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PROGNOSIS

A Series of Signed Articles contributed by invitation

1.—PROGNOSIS IN GALL-BLADDERDISEASE

To the patient suffering from gall-bladder disease,especially that form of it which is associated withrecurrent attacks of severe pain, the practical problemof relief depends on the likelihood of improvementor cure under medical measures or the dreadednecessity for operative treatment.Does inflammatory disease of the gall-bladder everclear up completely Q Does it often pass into longperiods of quiescence 1’ If gall-stones have formedmay they, under treatment, dissolve or be passed bythe bowel 1 Is the patient’s general health likely tosuffer from the presence of a diseased gall-bladder,and is any risk to life run by leaving a diseased gall-bladder in situ ? ° Does surgical treatment involvemuch risk to life ? If survived, will the operationrelieve all the symptoms ’? What chance is there ofthe trouble recurring after operation ‘ Does removalof the gall-bladder per se give rise to any disagreeableor disabling symptoms I Does the presence of a

stone or stones in the common bile-duct make theoperative risk and the future prospect grave Whatis the outlook from operation in the patient who isdeeply jaundiced ’lThese and other questions are being raised daily inpractice, and in this communication I will endeavourto answer them.Might I first emphasise the difficulty in some cases

of being sure of the diagnosis and thus of assessingthe value of various forms of conservative treatment 7I have on more than one occasion, whilst operatingfor another upper abdominal lesion, exposed a

perfectly normal gall-bladder, the known disease inwhich was said to have been kept in abeyance foryears by careful medical treatment. It is inevitable,therefore, that in any series of cases treated on medicallines, we will have a number in which the diagnosiswas sufficiently in doubt as to make accuratestatistical record impossible. On the other hand,we have a sufficiency of cases in which the diagnosiswas clear, and in which medical treatment was

employed, to give an approximately accurate estimateof prognosis.

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CHANCES OF SUCCESS WITH MEDICAL MEASURES

. Have we any reason to doubt that inflammation inthe gall-bladder will clear up completely in a certainnumber of cases 1 We know that cholecystitis is

frequently a chronic and indolent disease ; that thecausal organism is embedded in the gall-bladder walland is killed or dislodged with difficulty. We alsoknow that the -common association with gall-stonesand the intermittent obstruction of the cystic ductwhich is liable to take place aggravates and per-

petuates the cholecystitis. None the less it is truethat in a certain number of cases of indubitablecholecystitis, symptoms have disappeared for longperiods of years after medical treatment and a lastingsymptomatic cure has been effected.

If we have diagnosed the presence of gall-stones,either from typical biliary colic or from X raydemonstration, what chance is there of cure bymedical treatment 7 It may be said at once that noknown drug or diet will cause the solution of gall-stones. Can we induce the passage of the stones byway of the ducts and bowel I There is no questionthat sometimes after the administration of generous

doses of olive oil a number of small stones may pass,and this form of treatment is well worth a trial,provided we do not know that there is a stone presentthe size of which makes passage down the ductsimpossible. Experience points to the percentage ofcases in which such treatment can be followed bylasting success being extremely small-in the regionof 5 per cent.We have obtained abundant evidence in the past

few years of the sinister consequences of untreatedgall-bladder infection. Firstly, a stone may lodge inthe common bile-duct and give rise to the disabling,and sometimes dangerous, symptoms which followobstruction of the duct. A suppurative obstructivecholecystitis may be followed by a subphrenic abscessor a pylephlebitis, or a large stone ulcerating throughinto the intestine may cause acute intestinal obstruc-tion. A pancreatitis, either of the slow sclerosingvariety or of the dangerous acute hgemorrhagic type,may develop. Toxic changes in the heart muscle, inthe fascial planes, in joints and in kidneys, resultingfrom absorption of organisms and their toxins fromthe chronic infective focus in the gall-bladder, are nowknown to be not infrequent sequelae of cholecystitis.

