The Liver and Gall Bladder . 201 



branches of which go to the clavicular and acromial re- 

 gions, it is altogether likely that the course of the reflex 

 path is through these nerves, i.e., from the phrenic nerve 

 to the third and fourth cervical, thence to the cutaneous 

 branches over the shoulder; when pain is felt down the 

 arm, it is transferred probably through the fifth nerve to 

 the brachial plexus. Pain in disease of the gall bladder 

 may be due to the same nervous relationship, while the 

 sense of weight or discomfort felt behind the scapula, in 

 disease of either liver or gall bladder, may be due to the 

 sympathetic system which forms the hepatic and cystic 

 plexuses and which communicates by means of the 

 splanchnics with the lower six intercostals whose posterior 

 cutaneous branches supply this region. In diseases of the 

 liver in which the circulation through it is disturbed as, 

 for instance, in cirrhosis, pylephlebitis, etc., symptoms 

 referable to interference with the blood current, such as 

 ascites, gastro-intestinal catarrh, piles, etc., do not present 

 themselves until the collateral circulation fails to provide 

 for the increasing pressure on the portal vein, and since 

 this collateral circulation takes such a prominent part in 

 prolonging the life of the patient it is certainly worthy of 

 examination. The principal veins that carry on the cir- 

 culation under these circumstances are : The remains of the 

 umbilical vein communicating with the paraumbilical and 

 the latter with the epigastric (superficial and deep), and 

 with the superior epigastric of the internal mammary ; the 

 rootlets of the branches of the portal, especially the veins 

 of the large intestine, communicating with the inferior 

 vena cava through the lumbar and phrenic veins ; the 

 superior hsemorrhoidal with the middle and inferior 

 haemorrhoidals of the internal iliac and the pudic ; the gas- 

 tric vein with the cesophageal branches of the vena azygos 

 minor ; lastly, veins of the cortex of the liver, especially of 



