The Liver aud Gall Bladder. 205 



sence in, or their passage through the neck of the gall 

 bladder into the cystic duct. Should a stone block the 

 neck of the bladder or the cystic duct, the gall bladder 

 may become distended without the production of jaundice, 

 since it is merely a reservoir, whereas, when the stone 

 lodges in the common bile duct, in addition to pain and 

 fever, there' are symptoms of jaundice. Should the stone 

 pass, or should it become floated up by the bile collected in 

 the duct, or in the ampulla of Vater, the jaundice will sub- 

 side to recur in another attack. In the operation for gall 

 stones an incision may be made from a point below and ex- 

 ternal to the ensiform cartilage, parallel to the chondral 

 margin,or, from a point opposite the eighth cartilage, ver- 

 tically downwards to the level of the eleventh cartilage, 

 or, as Abbe advises, one along the outer border of the rec- 

 tus muscle, enlarging it, if necessary, by a cross cut 

 through the fibres of this muscle. When the gall bladder 

 is exposed the following operations may be performed, 

 but, inasmuch as the steps of these operations, belong to 

 the domain of Surgery proper, we will draw attention, 

 very briefly, to the operations : Cholecystotomy means 

 opening the gall bladder, and, after removal of the stones, 

 suturing the wound in its walls and then replacing it in 

 the abdomen ideal cholecystotomy ; or, leaving the 

 wound in the bladder open and suturing the edges of the 

 wound to the abdominal walls the usual operation. 

 Cholecystectomy consists in the removal of the gall blad- 

 der, after ligating the cystic duct and separating the peri- 

 toneum from the surfaces of the gall bladder. Choledo- 

 cotomy means an incision into the common bile duct to re- 

 move stone or tumor. Cholelithotrity is crushing the 

 stone in the cystic or common bile duct. Cholecystenteros- 

 tomy. In this an anastomosis is made between the gall 

 bladder and the large* or small intestine, by means, as a 

 rule, of the Murphy button. 



