SOME CLINICAL FEATURES OF 
DISEASES OF THE GALL- 
BLADDER AND BILE DUCTS 
DUE TO GALLSTONES, AND 
THE INDICATIONS FOR 
THEIR SURGICAL TREAT- 
MENT. 
BY 
Charles A. Elsberg, M.D., 
NEW YORK. 
Reprinted from the 
new VorK medical Journal 
and Philadelphia medical Journal 
for March 26, 1904. 
CONSOLIDATED Reprinted from the New York Medical Journal and Phila- 
delphia Medical Journal, Consolidated, for 
March 26, 1904. 
SOME CLINICAL FEATURES OF DIS- 
EASES OF THE GALLBLADDER AND 
BILE DUCTS DUE TO GALL- 
STONES, AND THE INDICA- 
TIONS FOR THEIR SUR- 
GICAL TREATMENT.* 
By CHARLES A. ELSBERG, M. D., 
NEW YORK, 
ADJUNCT ATTENDING SURGEON, MT. SINAI HOSPITAL. 
During the last five years there have been great 
advances in our knowledge of cholelithiasis and 
its complications. We are beginning to recog- 
nize that many cases of indefinite gastric and in- 
testinal symptoms are really due to diseases of 
the gallbladder, and medical opinion is travelling 
along the same road that it did a decade or so ago 
in the case of the vermiform appendix, when a 
large number of irregular intestinal symptoms 
were finally recognized as being caused by dis- 
ease of that organ. The indications for opera- 
tive interference have also been much extended, 
but there is not, as yet, a full agreement on the 
limitations of medical and the indications for sur- 
gical treatment. The following short paper is 
based upon cases, seen'upon the second surgical 
service of Dr. Lilienthal, at the Mount Sinai Hos- 
• Read at a meeting of the Harlem Medical Association, May, 
1903. Elsberg: Diseases Due to Gallstones. 
pital, and in my private practice, during the past 
two years. 
The gallbladder shares the fate of the stomach, 
the bladder, the pelvis of the kidney, and the vermi- 
form appendix. So long as there is nothing which 
prevents these organs from emptying themselves 
of their contents, they are very apt to remain nor- 
mal ; lack of the power to do so is often followed by 
infection and inflammation. 
In the case of the appendix the best surgical 
treatment is the removal of the diseased and useless 
organ, if possible, and medical men are becoming 
more and more convinced that the interval between 
the diagnosis of appendicitis and an operation must 
often be a very short one. The question might well 
be asked, Why not remove the gallbladder early? 
The body can do perfectly well without it; the re- 
moval of the organ at an early stage of disease will 
prevent recurrent attacks, the danger of a possible 
severe attack, the possibility and probability of the 
passage of stones from the gallbladder into the 
common bile duct with its increased dangers. It 
will do away with the well-known tendency 
to carcinoma of the gallbladder in later life. 
Some writers (Riedel, Park, Winiwarter) believe 
that cholecystectomy should always be done early, 
in most cases soon after the first symptoms of stone 
in the gallbladder. While few will agree with them 
in this extreme—and up to the present time un- 
justified—view, most operators are beginning to 
believe that the indications for the removal of the 
gallbladder should be much extended.1 The mor- 
1 It need hardly be mentioned that cholecystectomy should 
never be done unless the common bile duct is patent or has been 
rendered patent. Elsberg: Diseases Due to Gallstones. 
tality from primary cholecystectomy in acute dis- 
ease of that organ is as small as that of cholecystot- 
omy and drainage, and in disease limited to the gall- 
bladder and cystic duct, is no larger than that of 
appendicectomy in acute appendicitis. Thus, twenty- 
four cholecystectomies for uncomplicated acute or 
chronic disease were done on the second surgical 
service of Dr. Lilienthal, at Mt, Sinai Hospital, 
during the past eighteen months without a death. 
The cases upon which this paper is based are ar- 
ranged in the following classes: 
I. Cases Seen in the First Mild Attack.—ln these 
patients the indications 'for surgical treatment are 
very limited. If the symptoms are of mild char- 
acter, and very slight or no symptoms of peritoneal 
irritation appear, medical treatment is usually in- 
dicated. Very few of these patients are seen by the 
surgeon, most of them remain in the hands of the 
internal practitioner. Under medical treatment-the 
attack usually yields, the inflammation in the gall- 
bladder subsides, the stones—if present—either pass 
into the intestine, or (in about 70 per cent, of the 
cases) remain in the cystic duct or drop back into 
the gallbladder and remain quiescent, and the 
swollen gallbladder disappears. Probably 10 per 
cent, of these patients remain permanently well. 
