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mon duct in the absence of infection of the liver, and especially in the presence of serious organic disease of other organs, operation should not be entertained.

The technic of operation, of course, depends in great measure upon the lesion present. There has, however, been some discussion among surgeons recently as to the choice of operation in gallbladder lesions when the wall of the organ is considerably diseased. Whether it is better to remove the gallbladder (cholecystectomy) or to open it and depend on drainage for a cure (cholecystostomy) has been the question at issue. If ulceration, stricture, or adhesions threaten the future patency of the common duct, removal of the ballbladder renders a subsequent cholecystenterostomy of course impossible, and the operator is forced to make an external fistula or anastomose the duct to the bowel. In the absence of the gallbladder, the fistula requires extensive gauze packing, and choledochoduodenostomy is difficult, if not in most instances impossible to perform safely.

It should also be borne in mind, that when prolonged drainage of infected bile is desired, it is better to retain the gallbladder, as the other alternative, direct tubage of the common duct, is more hazardous. In my own practice I never perform cholecystectomy when I intend draining the liver ducts, unless the gallbladder is greatly thickened, distended, shrunken, filled with stones, perhaps pus, and entirely functionless. I never perform cholecystectomy in a comparatively normal gallbladder, and frequently in those which are extensively diseased a partial cholecystectomy with drainage has been followed by healing. When acute pancreatitis is complicated by the presence of gallstones, the pancreas is freely incised and drainage of the lesser sac provided for if necessary. The removal of the calculi must then be undertaken. When the stone occupies the common duct, especially in its course beneath the head of the pancreas, the greatest ingenuity and operative skill are often required to prevent a fatal catastrophe from a subsequent peritonitis by leaking, infected bile. A choledochotomy may be performed if the stone cannot be dislodged or the

duodenum opened and the papilla split up, depending upon the exigencies of the case.

In chronic pancreatitis the biliary calculi must also be removed and temporary or permanent drainage of the bile provided for. The method of making the fistula has caused considerable discussion, most surgeons preferring the external opening, or cholecystostomy. The great advantage of the latter fistula is the ability to keep the drainage constantly under observation. It has been urged that the closure of such a fistula is often difficult but I find from my experience, that the nonclosure is always due to the continued existence of an obstruction, either persistent enlargement of the pancreas, a stone, or a stricture, or from faulty technic in establishing the fistula. If the fistula closes after performing cholecystenterostomy or cholecystgastrostomy, which I strongly condemn, the liver may become damaged by the infected bile, jaundice supervene, and a dangerous reoperation become necessary.

When the stone is located as being in the ampulla, and cannot be carried back into the common duct, it is best to open the duodenum and slit up the papilla. If the calculus is somewhat to the proximal side of the ampulla of Vater, and cannot be reached by slitting the latter, nor carried up into the duct, a choledochotomy must be performed, after dividing the peritoneum to the outer side of the duodenum and lifting the latter upward. The wound in the duct may be closed by suture, but it is my practice to drain all of these

With a higher position of the stone, the duct is usually dilated, and the calculus can be pushed up to the cystic duct, and by a choledochotomy removed, and, if not able to carry the stone into the proximal portion of the common duct, the duct may be opened at the site of the stone. In all cases in which an infectious cholangitis is present in addition to the pancreatitis, the liver should be drained by means of a rubber tube introduced into the gallbladder, common, or the hepatic duct. It is my practice to drain all cases when I have occasion to open the common duct.

Pancreatitis without stone is frequently, completely relieved by a simple cholecystostomy which, by diverting a

cases.

large amount of bile from the ampulla of Vater, allows better opportunities for the drainage of the pancreatic secretion.

Chronic pancreatitis with glycosuria and without obstruction of the biliary apparatus may be relieved, to a great extent, by a cholecystostomy, but theoretically an operation offers no hope of cure, as the diseased “islands” are not dependent upon any lesion ascending through the ducts.

Adhesions require careful dissection to effect their safe breaking up. They may be divided between hemostatic forceps, any bleeding points being, of course, secured. When adhesions are extensive and attached to the stomach, particularly the pylorus, and there is resulting traction on the pylorus and dilation of the stomach, it may be more propitious not to make an attempt to deal with the adhesions, but at once to do a posterior gastroenterostomy. If the pyloric orifice is also the site of an infiltration and thereby contracted, in a certain percentage of cases, pyloroplasty is performed in connection with posterior gastroenterostomy.

In dealing with fistulas between the biliary tract and the various organs, fixed and fast rules cannot be laid down, as the surgeon must use his judgment, taking advantage of his experience in dealing with like cases in the past. In some cases I separate the connection between the organs and close the openings separately, while in others I allow them to remain intact, especially when it is possible to deal with the actual lesion without forcing a separation to gain access to the site of lesion.

In performing cholecystectomy one should remember that the gallbladder and the cystic duct hold the same relation to the common duct as do the cecum and the anterior longitudinal muscular band to the appendix. Traction upon the former makes evident the common duct in the right free border of the gastrohepatic omentum, as does traction upon the cecum and the anterior longitudinal muscular band make evident the base of the appendix.

When the gallbladder can be dissected free from the liver, commencing the dissection at the fundus and carrying it toward the cystic duct, and when the integrity of the gallbladder will permit of traction, the outline of the cystic duct,

the common duct, and the cystic artery is very beautifully demonstrated and made easy to deal with. When feasible, we should allow that portion of the serous coat of the gallbladder adherent to the under surface of the liver to remain intact, in this wise preventing oozing from the torn liver substance, which may be difficult to control with sutures. The cystic duct and the cystic artery are carefully tied so that there will be no leakage from the former or hemorrhage from the latter. It is better to tie the cystic duct with catgut.

Cholecystostomy is performed by aspirating the gallbladder, incising, and removing any stones or concretions. A rubber drainage-tube is introduced for a distance of about 1.5 cm., and fastened by a catgut suture to the edges of the gallbladder wound. The latter are then invaginated inward and a pursestring Lembert suture introduced, holding the rubber tube firmly in position. Gauze drainage is introduced to the subhepatic space beneath the gallbladder, and to the site of the opening in the gallbladder, guarding the intestinal side with rubber tissue.

It would be interesting to discuss the postoperative treatment of the conditions referred to in this paper were it not for the amount of time it would consume.

BIBLIOGRAPHY. Welch and Blackstein: Johns Hopkins Hosp. Bull., Vol. xi, p. 121, 1891. 'Cushing : Ibid, Vol. ix, p. 91, 1898. 8Opie : Diseases of the Pancreas, 1903.

*Cases 1 and 2, Deaver, Amer. Jour. Med. Sc., February, 1903. Case 3, Deaver and Muller, International Clinics, Vol. ii thirteenth series.

Case 4, Deaver and Muller, American Medicine, March 19, 1904.

"Starling : Trans. Path. Soc. of London, 1903, p. 253,
"Legg: St. Bartholomew's Hospital Reports, 1873, Vol. ix.
*Ford : Am. Jour. Med. Sc., January, 1901, p. 79.
Weber : Trans, London Path. Society, 1903, p. 121.
'Weber : Trans. London Path. Soc., 1903, p. 103.

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