One cannot say that any remarkable discoveries have been announced during the past several years in any phase of gallbladder disease, but certain advancements have gradually been made. For example, the belief that cholecystitis starts primarily as a chemical lesion has become more and more prevalent. Supporting evidence for this hypothesis is available in the fact that cultures of the bile and wall of the gallbladder in cholecystitis are so often negative. I am convinced that the infectious phase of cholecystitis is usually superimposed on an initial chemical inflammation. The role of infection in gallbladder disease has definite clinical significance, particularly in cases of fulminating acute cholecystitis when there may be indecision as to whether cholecystectomy or cholecystostomy should be performed. When systemic reaction is severe, the demonstration of numerous bacteria in a smear made from bile aspirated from the gallbladder at the operating table may correctly indicate the performance of cholecystostomy instead of cholecystectomy. The problem of formation of gallstones is likewise unsolved, but the ratio of bile salts to cholesterol in the bile as emphasized years ago by Andrews is unquestion¬ ably important. As the bile salt content of bile decreases, cholesterol tends to be precipitated.Although differential diagnosis in the average case of gallbladder disease is not difficult, it may be extremely complicated in atypical cases. It should also be empha¬ sized that, although the average cholecystectomy may be a simple surgical procedure, operations on the biliary tract on certain occasions may tax the skill and ingenuity of the best surgeons. DIAGNOSIS No attempt will be made to describe the symptoms of gallbladder disease. However, I wish to call attention to the atypical features of the disease and to some of the misconceptions in diagnosis.In a detailed study being made by Harridge and Helsby 1 of 211 consecutive patients having had chole¬ cystectomy at Illinois Research Hospital in Chicago during the three or four years prior to this writing. 45.6% had pain in only the right upper abdominal quadrant. Pain was located in the epigastrium alone in 27.2% and in the epigastrium as well as right upper ab¬ dominal quadrant in 18.9%. In 5.3% of the patients, pain was located elsewhere, including the left upper ab¬ dominal quadrant and precordium. Although it is well known that the pain of cholecystitis may be referred to anatomic areas other than the right upper abdominal quadrant, it should be emphasized that this happens only occasionally and the clinician must be cautious in blam¬ ing the gallbladder for the symptoms. In the atypical cases this is particularly true, since gallbladder disease, including cholelithiasis, is so common and will frequently be present along with other diseases. For example, Robertson and Dochat found from postmortem studies that 32% of women past the age of 40 had gallstones and 16.2% of men past the age of 40 had stones. Yet it is well known that less than one-third of patients...
