RECENT CONTROVERSIAL QUESTIONS IN GALL-BLADDER SURGERY*
BY WALTON MARTIN, M.D. OF NEW YORK, N.Y.
In Conclusion.-There have been no reports of serious interference with
function or loss of nutrition following the removal of the gall-bladder,
although thousands have been removed during the last forty years.
There are occasional reports of damage done to the common duct during
simple cholecystectomy, even by operators of large experience.
The removal of a slightly infected gall-bladder or its drainage is accom-
panied at times by extensive adhesions fixing the pylorus or the duodenum
to the under surface of the liver and giving symptoms of interference with
the functions of these organs.
The proof that the gall-bladder should be removed for very slight lesions
of the wall, accompanied by symptoms of indigestion, seems to me not yet
It goes beyond demonstrated fact to assume that slight degrees of chole-
cystitis do not resolve.
The prophylactic removal of a normal gall-bladder does not seem justified.
The proof is not convincing that the majority of infections of the wall
of the gall-bladder, sufficient to give symptoms, represent a direct extension
to its walls from an inflamed liver through the lymphatics.
That bacteria enter the portal circulation from an obliterated appendix
in large enough numbers to produce a hepatitis and cholecystitis recognizable
clinically is by no means established.
In the very large percentage of cases of cholecystitis cholelithiasis must
be considered as an important factor in determining the initial lodgment, the
persistence and the transference of the infection.
Autopsy records and clinical experience furnish abundant evidence of the
very slow progression of lesions in the gall-bladder.
The removal of the gall-bladder for gall-stones and well-marked lesions
of the gall-bladder wall, uncomplicated by lesions of the common duct, is
accompanied by a low mortality and by excellent results.
There is little clinical or autopsy evidence of the association of persistent
hepatitis, cirrhosis or pancreatitis when the disease is confined to the gall-
Common duct stones, choledochitis and cholangitis are late lesions and have
a high mortality, and patients should come to operation before these