Apart then from the dangerous complication wherelife is in jeopardy, an indolent gall-bladder infectionmay play a definite and important role in bringingabout those degenerative changes which, coming on.in late middle life, precipitate the patient into a

premature old age.FACTORS DIMINISHING OPERATIVE RISKS .

What is the immediate risk attached to operationson the biliary passages It is obvious that theanswer to this question depends on several factors-viz.; the care taken in pre-operative preparation, theskill and experience of the surgeon, and the qualityof the nursing in the post-operative period. Manypatients with biliary disease are bad subjects for

operation. They are often very stout and breathlesson exertion, and in some cases are poisoned andjaundiced.The immediate prognosis will be greatly improved

if an appropriate pre-operative regime be instituted.If the patient is very obese a delay of three months,during which weight is reduced on a suitable dietwith regulated exercise, will facilitate the operativemanipulations, and, by ensuring well-maintainedcardiac action, will lessen the risk of post-operativethrombosis and embolism. Since adopting a periodof pre-operative dieting and physical training in

stout, flabby subjects, I have found my mortality-ratein biliary surgery has been reduced to half its previouslevel. An adequate pre-operative supply of fluidand sugar is another safeguard, especially in cases inwhich an infected and obstructed common bile-ducthas led to loss of weight and impairment of hepaticefficiency.

In uncomplicated cases of gall-bladder disease inwhich operation has been undertaken on accountof recurring colic or chronic dyspepsia, the riskto life from removal of the gall-bladder shouldnot be more than 2 per cent. Evacuation anddrainage of the gall-bladder in such cases should bearan even lower mortality; but it is not advisedbecause a diseased organ is left behind, gall-stonesrecur in approximately 10 per cent. of cases, biliarydyspepsia may persist, and, in some cases, carcinomaof the gall-bladder develops.

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Bmergency operations..-In cases of acute obstructivecholecystitis where the condition does not yield toexpectant and medical measures, operative treatmentof an emergency nature must be undertaken. Thisshould consist merely in an exposure, opening andevacuation of the gall-bladder, followed by drainage.In elderly subjects with a tendency to chest compli-cation this operation is by no means free from risk.A preliminary narcotic and local anaesthesia willpermit of adequate access and is well tolerated.Where the gall-bladder is partly gangrenous B. welchiiis usually found. In such cases the abdominal woundshould be left open and packed and anti-welchiiserum-40 c.cm.—given at once. After such emer-gency operations recovery may be complete andlasting. My experience has been, however, that in50 per cent. of such cases symptoms recur, often withthe formation of further stones, and in two of mycases with the development of carcinoma of the

gall-bladder. Owing to this tendency to persistenceof some of the symptoms, to the recurrence of stones,and to the development of malignancy, the operationof drainage of the gall-bladder has been largelysuperseded by that of removal.

RESULTS AFTER OPERATION

What chance is there of persistence of symptomsafter removal of the gall-bladder We find, from afollow-up, that the patients are relieved of symptomsin over 70 per cent. of cases. The poor results andthe qualified benefit are found, for the most part, inthe cases in which the pre-operative symptoms weresomewhat atypical and the pathology disclosed atoperation was not gross. Flatulence, heartburn,and intolerance of fats are the usual residualsymptoms. Occasionally attacks of colic will persistafter operation, to the chagrin of both patient andsurgeon. Such attacks may mean that a stone inthe common bile-duct has been overlooked or merelythat the sphincter of Oddi is still subject to spasm.Patience and belladonna are indicated for some

months after operation in such cases, and onlyif jaundice supervenes should further operativeinterference be considered.

