Common and Hepatic Duct Stones
Authors: Frank H. Lahey
Journal: New England Journal of Medicine (1932)

T HAT gaIlstones occur in a great many peopIe is, of course, a demonstrated and accepted fact today, and that they produce distress and discomfort, that they resuIt in Ioss of time in many individuaIs and that they produce fataIities in others is Iikewise accepted. The IogicaI approach to the management of the gaIIstone probIem wouId, of course, be the prevention of their occurrence and since this is not as yet possibIe nor is there any evidence of its immediate accompIishment, the next most IogicaI approach is to discuss whether it is safer for a given individua1 to keep his gaIIstones with no operation or to have them removed by operation. It must be accepted, we beIieve, that with the exception of simpIe dietary precautions, there is no rea1 medica treatment of gaIIstones. It is probabIe that if peopIe eat reasonabIy, maintain proper bowe1 function and Iive reasonabIy, the number of attacks of gaIIstones may we11 be Iessened. On the other hand, since there is no rea1 time eIement in the occurrence of gaIIstone coIic or IocaI pain, since this appears to be pureIy a matter of chance, one can never be sure as to whether or not the reIief accompIished without operation is the resuIt of chance or care. With the above facts in mind, another question to settIe is if such patients are not operated upon what are the disadvantages that they suffer? In many cases, indigestion, in others, severe pain, and sureIy in others, actua1 fataIities occur. Another consideration which must aIways arise in the question of deferring operation for gaIIstones is the fact that in patients known to have gaIIstones but not operated upon, there is aIways the possibiIity that acute emergencies such as acute cholecystitis, deep jaundice and obstruction caused by stones in the common biIe duct, may occur after patients are advanced in age when they are not good subjects for surgica1 procedures. We have aIways been of the conviction that there are no harmIess gaIIstones and that because of the above dangers and disadvantages a11 gaIIstones shouId be removed. It has frequentIy been urged and practiced that a proper attitude to take toward gaIlstones is that operation should not be undertaken unti1 they produce symptoms. If one deaIs with gaIIstone patients in large numbers one cannot heIp being impressed with the fact that this phiIosophy resuIts in many serious situations and in fataIities which wouId not have occurred had the operative procedure been undertaken earIier. If earIy operation be accepted as the most desirabIe way to manage patients with gaIIstones whether or not they produce symptoms, then a11 physica examinations shouId incIude investigations of the gaIIbIadder in order that stones may be demonstrated early in their occurrence and removed before pathoIogic changes have taken pIace, and the gaII-bIadder removed with its contained stones before changes have taken place in the common biIe and hepatic ducts. If a11 patients could be operated upon for gaIIstones earIy in the course of the disease before there are many pathoIogic changes in the waI1 of the gaIIbIadder or many adhesions about it and before marked infection had taken pIace within the common biIe and hepatic ducts