Jaundice occurs in less than one third of the cases, 
and when present is due to the inflammatorv swell- 
ing of the mucous membrane of the common bile 
duct. In many of these patients we used formerly 
to diagnosticate their trouble as gastric or intestinal 
colics, but we now recognize them in their true light 
as gallstone colics. 
3 Elsberg: Diseases Due to Gallstones. 
11. Cases Seen First in a Subsequent Mild Attack. 
—Some patients are seen in a mild attack and give 
the history of having had a large number of mild 
attacks in some of which they perhaps passed a 
small stone or several stones. In these cases it is 
allowable to wait a long time before recommending 
surgical interference—especially if the intervals be- 
tween the attacks are considerable and the patient 
is able to follow out the medical treatment pre- 
scribed for him. Cases of this class most often re- 
main under the care of the internist, but the sur- 
geon will see quite a number of these patients, will 
be asked as to the advisability of an operation, and 
will often have to give the weight of his opinion 
against operation. Although we know that it is 
very possible that the patient will have further and 
more severe attacks in the future, we must advise 
delay, as it is perfectly possible that in this last 
attack the stone was passed, and that the patient 
will thereafter remain perfectly well. The time 
may not be far distant, however, when most cases 
of this kind will be promptly and permanently cured 
by the removal of the gallbladder. 
111. Cases with Repeated Severe Attacks.—ln a 
third class of cases the attacks of colic or pain are 
so frequent that the patient is either incapacitated 
from doing his work or the general health is mark- 
edly affected. In these patients the frequent use 
of morphine may be necessary, and there is the dan- 
ger that a drug habit may be acquired. Cholecys- 
tectomy is the operation of choice, and by the re- 
moval of the organ every advantage will be gained 
that is to be obtained by the removal of a diseased 
4 Elsberg: Diseases Due to Gallstones. 
appendix vermiformis giving rise to recurring at- 
tacks of appendicular trouble. The following case 
is an example: 
Case I.—H.C., married, mother of eleven children, 
admitted to the second surgical service of Mt. Sinai 
Hospital on September 19, 1902, with a history 
of frequent attacks of pain in the right hypochon- 
driac region for the last thirty years. For one year 
the attacks had occurred every few weeks and were 
sometimes accompanied by jaundice. The patient 
had become a chronic invalid. The last attack was 
of two days’ standing. The gallbladder was en- 
larged and very tender, there was slight icterus 
T., 102.20 F.; P., 98. Operation was recommended, 
and at the operation I removed a very large and 
thickened gallbladder containing four large and 
numerous small stones. The patient made a rapid 
and uninterrupted recovery and has remained well 
up to the present time (May Ist). 
IV. Prolonged Cases with Sudden Change of 
Character.—In some patients the disease runs the 
course of a mild attack for a few days, but the symp- 
toms are prolonged until they gradually or suddenly 
change their character. The fever remains more or 
less continuous, the tenderness over the gallbladder 
becomes more marked, the pulse begins to rise, and 
signs of invasion of the peritonaeum appear. In 
these patients it is sometimes difficult to differen- 
tiate the disease from acute appendicitis. There is 
a rapid pulse, more or less fever, marked rigidity 
of the right rectus muscle or of both recti, pain and 
tenderness along the right side of the abdomen— 
perhaps below the level of the umbilicus—vomiting, 
etc. These cases always require early operative in- 
terference. The gallbladder and more or less of the 
5 Elsberg: Diseases Due to Gallstones. 
cystic duct will usually be found to be much dis- 
eased ; these organs may contain a greater or less 
number of calculi, and thin or thick infectious bile 
or more or less purulent fluid. The walls of the 
gallbladder may be the seat of a variety of patholog- 
ical changes, from slight inflammatory thickening 
to localized or extensive necrosis of the mucous 
membrane or of the entire walls of the organ. 
