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Pepsia" the GALL-BLADDER Characterized by Pressure Distress, Accumulation of by CHARLES S

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Pepsia OCtOber, 1925 CALIFORNIA AND WESTERN MEDICINE 1313 RECOGNITION OF SURGICAL DISEASES OF thorough careful painstaking history than upon any other one factor. In a case of "chronic dyspepsia" THE GALL-BLADDER characterized by pressure distress, accumulation of By CHARLES S. JAMES, M. D., Los Angeles gas in the upper abdomen, eructation and sour re- occurring promptly after eating a heavy I believe firmly that the typhoid and colon bacilli are gurgitation the chief instigators of gall-bladder disease. meal or some special food, epigastric distress radiat- I further hold that all cases of gall-bladder disease ing to the back or the tip of the right shoulder-blade are primarly medical cases. (Boas' area), history of attacks of acute indigestion The belief qvas formerly prevalent that "latent gall- with or without a colicky phase, and with or with- stones" cause no appreciable disturbance; but it is now out varying acholia, one is strongly inclined to the recognized that they rarely fail to produce symptoms opinion of gall-bladder disease origin and recall the commonly referred to the stomach. trite saying of our clinical forefathers, "Fat, fair, We should not accept the diagnosis "nervous dyspep- sia," "acute indigestion," "neuralgia of the stomach," and forty." "gastritis" or "gastric neurosis" so frequently as we do Boas' point tenderness and pain referred to the in patients presenting the history of dyspepsia of a right back are common and valuable symptoms, but chronic resistant type. we must recognize their occurrence from other DISCUSSION by James A. Mattison, Soldiers' Home, Los lesions than gall-bladder disease, and also that this Angeles County; Sterling Bunnell, San Francisco. pain is sometimes referred to similar locations on T HE various surgical diseases of the gall-bladder the left side. I mention this fact because the pro- and ducts will be better understood if we con- fession is educated to exclude gall-bladder pathology sider and accept the underlying etiological factor to when pain is referred to the left. be infection; that the infection is of hematogenous Gall-stones may be present for years and recog- transmission through the portal vein or hepatic nized for the first time on the operating table or at artery; and that the reaction of the infection pri- autopsy. "Latent gall-stones" constantly pass recog- marily is in the walls of the gall-bladder. nition, and it is only when associated with the varied I firmly believe that the typhoid and colon bacilli degrees of activated cholecystitis or cholangitis that are the chief instigators of gall-bladder disease. they are considered. I further hold that all cases of gall-bladder dis- We should not accept the diagnosis "nervous dys- ease are primarily medical cases with the possibility pepsia," "acute indigestion," "neuralgia of the stom- of complications developing or arising of a surgical ach," "gastritis," or "gastric neurosis" so frequently character, and after surgical intervention and the as we do in patients presenting the history of dys- correction of the surgical phase, the patient again pepsia of a chronic resistant type, and we should becomes medical in the sense that the individual remember that all these cases occurring during the should be under competent management and ob- third and fourth decade, or later, with a preceding servation until a complete maintained re-establish- period of immunity, in general, suggest gall-bladder ment of health is had and not discharged as cured disease, or possibly cardiorenalvascular disease, or immediately upon making "an operative recovery," carcinoma, and is worthy of our most exhaustive as is too often the case. investigation. If we accept the primary etiological factor to be In order to definitely diagnose disease of the gall- bacterial, it is easier for us to account for the dis- bladder, one requires more than a history of reflex eases of the gall-bladder presenting such a wide gastric symptoms; he must, by examination, deter- range in their degree of severity and persistence; mine localizing symptoms, such as the colic of chole- and the occurrence of varied surgical complications lithiasis or the pain and tenderness of cholecystitis or with the element of too frequent apparent failure cholangitis, and it is here that we must rely largely following surgical intervention, due to the uncor- on the older diagnostic measures. rected underlying and continuing infection; i. e., Distention and tenderness in varying degrees con- cholecystitis or cholangitis. stitute probably the most constant clinical localized It is then almost entirely the complications and expression of cholecystitis. The distention is deter- sequela of this underlying disease that constitute the mined by the varied forms of palpation. A palpable surgical diseases of the gall-bladder and ducts, the gall-bladder is usually a pathological one, usually most frequent of which are chronic resisting