268 BILIARY FISTULA. [BOOK II. 



ing been kept without food for 24 hours preceding the opera- 

 tion, and having been deeply narcotised, first by means of morphia 

 and then of chloroform, an incision about two inches in length is 

 made through the abdominal wall in the lined alba, commencing 

 at the xyphoid cartilage. The gall-bladder, which is distended with 

 bile in the fasting animal, is brought into view and, with little 

 difficulty, the cystic is traced to the common bile-duct (ductus 

 communis choledochus). The latter runs by the side of the portal 

 vein and the hepatic artery. By means of a blunt aneurism needle, 

 the common bile-duct is separated and a ligature applied, in the 

 first instance, as near as possible to the junction of the cystic with 

 the hepatic duct. The duct is then followed down and a second 

 ligature applied as close as possible to the duodenum. The portion 

 of the duct intervening between the two ligatures is cut out, with 

 the object of preventing the re-establishment of the duct, an event 

 which is otherwise very apt to occur, especially if any temporary 

 hindrance to the outward flow of bile should arise. 



This, the first and easier, part of the operation having been 

 completed, the apex of the gall-bladder is seized, by means of artery 

 forceps, and drawn to the upper end of the incision in the abdominal 

 wall. Two sutures are then introduced, one at either side, very close 

 to the apex of the gall-bladder, and these are fixed, one on one side 

 and one on the other, to the upper end of the incision. The lower 

 part of the latter is brought together lege artis by sutures, and then 

 the very apex of the gall-bladder is incised by means of scissors. 

 Having applied additional sutures so as to unite firmly the muscular 

 and cutaneous edges of the incision except at the point where the 

 gall-bladder is secured, the animal is left for a few days. The appli- 

 cation of a shield (fitted to the animal before the operation), partly 

 made of guttapercha and partly of metal, and which admits of 

 being strapped across the animal's back, is of great assistance in the 

 after treatment. 



If the operation has been performed, as should invariably be the 

 case, with the strictest antiseptic precautions, the animal usually 

 recovers. It is, however, only in comparatively rare cases that a 

 cannula can be so adjusted as to collect the whole of the bile secreted. 



In cases where the apex of the gall-bladder admits of being 

 brought well in contact with the abdominal wall, a cannula of the 

 pattern of the one usually employed for gastric fistulaB (see p. 74) 

 but of much smaller size, may be introduced and retained. When 

 such is the case the free end of the cannula may be closed by an 

 indiarubber stopper, perforated by a glass tube, to which is attached 

 an indiarubber tube leading to a bag of the same material in which 

 the secretion is collected. 



SchiffVam- If a large fistulous aperture be established between 

 pWboiic' fistu- the surface of the abdomen and the gall-bladder, with- 

 lse - out the common bile-duct being ligatured, the bile 



