I730 HUiMAN ANATOMY. 



during inspiration. If the 'cause of the enlargement is inflammatory and adhesive 

 peritonitis has resulted, the tumor may be fixed so that it does not move with res- 

 piration ; but there is then, especially in acute cases, apt to be pain and tender- 

 ness over the swelling or at a point between the ninth costal cartilage and the 

 umbilicus. 



It may be mentioned here that the diagnosis between the chronic form of gall- 

 bladder disease and movable kidney is not always easy ; that the two conditions not 

 infrequently coexist in the same person ; and that the possibility of error is increased 

 by the fact that they are each met with much oftener in women than in men, and 

 that the right kidney is far more frequently movable than the left. 



The anatomical explanation is that in women with flabby abdominal walls 

 either tight lacing or a relatively slight jar or strain tends to produce displacement of 

 both the kidney and the liver, the latter resulting in tension or angulation and con- 

 sequent obstruction of the bile-ducts. The two conditions also act reciprocally, 

 descent of the li\-er causing displacement of the kidney, which, through its traction 

 upon the duodenum, tends to obstruct the bile-ducts. 



A movable kidney, as compared with an enlarged gall-bladder, is less influenced 

 by respiration ; has a wider range of motion, especially in the long axis of the body ; 

 is more influenced by position ; slips backward towards the loin instead of upward 

 beneath the liver ; is less often visible and less frequently tender on pressure, which 

 is apt to cause a sickening sensation analogous to testicular nausea (page 1951). 



Acute cholecystitis (phlegmonous) is due to infection. The colon or typhoid 

 bacillus, or the pneumococcus. streptococcus, or staphylococcus, may reach the gall- 

 bladder either through the blood, as during a pneumonia, by lymphatic and vascular 

 channels, as after an appendicitis, or through the intestine and bile-ducts, as in some 

 of the post-typhoidal cases. 



The symptoms are (a) generalized abdominal pain, due to the association of 

 the cystic plexus, through the coeliac, with the superior mesenteric ; {b) pain below 

 the right costal margin passing towards the epigastrium, — i.e., referred to the coeliac 

 and solar plexuses, — and towards the right scapular region, from the association of 

 the phrenic and the supra-acromial nerves through the fourth cervical (page 1758) ; (c) 

 rigiditv over the right hypochondrium, due to the connection between the splanch- 

 nics and the intercostals ; {d ) nausea, vomiting, and prostration, due at first to the 

 close relation of the cystic plexus with the cceliac and solar plexuses, later to toxaemia 

 and to peritonitis ; (e) localized tenderness at the junction of the upper and middle 

 thirds of a line drawn from the ninth rib to the umbilicus, — i.e., over the fundus of 

 the inflamed gall-bladder; ( /) distention and paresis of the intestines, due sometimes 

 to a localized peritonitis affecting the hepatic flexure of the colon and simulating 

 an acute intestinal obstruction. 



Gangrene has occurred, emphasizing the clinical and pathological resemblance 

 of this condition to appendicitis, but is very rare, illustrating the importance of one 

 anatomical factor — the scanty blood-supply — in causing the gangrene which is so 

 exceedingly common in that disease (page 1682). Bacterial infection and absence of 

 drainage (and therefore tension) are two conditions predisposing to gangrene, 

 present in both cases ; but the third — thrombosis of the nutrient vessels — determines 

 the frequency of gangrene in the appendix, which is supplied by only one nutrient 

 artery, and is relatively ineffective in the case of the gall-bladder, which has a rich 

 blood-supply through the large cystic artery and also through the anastomoses of its 

 branches with the hepatic vessels where the gall-bladder is fixed to the liver (Mayo 

 Robson). 



Empyema of the gall-bladder (suppurative cholecystitis), due usually to chole- 

 lithiasis, obstructive catarrh, and infection through the ducts, may discharge itself in 

 various directions determined by the occurrence of inflammatory adhesions. The 

 most common communication is with the cutaneous surface, the pus having been 

 evacuated through the parietes beneath the costal margin in 50 per cent, of Cour- 

 voisier's 184 cases, and in the umbilical region, where it was conducted by the sus- 

 pensory ligament, in 29 per cent. The colon or duodenum beneath, the subphrenic 

 space or pleural cavity above, and the right prenephric peritoneal pouch — walled 

 off by adhesions — have been favorite seats for the spontaneous evacuation of pus 