There are usually fresh adhesions to the neighbor- 
ing structures—pylorus, duodenum, hepatic flexure 
of the colon. The following is the history of a case 
of this class: 
Case lI.—R. H,, admitted July 19, 1902, dis- 
charged August 23, 1902. For four days patient, a 
very stout woman, had had severe colicky pain in 
the region of the gallbladder without jaundice. It 
was her first attack of this kind. She had a severe 
chill a few hours before her admission to the hos- 
pital. On admission, T. 101.40 F.; P. 128; a large 
distended and very tender gallbladder was to be 
felt; the right rectus muscle was distinctly rigid; 
there was slight tenderness over the entire right side 
of the abdomen. Operation was done at once, and 
a large distended gallbladder, with numerous deep 
ulcerations of the mucous membrane and with a 
large calculus in the cystic duct, was removed by 
me. The patient made a rapid recovery and was 
discharged cured about four weeks after the opera- 
tion. 
If operation is delayed in these cases, perfora- 
tion of the gallbladder may occur with formation of 
a pericholecystic abscess, perforation into one of 
the neighboring organs, or rupture into the general 
peritoneal cavity with resulting peritoneal infection, 
or infection of the liver itself. The clinical history 
6 Elsberg: Diseases Due to Gallstones. 
of the following case shows that the patient should 
have been referred to the surgeon much earlier than 
was done: 
Case 111.-—Fanny H., admitted to hospital and 
operated on April 13, 1903, in her third attack of 
gallstone disease of three weeks and a half’s stand- 
ing. For two and a half weeks the disease had run 
the course of a mild cholecystitis with occasional 
slight rises of temperature and without jaundice. 
One week before admission, the pain had become 
more severe and continuous, the fever remained 
continuous, and the patient had begun to look bad. 
Two days before admission, the abdomen had be- 
come distended and generally tender, the pulse had 
become more rapid, and the patient had begun to 
vomit. She had several chills followed by sweating. 
On admission, T. 102.8° F.; P. 130; abdomen much 
distended and very tender and rigid; liver enlarged 
to percussion and palpation; tenderness most 
marked in the right hypochondriac region where a 
small mass was to be indistinctly felt. At the opera- 
tion, I found the gallbladder gangrenous and per- 
forated, there was an abscess between the organ 
and the colon, which contained two large calculi, 
there was a communication between the gallbladder 
and the second portion of the duodenum. As the 
poor condition of the patient did not allow of ex- 
tended manipulations, the calculi were removed 
and the abscess drained. During the first twelve 
hours, the patient’s condition remained very poor. 
Improvement then began and continued. The com- 
munication between the gallbladder and the duo- 
denum was closed at the expiration of six weeks. 
V, Patients with a Persistent Biliary Fistula from 
a Previous Operation.—ln these cases there is a 
discharge of either bile or mucus from the fistula. 
If the discharge is mucous, the persistence of the 
7 Elsberg: Diseases Due to Gallstones. 
fistula generally means persistent disease of the 
gallbladder or cystic duct, perhaps with obliteration 
of the cystic duct or obstruction of the same by a 
large calculus. If the discharge is biliary and there 
are clay-colored stools, there is probably a common 
duct obstruction; if the discharge is biliary but there 
are no clay-colored stools, there is persistent dis- 
ease of the gallbladder or bile ducts. Although 
some patients will get along very well for consider- 
able lengths of time with a biliary fistula, the dis- 
comfort from the continuous discharge is always 
very great, and the general health will suffer sooner 
or later. Hence—unless there are special contra- 
indications—a biliary fistula which refuses to heal 
in spite of all treatment requires surgical interfer- 
ence. The operation that usually has to be done 
is removal of the gallblader and the calculus in the 
cystic duct, if there is one, or removal of the com- 
mon duct stone by choledochotomy and drainage, 
perhaps with removal of the gallbladder. It need 
hardly be mentioned that the foregoing remarks do 
not refer to those cases in which the biliary fistula 
is due to malignant disease of the bile passages or 
head of the pancreas, or where the fistula has been 
made as a therapeutic measure in chronic interstitial 
inflammation of the head of the pancreas (Mayo 
Robson). 
In one patient with a persistent fistula, I removed 
the gallbladder after dividing a large number of 
adhesions in which the organ was enveloped. Re- 
covery from the operation was prompt, but the pa- 
tient’s family physician tells me that the patient has 
occasional attacks of pain in the gallbladder region, 
8 Elsberg: Diseases Due to Gallstones. 
due to the adhesions. In a second case the fistula 
was due to a stone in the common bile duct; here 
the stone was removed by choledochotomy with 
drainage and the gallbladder was extirpated. The 
patient was a very stout woman; she died suddenly 
twenty-four hours after the operation from cerebral 
embolism. 