chole- moves with respiration and is movable only in a cystitis-cholelithiasis-suppurative cholangitis and small segment of the circle, the center of which is empyema of the gall-bladder. Carcinoma of the at the point of the gall-bladder attachment at the gall-bladder and ducts is increasing in its recognized external tip of the ninth costal cartilage. Tender- frequency. ness is best elicited by deep thumb or finger-tip pres- The belief was formerly prevalent that "latent sure maintained during complete respiration and ex- gall-stones" cause no appreciable disturbance; but piration or "respiratory arrest test." A test for it is now recognized that they rarely fail to produce tenderness that I have found quite reliable is similar symptoms commonly referred to the stomach-sud- t; the stroke test of Murphy for kidney tenderness, den attacks of indigestion with flatulence at irregu- but is applied in a similar manner anterior and just lar intervals, ofttimes nocturnal, with indefinite over the tip of the ninth rib, with the patient either right-sided tenderness, or slight distress referred to in the supine or sitting position; which, if positive, the right- shoulder and variable degrees of acholia. causes a sharp decisive pain with its origin in the This group of hazy subjective symptoms may char- gall-bladder. acterize a type of "stomach trouble" occurring years Jaundice is a variable symptom in gall-bladder before. disease; obstruction at the first or second portion The diagnosis in many instances rests more on the of the cystic duct will result in no jaundice; if 1314 CALIFORNIA AND WESTERN MEDICINE Vol. XXIII, No. 10 in the terminal portion, there may be a variable hereinabove mentioned; but it is with the extra gas- amount of jaundice, depending on the amount of tric lesions that we find confusion and concern. pressure upon the hepatic or common duct, or the Digestive complaint may constitute the chief com- degree of associated cholangitis present. With ob- plaint associated with remote systemic disease, such struction in the common duct, jaundice may vary, as pulmonary tuberculosis, grave anemia, chronic for obvious reasons, from slight and transient to per- pancreatitis, cardiorenalvascular disease, pelvic pa- sistent and severe. thology, appendicitis, stone in the kidney or ureter, Again, we may have the so-called ball-valve acting and many consultants have seen cases of tabes not stone in the common duct with associated paroxys- relieved of their crisis by a preceding operation upon mal chills, fever, and sweating (Charcot's fever) the gall-bladder. simulating empyema of the gall-bladder. But with The physical examination should serve to exclude persistent variable jaundice, bile is seldom absent pulmonary tuberculosis, grave anemia, cardiorenal- from the duodenal contents in common duct-block vascular disease and other systemic diseases asso- unless the cause is carcinoma. ciated with digestive symptoms. In suspected cases of gall-bladder diseases the Among the colic-causing diseases we may cite that urine should be frequently tested for trace of bile; in chronic pancreatitis symptoms may not differ for slight degrees of obstruction, not causing ob- from those of gall-stones, and the two often co-exist. servable jaundice, sometimes show a trace for a short The pain, however, is more apt to be in the mid- period. The examination of the stool is of value in line or referred to the left of the upper abdomen- evidencing gross acholia, more minutely determined more weight loss and the laboratory may show dimi- chemically by the Schmidt bichloride test, and by nution of pancreatic enzymes. laboratory methods may prove of value in aiding Acute hemorrhagic pancreatitis is attended with in the differential diagnosis of amoebic abscess of greater collapse and rectus rigidity. liver, membranous colitis, occult blood of ulcer or Floating kidney, with Dietl's crisis, may present carcinoma, etc. urinary signs and a more movable tumor, both poles palpable and the maximum mass to the back, as The radiologic examination is of value largely by compared to gall-bladder maximum to the front. exclusion of ulcer and carcinoma of the stomach and Nephrolithiasis, by the pain radiating to the pelvis nephrolithiasis. It is true that occasionally brilliant and thigh, vesical irritation, urinary findings, no positive results are presented in showing calculi or jaundice. the presence of confirmatory indirect signs as duo- Carcinoma of the head of the pancreas presents denal cap indentation, adhesive distortion, or visable tumor fixed and deep, loss of flesh, profound con- gall-bladder, but in general it may be said that an tinuing jaundice, with enlargement of gall-bladder. affirmative report is highly valuable but a negative Carcinoma of the pancreas, gall-bladder, or pyloris report valueless. There is no such thing as exclu- can be excluded, however, at times with great diffi- sion of gall-stones by radiology. culty; nevertheless, tumor cachexia and ascites when Graham and Cole describe the phenoltetrabrom- present speak strongly for carcinoma.
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