is diagnostic. When the diagnosis is doubtful we need not hesitate to resort to exploratory operation, for then no doubt can remain and it is attended with comparatively little risk.

The greatest difficulty presents itself in inflammatory types of the disease. The most prominent are cholecystitis of the gall-bladder, and cholangitis of the ducts, generally due to some infection, but concretions are also found; these types are distinguished as the noncalculous and calculous forms. The type may be catarrhal, suppurative, or phlegmonous, and may result in gangrene, perforation and localized or general peritonitis. There may be repeated attacks.

In cholangitis the type of inflammation may also be catarrhal, suppurative, or phlegmonous, with results similar to the calculous form. If impaction is in the cystic duct there may follow gallbladder dropsy, or infectious inflammation which runs an ordinary course. If in the common duct, it is distinguished by jaundice of more or less intensity which persists for a year or more, splenic enlargement, slight or no enlargement of the liver and gall-bladder,