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. phthalein test for radiologic visualization of the gall- The diagnosis of acute appendicitis may present bladder which, if clinically proven of definite value, considerable differential difficulties, especially if the gives promise of opening up a field of great diag- appendix lies high or Riedel's lobe be elongated. nostic possibilities. The salt injected into a vein is However, the pain reference is different and rectal excreted almost entirely into the bile, helping the examination may serve to make clear the situation. gall-bladder to cast a shadow upon the roentgen-ray As regards the gastric symptoms reflex from the plate, recording its shape, size, and contained stones appendix, it is noted that the reflex gastric symp- if present. toms of gall-bladder disease occur promptly in ten Indicative of the relative occurrence of gall- to thirty minutes after food intake, while if of ap- bladder disease, Blackford and Dwyer of Seattle, pendical origin the time elapsed is more like that reporting a study of 1650 patients complaining of pertaining to gastric or duodenal ulcer-two to four chronic dyspepsia, state: "The approximate relative hours. frequency of abdominal organic disease causing dys- In closing I may mention a group ofttimes pre- pepsia in this series is: Gastric ulcer, 1; gastric car- senting special differential diagnostic difficulties as cinoma, 2; reflex appendix, 4; duodenal ulcer, 6; suppuration complicating common duct stones, em- gall-bladder disease, 12"- or nearly one-half due to pyema of the gall-bladder, necrosis and rupture with gall-bladder disease. hepatic abscess, or perforation with peritonitis, all This report closely parallels my own observation of which present gross evidence of gravity and may and conforms to the experience of many other clini- be classed under the medical slang phrase, "acute cians and should serve to stimulate our interest in surgical belly," which calls for prompt surgical in- the law of probability when surveying our cases of tervention. "dyspepsia" of occult origin. In considering the differential diagnoses, the gas- Westlake Professional Building. tric diseases-ulcer, carcinoma, and syphilis-are DISCUSSION in to the but few number, compared many extra JAMES A. MATTISON, M. D. (Soldiers' Home, Los An- gastric lesions producing symptoms masquerading as geles County)-My discussion on Doctor James' very diseases of the stomach, for the "stomach is the excellent paper will be very brief. alarm-clock of the human system." Since all of our gall-bladders removed at operation are A taken and sent to the pathological laboratory for complete examina- carefully history thorough physical tion and report, there is no longer doubt in regard to the and radiologic examination usually serves to make fact that the chief etiological factor is bacterial in origin, clear the diagnosis of the intrinsic gastric lesions the infection entering the biliary tract either by direct October, 1925 CALIFORNIA AND WESTERN MEDICINE 1315

extension or through hematogenous or lymphatic chan- qualitative, intermittent, gradually increasing in severity nels. Notwithstanding that great progress has been and length of attacks and accompanied by symptoms of made in diagnostic methods, it still remains a fact that infection, both general and local, in the region of the the most important part of our diagnostic information is gall-bladder, this organ comes decidedly under suspicion. derived from a careful study of a thorough history of It is, however, only after a survey of all other symp- the case. toms, x-ray findings, physical signs and past history, and In making a differential diagnosis of gall bladder dis- a due consideration of other possibilities, that we can ease, gastric and duodenal ulcers are among the con- arrive at a judgment of the case of sufficient value to ditions which call for the most careful consideration. advise surgical relief. Here, again, we find a carefully taken history of first importance, and in differentiating the intra-gastric dis- eases the most important aid which we have at our THE REFLEX NERVOUS DISORDERS AS command is the x-ray. This gives us definite information in from 90 to 95 per cent of cases of gastric ulcer, pro- DESCRIBED BY BABINSKI vided it is in the hands of an expert roentgenologist. It is generally conceded, however, that the x-ray in gall- By A. R. TIMME, M. D., Los Angeles bladder disease furnishes confirmatory evidence rather Sets up a group of nervous disorders which may not be than definite evidence. From our experience, I have classified as either functional or organic by usual meth- found a careful study of the gastro-intestinal tract with a ods. One case report. large series of x-ray plates is likewise of value in the These patients exhibit symptoms far more profound diagnosis of gall-bladder disease, aside from the infor- than could be accounted for on a functional basis, and mation furnished of intra-gastric conditions. yet not typical of any of the ro-called peripkeral or cen- In our study of gall-bladder conditions, it is necessary tral to constantly keep in mind the fact, too, that the associa- lesions. tion of peptic ulcer and tholecystitis and chronic