11111 Every time you buy an article you view the value from three angles. Quality, Price and Service are the three essentials ever sought by the conscientious buyer. These important factors form a trinity merging into every satisfactory purchase. Fortunate, indeed, is he who secures all three. He who buys for Price alone, buys for today with little thought of tomorrow. Quality, unless judged from point of use, may merge into extravagance. Service is an essential without which both Quality and Price become valueless. Nowhere are these essentials so important as in the purchase of technical equipment and supplies. Nowhere are they so readily obtainable as from the nearby dealer who specializes in medical and surgical equipment and supplies. The Service offered by our establishment is greater than the ordi- Not only do you get What you want, but you get it When and This means much in emergencies, when such service is of vital im- The Quality of any article we sell is assured by a double warranty -the manufacturer's word and ours. Goods of doubtful character are never considered by our buyers. And as to the matter of Price that we are more than reasonable. -a trial purchase will prove to you PHYSICIANS & HOSPITALS SUPPLY CO. Surgical Instruments, Apparatus and Appliances 413 South Sixth Street Laboratory instruments, glassware and supplies Telephone Main 0317 VOL. IV Journal of the Minnesota State Medical AssobicHiQTY ( JANUARY, 1921 SEP 21 1922 ORIGINAL ARTICLES CHOLECYSTECTOMY WITH MODIFIED DRAINAGE* By CHARLES H. MAYO, M. D. A problem which frequently confronts the surgeon in operations for gallstones, and for cholecystitis, with or without stones, is whether to close, drain, or remove the gallbladder. In the eventful evolution of surgery during the last thirty years notable progress has been made in surgery of the gallbladder. Progress has been made of course in all surgery of the upper abdomen which in early years was practiced to conserve life; operations of necessity were the rule for obstruction, acute pain, and infection in advanced stages of disease. In the lower abdomen the surgery has been largely that of sacrifice in dealing with infection in organs of reproduction or with unessential structures such as the appendix. No. 1 year 1919 whe/24Apatients were operated on for cholelithiasts and cholecystitis, 714 (61 per cent) of whom had stones; the operative mortality was 2.2 per cent. Cholecystitis without stones with changes in the mucous membrane of the gallbladder caused papillomas, degenerative processes, and the so-called strawberry and fish-scale types in 490 patients (39 per cent). The operative mortality in these was 2.4 per cent. In 1886 Galippe first suggested bacteria as a causative factor in gallstones. Gilbert, in 1898, followed with practical demonstrations of infected gallbladders and stones, and in the same year Welch demonstrated bacteria in gallstones. Later investigators have found bacteria in the bile of the gallbladder and studied the infections with cholecystitis, even producing gallstone crystals in the mucous membrane. The routes of the infection ordinarily accepted were based on the theory that the bile primarily was infected; this could occur, first, through the portal circulation, the bacteria not having been destroyed in passing through the liver, second, through the lymphatic system by common and cystic ducts from the intestine. Operative indications in the upper abdomen. in the early period of antisepic surgery in retrograde movement, and, third, through the volved a high mortality, especially in diseases of the gallbladder. It was soon recognized that the danger lurked in the complications such as abscess of the liver, pancreatitis with fat necrosis, perforating gallbladder, and jaundice. Practically a vicious circle was developed by a late operation which resulted in high mortality, and the high mortality lead to dangerous delay. The gallstones which were essential to early operative procedures on the gallbladder, although often a cause of obstruction with secondary complications, lost their role as a primary entity in disease and cholecystitis became accepted as the primary condition. This is demonstrated by the Clinic records for the •Presented before the Minnesota State Medical Association, September, 1920, St. Paul, Minn. The opening of the gallduct, which also delivers the pancreatic secretion, is usually located beneath an over-hanging fold of mucous membrane in the duodenum and is thereby well protected. The little terminal opening is surrounded by the muscle ring of Oddi which keeps it closed and which should serve to equalize the tension of bile in the ducts and gallbladder as opposed to the hepatic circulation producing it. The sphincter of Oddi is stronger in animals that have gallbladders than in those without The gallbladder them, according to Mann." in health has a capacity for temporary storage of several ounces of bile, and rhythmic contractions stimulated by the contents of the gallbladder and ducts occur, causing such delivery 2875% |