A sandbag. placed under the patient at the level of the liver, will push the spine forward and with it the liver and bile-ducts; so that the common and hepatic duets are brought several inches nearer the surface. The writer always makes his incisions over the middle of the right rectus and in line parallel with its fibres, which are separated by the finger. If more room is required, the incision is carried upward in the interval between the ensiform cartilage and the r4,cht eostal margin as high as possible. By lifting the lower border of the liver. first drawing the organ down ward from tinder the cover of the ribs, the whole of the gall-bladder and the cystic and common duets are brought to the surface. An assistant gently draws the gall-bladder -upward with one hand and retracts the left side of the wound and the viscera with the other. The gall-bladder. cystic arid common ducts now form a straight passage from the fundus of the gall-bladder to the duodenum, and the whole length of the ducts, with the cluodennin and head of the pancreas, are in view. Stones in the ducts are detected by palpation and re moved by incision into the ducts. If the common duet has been incised, a probe may be passed into the hepatic duet and down the common duct into the duodenum. The incision into a bile duet is .closed by a curved needle held in the fingers without a. needle-holder, a continuous catgut suture being used for the margin of the duet proper, and a continuous catgut or celluloid thread being employed to close the peritoneal edges of the duct. When the gall-blad der is eontracted and a, swollen pancreas presses on the common duct, a drainage tube is inserted into the hepatic duet, passing niiward through the comunon duct, and here held by a catgut stitch. Prolonged manipulations are never made on a stone deeply impacted even in the cystic duct, but the duct is at once incised and the eoncretiou removed. Drainage is effected by gauze surrounded with a split drainage tube, which is brought out by the side of the gall bladder drain. All bleeding points and all firm adhesions are ligated. Ideal cholecystotomy (cholecystotomy in two stages) and partial cholecystectomy (Mayo) are not regarded with favor. A contracted gall-bladder which cannot be brought to the surface may be drained by fixing a tube into it with a purse-string suture, the general peri toneal cavity being protected by gauze packing. In many of these eases it is better to remove the gall-bladder. If a stone is impacted in the duodenal ends. a ditodeno-choledochotomy is sometimes the easiest operation. A cholecysten terostomy is rarely used because the trouble is not removed; Wile11 it is nec essary it will be found easier to ana.s tomose the gall-bladder with the colon.
detachinfc adhesions a careful search imist always be made for an opening into the hollow viscera. A. W. Mayo Robson (British Medical Journal, Jan.
24, 1003).
Cholecystotomy is the operation of choice in cholelithiasis, and it is consid ered safer, after opening the gall-blad der, removing the calculi, and ascertain ing that the biliary passages are clear, to suture the walls of the gall-bladder to the edges of the wound than to perform the so-called "ideal" operation of sutur ing the opening in the gall-bladder and returning it into the abdomen. It is better to suture to the aponeurotic layer of the abdominal wall and not to the skin. Mayo Robson prefers, when there is time, to stitch the peritoneal layer of the gall-bladder to the parietal perito neum and the mucous layer to the apo neurosis. A drainage-tube is then in
serted.
When a fistulous opening is left, cal culi not removed at the operation may find an exit. When the incised gall bladder is returned to the abdominal cavity leakage may take place.
When the gall-bladder is contracted and cannot be brought to the edge of the wound, Mayo Robson sometimes tucks down the parietal peritoneum to the gall-bladder and sutures it to the edge of the incision. When he cannot do this, he utilizes the right border of the omentum by suturing it to the gall bladder opening and to the parietal peri toneum around the drainage-tube and shutting out the general peritoneal cav ity. If neither of these methods can be adopted, he passes a drainage-tube through the opening into the gall-blad der and plastic peritonitis shuts off the general peritoneal cavity. The tube is somethnes packed around with gauze. lie prefers to drain the peritoneal cavity by passing a tube into the right kidney pouch through the original abdominal incision or through an opening in the side of the abdomen.
A fistula does not close because the mucous membrane is sewed to the skin, but it does close when united to the eut edges of the peritoneum and transversalis ' faseia. Perkins (Boston .Med. and Surg. Jour., Jan. 25, '94).
In cases of obstrnction of the eonunon duct, no attempt should be made to suture the opening after the obstruc tion bas been removed, as the patient's condition is nearly always serious and a prolonged operation would terminate fatally. The obstruction should always be removed, if possible. Experiments demonstrating that the peritoneum is capable of bearing the presence of a small amount of bile. but that large quantities or the constant extravasation of it would produee a. fatal peritonitis, usually in from twenty-four to forty eight hours. 117. E. B. Davis (N.Y. Med. Jour., Oct. 26, '95).
Case of biliary obstruction complicated by peritoneal adliesion.s. A first incision was made in a line of and down to a dis tended gall-bladder. A second incision was made in the right flank and abont a pint of fcetid and bile-stained pus was evacuated. The abseess-cavity was bounded above by the liver, behind by the colon, the distended gall-bladder on inner and parietal peritoneum on the outer side. Ten ounces of healthy bile and forty-three gall-stones were removed from the distended gall-bladder. W. P. Brook (British Medical Journal. Feb. 5, '98).
As results of 27 operations on eases of gall-stones, the following, conclusions are reached: 1. Tait's operation of simple cholecystotamy with drainage of the gall-bladder is the ideal operation in most cases. 2. Incision of the common and cystic ducts is the safest and most surgical means of removing stones in them. 3. Excision of the gall-bladder may find a wider field than heretofore. 4. McBurney has shown that incision of the duodenum, and either dilatation or incision of the common duct through this incision, is, in skilled hands, both efficient and safe for the removal of stones low down in the common duct. In neglected eases with dense and many adhesions and dilated stomach. an additional gastro cnterostomy or pyloroplasty will save eases which would otherwise die. 5. The mortality of the simple cases is prac tically ni/. W. W. Seymour (Amer Jour. of Obstet., Nov., '99).