PRACTICAL CONSIDERATIONS : THE GALL-BLADDER. 1729 



other operations, by traversing either the peritoneal or the pleural cavity. In 

 doubtful cases, or when there is an anterior swelling, a vertical incision in the mid- 

 line through the right rectus or at its outer edge, beginning at the costal margin 

 and prolonged downward, will permit of exposure of the liver and evacuation of the 

 abscess or cyst, the peritoneal cavity being walled off by gauze packing. If the 

 liver is approached above the lower ribs or posteriorly, it will be necessary to resect 

 a portion of one or more ribs, suture the diaphragmatic and parietal pleurae 

 together or to the thoracic wound, and then incise the diaphragm. If the liver is to 

 be reached laterally, i.e. , in the right axillary line, resection of the tenth rib will 

 disclose the diaphragm with no intermediate layer of pleura. Penetration of the 

 diaphragm opens the peritoneal cavity and permits access to the lower and outer 

 portion of the right lobe. 



Cancer of the liver is usually secondary (to metastasis through the portal 

 system), multiple, and diffuse. When primary and consisting of a single nodule, 

 excision may be attempted. In controlling hemorrhage, the friability of the liver- 

 substance makes ligation of separate vessels difficult, and it may be necessary to 

 employ an elastic tourniquet, the cautery, gauze pressure, or all three. 



Lymphatic involvement secondary to hepatic cancer may be found in the 

 cesophageal, mediastinal, lumbar, or omental glands. 



The relation to the cesophageal lymphatics is also shown by a case in which 

 hepatic abscess followed a mediastinal cesophagotomy. 



The Gall-Bladder. This sac may be absent, as is normally the case in some 

 of the lower animals ; it may be congenitally of hour-glass shape ; it may be bifid ; it 

 may communicate directly with the liver by a " hepato-cystic' ' duct ; it may be 

 transposed (in conjunction with other viscera), and in one such case cholecystostomy 

 for gall-stones was performed on a gall-bladder lying on the left side. 



Wounds of the gall-bladder are rare. 



Rupture of the gall-bladder may occur from traumatism to the abdominal pari- 

 etes ; it is favored by distention of the viscus and by enlargement of the liver, both 

 of which carry the gall-bladder downward to a less protected position and favor the 

 direct transmission of the force. Extravasation of bile into the general peritoneal 

 cavity follows. It may be sterile, and may then act merely as an irritant, causing an 

 extensive plastic exudate, but is apt to be fatal by setting up septic peritonitis. 



If operation discloses such a rupture, it may be remembered (i) that the 

 extravasated bile first flows into the large peritoneal pouch bounded above by the 

 right lobe of the liver, below by the ascending layer of the transverse mesocolon 

 covering the duodenum internally, externally by the peritoneum lining the parietes 

 down to the crest of the ilium, posteriorly by the ascending mesocolon covering 

 the kidney, and internally by the peritoneum covering the spine ; (2) that this 

 pouch can be easily and thoroughly drained through a lumbar incision ; and (3) 

 that it is capable of holding nearly a pint of fluid before it overflows into the 

 general peritoneal cavity through the foramen of Winslow or over the pelvic brim 

 (Morison). 



Distention of the gall-bladder is ordinarily due to ( i ) inflammatory obstruction 

 of the cystic duct (cholangitis) ; (2) mechanical obstruction of the cystic duct, usu- 

 ally from the impaction of gall-stones ; (3) acute cholecystitis, (a) catarrhal, () 

 suppurative ; or (4) obstruction of the common duct from tumor or, much more 

 rarely, from impaction of a calculus in that duct before the gall-bladder has become 

 inflamed, contracted, and formed adhesions. The gall-bladder itself may be the 

 primary seat of a malignant growth. It is impossible to feel the normal gall-bladder 

 through the abdominal wall. 



Enlargement of the gall-bladder from any cause usually takes place in a down- 

 ward and forward direction on a line which, beginning a little below the ninth costal 

 cartilage, crosses the linea alba just below the umbilicus. If the liver is of normal 

 size, the neck of the gall-bladder is about opposite the ninth costal cartilage. If the 

 liver is enlarged, the gall-bladder will be so much depressed that its neck may be on 

 a level with, or even lower than, the umbilicus. The rounded, pear-shaped, or 

 gourd-like fundus can usually be felt, movable laterally, and sometimes with a pal- 

 pable groove between it and the lower edge of the liver. The swelling descends 



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