The method is graphically shown in the annexed colored plate, while the mer and the yarious diarneters of the latter employed are illustrated here.
Series of 209 laparotomies for gall stones with special reference to 30 cases of choledoehotonly. He classifies his operations into five groups:— 1. Those in which the stone i.s found in the gall-bladder or cystic duct; 97 mies. Altogether 127 gall-bladder opera tions with but 1 death.
2. Two cystectomies and 1 death.
3. Stone in choledoch-duct which could not be moved into the gall-bladder or duo denum; 30 choledochotomics, 2 deaths.
4. Seventeen eases with dense adhe sions, fistula, etc.
5. Cases complicated by carcinoma and other conditions necessarily fatal in the end.
The mortality bore a definite relation ship to the pathological conditions pres ent. In the 209 laparotornies there were 17 deaths, being S per cent.; but the mortality was reduced to a minimum in the case of stones on the g.all-bladder and cystic ducts, while it reached 6 per cent. when there were changes in the gall-bladder which demanded cholecys tectomy. Suppurative cholang,itis proved a very fatal condition. Emphasis laid iipon the following, three points, viz.: ac curacy in the diagnosis of gall-stones, a thorough knowledge of the pathology of the disease, and perfection in the tech nique of the operation. Hans Kehr ("Verliiindlimgen der deut. Gesellschaft f. Chir.," xxv Congress, '00).
Cases of cholelithiasis treated in the St.Hedwig Hospital at Berlin during ten years analyzed. Of these cases SO were treated in the medical and 43 in the surgical wards. Fifty-seven of the med ically treated were traced and it was found that, after frorn 1 to 2 years. 13 patients still suffered; after from 3 to 4 years, 5; and after from 5 to S years, 5. Twenty-two, or 41.5 per cent., were cured, 4 had to be operated upon subse quently, and 4 died. The results of sur gical treatment showed -the mortality 12.5 per cent.; but when the cases in which death was due to causes inde pendent of the operation were deducted, the remaining mortality was only 2 per cent. In none of the cases was there a return of stone-formation or of colic. Two cases snffered from cramps which were probably connected with disturb ance in the eceliac ganglia and the abdominal sympathetic. H. Scheuer (Mtinchener med. Woch., June 12, 1900).
Morris mentions a case in which, after opening the gall-bladder and removing calculi, stones were found in the com mon duct which could not be removed. During the convalescence olive-oil was daily injected through the fistulous opening. In six or eight weeks the pas sage became patent and the patient made a good recovery.
Choledocolithectomy is the proper operation fc-m stones in the common duct except in very rare cases. such as those
in which the adhesions are so dense that it is impossible to isolate the ducts. In some cases the ducts above an obstruc tion will be fonnd enormously distended and the walls unhealthy and friable. J. F. W. floss (inter. Clinics, Jan., '98).
[Result of anastomosis of the gall bladder with the colon. .1. F. W. Ross reports a. case operated on in February, 1S96, as still in excellent health. The patient was suffering from a gall-.tone impacted in the common bile-dnct, pro ducing intense jaundice. At the time of the operation the adhesions were so great that it was impossible to isolate the com mon duct. The liver was torn in an at tempt to accomplish this. As a conse quence, au anastomosis was produced be tween the gall-bladder and the colon by means of a small Murphy button. The button was passed about the sixteenth or seventeenth day after operation. The jaundice rapidly disappeared and the patient soon regained his health. He was seen a month ago in perfect health. The fact that the bile was side-tracked into the colon had no visible ill effect.
Ross also reports having found gall stones lying in the COM111011 and hepatic duct, one beside the other like a row of cobble-stones. The stones in the hepatic duct vvere found far up to the end of the duct. They were removed by a milking process. In the first place, a silk suture was placed like a running string, on the wall of the duet. This was put in posi tion before the duct was incised, so that by pulling on it like a purse-string the orifice could be readily closed and the bile kept from welling into the tield of the operation. If the duet i.s incised first, the bile welling, out through the orifice obscures the view. Ile has adopted this method of procedure on several occa sions, and finds it of great service.
After the suture was placed he then made an incision into the common duct inside the oval formed by the suture. With the index finger of the left hand on one side of the duct and the index finger of the right hand on the other side, the stones were gradually squeezed down from the hepatic duct and up from the intestinal end of the common duct to the opening just made and pressed out through it. In this way ten or twelve stones were removed. As the gall-blad der had been previously opened and three stones removed from the interior of the gall-bladder, it was deemed ad visable to stitch the gall-bladder to the abdominal wall and place a drainage tube in its interior. The patient made ' an uninterrupted recovery and has since enjoyed excellent health. J. E. GRAHAM.] J. E. Toronto.