GALL STONES. 413 



and down movements. This is owing to the fact that the stalk of 

 the gall bladder is closely connected to the liver by its duct, and 

 also that, except in rare cases where a mesentery to the gall 

 bladder exists, the upper surface of the gall bladder is closely 

 attached by connective tissue to the fossa of the liver in which it 

 lies. Owing to the restraint exercised by its attachments to the 

 liver a greatly distended gall bladder may assume a forward 

 curve, and then its shape has been likened to a cucumber. The 

 transverse colon or even coils of small intestine may ride up over 

 the fundus of the gall bladder and lie between it and the liver. 

 In such cases, a resonant area may separate the fundus from 

 the liver dulness. Inflation of the stomach tends to carry the 

 enlarged gall bladder upwards and to the right, owing to the 

 pressure exerted on it by the pylorus and first part of the 

 duodenum, whilst inflation of the colon usually displaces it 

 upwards. 



The nerves of the gall bladder are derived from the eighth 

 and ninth dorsal segments of the cord, through the great 

 splanchnic nerve and the cceliac plexus. When the gall bladder 

 is inflamed, superficial tenderness may be present over an area 

 corresponding closely to the fundus, and another in the right 

 subscapular region at the level of the eleventh dorsal spine ; 

 the former is the site of maximum tenderness of the ninth 

 segmental area, the latter is situated in the eighth dorsal 

 segmental field. These tender areas are often met with in cases 

 of gall stones. (Figs. 20-23, p. 226.) 



Large gall stones may pass direct from the gall bladder into 

 the bowel by a process of adhesion and ulceration. Since the 

 under surface of the gall bladder lies in direct contact with the 

 duodenum and the transverse colon, it is into one of these that 

 the stone is likely to be discharged. Occasionally it makes its way 

 into the neighbouring pylorus. The fundus of the gall bladder 

 being directly applied to the anterior abdominal wall may become 

 adherent to it, and ulcerate into its deepest layer. The purulent 

 contents may then be extravasated into the connective tissue 

 which ensheaths the round ligament of the liver and point in 