There is a fairly widespread impression that afterremoval of the gall-bladder a patient never quiteregains normal digestion. This is quite erroneous.I have questioned many hundreds of patients on thispoint and the unanimous verdict is that digestion isas good as ever and better than for many months oryears before operation. The only exception is wherea functioning gall-bladder, the seat of early disease,has been removed; here for some months vaguedigestive disturbance results but in course of timegradually disappears.An analysis of the cases in which, following

cholecystectomy, troublesome symptoms have

persisted has shown that in the majority the diseasein the gall-bladder was mild in degree and withoutstones, and at operation some hesitation existedas to whether extirpation of the gall-bladder wasjustifiable. In such cases the diagnosis was probablywrong and the operation of cholecystectomy mustbear unwarranted discredit. In some cases a stonein the common bile-duct had been overlooked andlittle, if any, benefit has resulted. In some suchcases the disappointed patient will have no furthersurgical interference ; in most, luckily, the patientconsents to a second operation, when the duct iscleared, the patient relieved, and surgery rehabilitated.The lesson is that the common duct should always

be displayed and, if any doubt exists, opened andexplored at every operation on the biliary tract.

STONE IN THE COMMON BILE-DUCT

When a diagnosis of stone in the common duct ismade, surgical treatment should always be recom.mended. The possibility of a stone, which has beenarrested in the duct, passing on into the duodenumbecomes less with every day. Surgical treatment,whilst imperative, should not be precipitate. Ifintermittent jaundice and fever have punctuatedthe course of the illness, operation should, if possible,be timed to occur with a waning jaundice and areceding infection. When this can be done the riskof operation does not exceed appreciably that of

cholecystectomy. If, on the other hand, the obstruc-tion of the duct is complete, jaundice progressive,the stools devoid of bile, and the patient apatheticand drowsy, operation is demanded without unduedelay and the prognosis must be guarded.

In the first case chemical disinfection of the ducts bylarge doses of hexamine and the "schutztherapie "forthe liver--glucose and insulin-may with advantagebe carried on for a week or more. In the secondcase intensive pre-operative therapy over a periodof 48 hours by intravenous administration of fluidand glucose, of calcium chloride, and of blood, willlessen the considerable risk of haemorrhage and ofhepatic insufficiency, but will not render safe whatmust be at all times a dangerous procedure.

If on opening the common duct colourless fluidescapes-white bile-this is an index of severe backpressure on the liver and a bad prognostic feature;it calls for special efforts to promote liver functionby fluid, glucose, and by diathermy to raise thetemperature of the liver.

In spite of all our efforts the death-rate in thedeeply jaundiced patient will remain high, not lessthan 20 per cent. Consequently, we should see to itthat patients presenting symptoms of stone in thecommon duct are not left until they reach a dangerouscondition requiring desperate measures.

CARCINOMA OF THE GALL-BLADDER

When malignant disease of the gall-bladder occurs itis almost invariably as a sequel to gall-stones. The

gall-bladder is not a very common site for cancer-Ihave had to deal with 32 cases among some 800 casesof gall-stones, and in just over 1000 operations on thebiliary passages. Frequently it does not declare itspresence until, on the one hand by obstructing theneck of the gall-bladder, it gives rise to a palpablemucocele or empyema of that organ, or on the otherhand by pressure exerted by invaded lymph glandson the common duct it causes jaundice. Seldom,therefore, can the growth be successfully removed-the only successful cases in my experience are those(two cases) where it was discovered accidentally onopening a gall-bladder removed for gall-stones. Inall other cases where removal was attempted earlyrecurrence in the liver has taken place. Practicalexperience of these cases convinces one more and moreof the advisability of removing and not simply drainingthe diseased gall-bladder.

D. P. D. WILKIE, M.D., F.R.C.S.Professor of Surgery, University of Edinburgh.

AT the recent annual meeting of Melksham CottageHospital it was announced that the hospital is about toreceive the legacy of 100,000 bequeathed by the late Mrs.Ludlow-Bruges, who formerly lived in the neighbourhood.Owing to the appreciation of securities the sum mentionedwill probably be exceeded. A new wing is to be builtwith a portion of the money. The year 1933 closed withan adverse balance of ;&bgr;639, and the rating assessment ofthe hospital has been raised from no to :E87.

D. P. D. WILKIE, M.D., F.R.C.S.Professor of Surgery, University of Edinburgh.