attention has been given within the last three or four years to the improvement of this opera tion, and, although in many cases diffi cult, it can be performed with greater safety to the patient than formerly. The suturing of the incised walls can be much more easily and completely done, and leakage to a very great extent pre vented.
An exploratory operation is indicated when biliary retention ha.s persisted for three months without a.melioration. Such an operation is not always easy; when there are adhesions the relations are changed and the gall-bladder is not readily found. By following the course of the umbilical vein the duetus chole (loans will be found on a plane oblique to it. If its relations are normal the liver can be elevated and the left index finger introduced into the foramen of -Winslow, which is drawn down, while the right index finger follows the left border of the gastro-hepatie omentiun. When a calculus is present it is better to perform choledochotomy, when simple pressure of the finger is not enough to cause the stone to pass into the duo denum. The higher up the calculus.— that is, the nearer the liver—the more difficult is exploration, inci-ion of the canal, and suture.
In such cases the duct may be left open. as the fistula will heal spontane ously. but drainage must be established in order to isolate the area from the re mainder of the abdominal cavity. Quentt (Le Bull. Mal., May 12, '95).
With our present experience and tech nique WC may safely say that choledo chotomy, in the majority of cases, is a diflieult and tedious operation which may tax to the utmost the resources of the patient, but its results usually are emi nently favorable. Jaundice should not be allowed to exist too long. Let me emphasize once more that preservation of life and health in many cases depends upon the proper time being chosen for surgical interference. Lange (Mal.
News. May, '97).
In many instances biliary calculi may be removed front the common bile-duct through an incision in the anterior wall of the descending duodenum. This is an exceptionally good route, if the calculus be situated in the lower third of the com mon duet. The orifice of the duet may, if necessary, be incised for one-half inch, with perfect safety, and the duct itself is easily dilated. :Method employed on six different occasions, and in each instance the intestinal wound healed kindly. Charles MeBurney (Annals of Surg., Oct.. '98).
One of two incisions should be em ployed in exploring the region of the gall bladder or bile-ducts; the best one ex tends from about 1/, inch below the free border of the eostal cartilages to a point 2 or 3 inches above the umbilicus, pass ing just within the outer border of the rectus muscle. The second is a curved incision parallel with the free border of the eostal cartilages and abont 1 inch below them.
None but the ninth dorsal nerve will have been divided by either of the two ineisions as described. The longitudinal one is to be preferred. If the gall-stone be lodged in the gall-bladder the calculi are removed from an incision in the fun dus of the gall-bladder after the latter has been stitched to the abdominal wall. In order to avoid annoyance of a fistula's persisting. for weeks or months after operation. McBurney recommends follow ing modification of ordinary procedure: The circumference of gall-bladder about one-half inch below fundus is sutured to the alt....es of abdominal wound; a purse string suture is passed around gall-blad der between opening, in fundus and line of suture to abdominal wall; the free edge of incised fundus is now inverted, a small rubber draina:,:e-tube is inserted, and the purse-string is tightened, so as to prevent reversion of inverted edges. After this method the drainage-tube may be removed in the course of several days and in a short while the fistula will be permanently closed. C. _MeBurney and H. D. Collins (..),Ied. News. Nov. 26, '9S).
Dr. IV. S. Halsted, in an article in one-sided and 3 double-sided totoinies, 4 eystendysis and 23 eysteeto Johns Hopkins Hospital Bulletin, April, 1898, on the use of small hammers and th.e suture of the bile-ducts, commences as follows: "The surgery of common bile-ducts is still in its infancy. 'Suture of the thickened duct is difficult enough and suture of the normal duct is out of the question,' says one. 'It is not worth while to exercise great care in sewing up a slit in the common bile-duct, for it is almost impossible to prevent leakage, and a little additional leakage can do no harm if one drains,' says another. 'Wait until the common duct dilates and thickens before venturing to open it,' say all surgeons." Halsted states that he has ascertained from operations on dogs and man that the normal bile-ducts can be sutured easily, accurately, almost infallibly, and without danger of leakage or constric tion. He approves of Lange's suggestion to cut through one or two ribs and the diaphragm, if it is necessary thus to render the parts operated upon more ac cessible. He then describes small ham mers, the heads of which, being of vari ous sizes, he inserts into the common duct, after the incision has been made and the stone removed. The contents are thus prevented from escaping, and the duct can be raised or lowered at will by the operator. The wall is more easily sutured over the head of the ham mer. He has a series of hammers which he attaches to a long handle, using one of proper size to easily enter the duct.