VI. Cases with Adhesions Between the Gallblad- 
der and the Neighboring Organs Not Due to Dis- 
ease of the Gallbladder.—About one year ago I 
had occasion to operate upon a patient whose symp- 
toms pointed toward chronic obstruction of the 
common bile duct. At the operation, the obstruc- 
tion was found to be due to adhesions between the 
gallbladder and the anterior wall of the stomach. 
As the gallbladder appeared to be normal, the ad- 
hesions were simply divided between ligatures and 
the abdomen closed. The patient was well when 
last heard from—about six months after the opera- 
tion. 
VII. Cases of Calculous Obstruction of the Com- 
mon Duct.—Thus far, mention has been made of 
only a few phases of disease of the gallbladder and 
cystic duct due to calculi. When the stone passes 
into the common bile duct, conditions at once be- 
come more serious, unless the stone passes through 
the common duct into the intestine. The stone may 
remain quiescent in the common duct for a long 
time, but this is not so apt to occur as with a stone 
in the gallbladder, for the continual passage of bile 
along the duct is a constant disturbing factor. The 
calculus may, on the other hand, cause a chronic 
obstruction of the common bile duct with the char- 
9 Elsberg: Diseases Due to Gallstones. 
acteristic symptoms of colic, enlargement of the 
liver, jaundice, and clay-colored stools. 
If the symptoms of obstruction of the common 
bile duct are acute, it is always advisable to treat 
the patient medically for at least from one to two 
weeks unless symptoms of sepsis or peritoneal in- 
fection appear. The obstruction may be mainly due 
to the traumatic inflammatory swelling of the mu- 
cous membrane of the duct. As soon as the swell- 
ing has decreased, the passage of the stone into the 
intestine may become possible. Or the stone had 
already passed through the duct, and the symptoms 
are due altogether to the inflammatory swelling of 
the common bile duct. If a case of this kind were 
operated upon, nothing would be found as a justifi- 
cation for the surgical interference. 
In the majority of instances, the clinical picture of 
chronic obstruction of the common bile duct is quite 
different from that of obstruction due to neoplasm. 
The liver is usually enlarged and the gallbladder 
contracted and not palpable. Slowly increasing 
jaundice with a painless onset—especially if accom- 
panied by ascites—must always give rise to the sus- 
picion of new growth of the liver, bile ducts, or head 
of the pancreas. In common bile duct obstruction 
by stone, the operative indications are the removal 
of the stone or stones by incision of the common 
duct with drainage of the ducts, and treatment of 
the gallbladder according to the general principles 
previously mentioned. It is advisable to drain the 
common and hepatic ducts in most instances, as 
small stones might otherwise be left behind (Kehr). 
Conclusions.—The space allowed this paper has Elsberg: Diseases Due to Gallstones. 
necessitated the mention of only a few phases of 
gallstone disease, hence many points of importance 
have been omitted. I have attempted to bring Out 
the questions in therapeutics most often encoun- 
tered, and have attempted to formulate the indica- 
tions for medical and for operative treatment. These 
indications might be summed up as follows; 
No operation should be performed in 
I. Cases with mild symptoms, especially if the 
diagnosis is in doubt. 
11. Cases with recurrent mild attacks with long 
intervals of health. 
111. Acute obstruction of the common bile duct. 
IV. Any disease which would contraindicate a 
surgical operation of any kind unless under vital 
indications. 
Operative interference is indicated in 
I. Acute inflammatory diseases of the gallbladder 
with signs of severe infection or peritoneal in- 
vasion. 
11. Cases with very frequent mild attacks, which 
incapacitate the patient from work, which are ac- 
companied by much loss of flesh and strength, or in 
which the patient is in danger of acquiring the mor- 
phine habit. 
111. Persistent biliary fistula. 
IV. Rare cases in which the symptoms are due 
to adhesions of the normal gallbladder to neighbor- 
ing organs. 
V. Chronic obstruction of the common bile duct. 
It is probable that, in the future, medical men will 
agree upon more early and more radical treatment 
of many cases of gallstone disease, and that the re- Elsberg: Diseases Due to Gallstones. 
moval of the gallbladder—the fans et origo of gall- 
stones in the vast majority of cases—will be done 
more often. The indications for cholecystectomy 
will hence be much extended, and operations upon 
the common bile duct become of necessity less 
frequent. 
Madison Avenue and Sixty-third Street. 
12