appen- DISCUSSION by Harold W. Wright, San Francisco; dicitis is comparatively common and, in a certain number Samuel D. Ingham, Los Angeles; Edward W. Twitchell, of cases, may be the cause of considerable confusion, es- San Francisco; Thomas J. Orbison, Los Angeles. pecially where two or even three of these conditions are associated in the same patient. VJW E HAVE long been accustomed to labeling STERLING BUNNELL, M. D. (Physicians Building, San as functional any case of paralysis that did not Francisco)-The ideas expressed in this most commend- show classical symptoms of definite organic lesion of able paper appeal to me as the true conception of cho- the nervous system. Thus, localization and group- lecystitis. Instead of thinking in terms of gall-stone dis- ing of signs indicated to us whether a lesion was in ease and recognizing only veteran cases, we are learn- a ing to recognize infections of the gall-bladder in their peripheral nerve, in a plexus, spinal root, spinal incipiency. cord, or anywhere up to and including the cortex, We now know that the infection is not limited to the or in an artery, or in the meninges. Any case of gall-bladder, but is generalized in the biliary tract, paralysis or deformity that would not fit into any through the gall-bladder ducts, pancreas, accompanying of the above molds was very likely lymph glands and liver, and that it usually results from to be classified germ bormbardment coming from infections in the portal as functional or hysterical. system. There is, however, a group of cases, definitely Removing the principal focus, the walls of the gall- organic, that do not fall into either of the above bladder, by cholecystectomy, together with the original source of infection, if still present, usually cures, but for categories, i. e., these patients exhibit symptoms far the following reasons it is not surprising that it does more profound than could be accounted for on a not always do so: functional basis, and yet not typical of any of the Several months to a year or more are necessary for so-called peripheral or central lesions. the natural protective forces of the body to rid the rest of the biliary tract of infection, and especially so if deep- Although not explaining the pathology of the seated infection exists in the head of the pancreas or lesion, John Hunter, as early as 1835, called atten- liver. Again, time is necessary for normal function to tion to muscular atrophy following joint affections, return in a stomach which has acquired the indigestion e. g., arthritis. Charcot and Vulpian in the eighties habit. Frequently enough after cholecystectomy the re- sulting adhesions pull on the pylorus or trigger-point of first predicated a reflex origin of such atrophies. the stomach and cause a persistence of symptoms. Avoid- Babinski, in the beginning of the Great War, finally ing trauma in operation and routinely anchoring the end gave us an adequate description of this type of of the omentum in the duodenal-hepatic angle helps to lesion, in the form of papers, discussions, and an prevent this. Often tiny stones and sand in the common duct are elaborate monograph. He terms the condition "ner- overlooked, as it is impossible to palpate them through vous troubles of a reflex order" or "reflex nervous the duct walls. These cause a backfire of infection into disorders" and postulates a reflex pathogenesis in the liver and continue the symptoms. certain cases of paralysis, contracture and deformity, Disease of the gall-bladder makes its presence known and vasomotor to the clinician largely by a perversion of stomach func- atrophy, sensory change following tions, by general symptoms of infection, by disturbances wound or injury of an extremity that do not con- of bile flow, by pain from duct obstruction, by pain, dis- form to any of the classical conceptions of central tress and tenderness from local infection in the gall- or peripheral lesion of the nervous system or to hys- bladder. teria. an almost wound of an ex- The normal-acting stomach should handle the usual Thus, negligible articles of diet and, if it does not, an organic lesion is tremity can give rise to profound changes in mus- often the cause. It is unsafe, though, to yield to our cular tone and activity, can produce a dispropor- desire to simplify and assume that all dyspepsias are tionate amount of atrophy with vasomotor and sen- caused by the arch triumvirate, appendicitis, cholecystitis sory disturbance, or it can produce a marked de- *and peptic ulcer. When we consider what a multitude of diseases affect our outer covering, the skin, a tissue formity or contracture. These changes cannot be that we can see, we cannot but admit that our inner explained by any of the known nerve, cord or brain lining, the digestive tract, may also be subject to many lesions; they remain in a stationary or progressive different ailments. state for years after the initial wound or injury has However, when a patient tells of years of indigestion and of submission to prescribed diet lists and digestive healed. aids, the real cause can usually be found in one or Prerequisite to the development of the above more of the above triumverate. If the indigestion is symptoms is the initial trauma or irritation, whether