The hepatic duct passes towards, and, descending obliquely, somewhat behind, the pancreas to the lower part of the duodenum. It is inserted, from behind, nearly five inches below the pylorus by a sinus, into which the pancreatic duct also empties itself. This opening is oblique; for the two ducts pass between the cellular coat of the intestine, and again between the nervous and villous coats, before they open into its cavity, and at last are guarded from emptying their contents too rapidly by a convolution of the villous coat. Thus the mixture of the bile is slow and interrupted; for as the duct runs at least an inch between the coats of the intestines, any fulness of the canal must prevent its entrance. At the same time, the convolution of the villous coat, where the duct at last penetrates, must equally hinder fluids from being forced into the duct from the canal.
Near the portae the hepatic duct receives, at a very acute angle, another from the gall bladder, which, for a little space, seemed to run almost parallel with it. This is called the cystic duct; and another from the liver sometimes joins it previous to its union with the hepatic duct. We may just remark in this place, for reasons which will soon appear, that rats, camels, stags, the elephant, the horse, the rhinoceros, the trichechus ma-nati, and the greater number of herbivorous animals, with the dolphin, and many of the cetaceous tribe, have no gall bladder. (Cuvier Lecons de lanatomie Com-paree, vol. iv. p. 35 and 36.) The idea, however, that the bile is conveyed from the liver to the gall bladder appears improbable, by the retrograde course which it must take to arrive at the latter. To add to the improbability, the cystic duct is smaller than the hepatic, and much smaller than the choledochus formed by the cystic and hepatic ducts. We observe, however, in the other mammalia, that the angle at which the ducts join is neither so acute nor so distant from the gall bladder as in man. In these also the fundus of the vesica is downward, which facilitates the passage of the bile. In many animals, small canals come immediately from the liver to different parts of the vesica, as in the ox, the sheep, the wolf, the dog, the hedgehog, and the hare (Cuvier, iv. 42); but in man no such canal apparently exists.
Experiments have not been wanting to elucidate this-intricate subject. When the common duct is obstructed, both the cystic and hepatic ducts are said to be equally distended: when tied, the result is the same. If the cystic duct be tied, it swells between the ligature and the hepatic duct. Notwithstanding the angle, the bile passes readily, on pressure, into the liver; and in living animals it is seen, when the gall bladder is opened, to distil from the cystic duct. When the cystic duct is tied or obstructed, the gall bladder is not filled, and seems to contain only a serous, or sometimes a mucous, fluid. The vesica biliaris, in its natural state, is not in contact by the stomach; but when this viscus is distended, its greater curvature presses with some force against the gall bladder, and expels its contents.
If we compare these facts, we shall find it highly probable that the vesica is a reservoir for the bile, to keep up a constant supply, when from any accident the exigencies of the system require a larger quantity than the liver can furnish. We have no reason to think that the whole of the bile is sent to the cyst, nor has it been presumed that it gains any different quality. From the necessary absorption, it must become more concentrated, and more bitter and viscid; perhaps more acrid.
We have engaged at a greater length in this question than we should have thought necessary, as in the moment of concluding this article we received the ninety-first number of the Medical and Physical Journal, published in the present month (September, 1806), in which we find Dr. Rush's opinions respecting the use of the liver, etc. He thinks, that, instead of contributing to animalize the fluids recently taken in, the blood requires this circuitous route and this new secretion, to separate the remaining chylous particles which it may contain. The gail bladder, he thinks, as we have already stated, is the reservoir of the superabundant bile, not at the time necessary for the process of digestion; but, he supposes also, that the bile in the gall bladder is farther changed by a putrefactive process, and thus gains its bitter taste In fact, according to this author,
"the gall bladder appears to be to the liver what the colon and rectum are to the stomach," the receptacle only of hepatic faeces. In cases of sickness, indigestion, or long fasting, he adds, in which the office of the stomach is suspended, the liver performs a vicarious duty; and when the functions of the liver are suspended, the stomach, with double anxiety, supplies its place. When the stomach is most busy, the liver is most idle; for the discharge of bile is, in his opinion, obstructed by the fulness of the stomach; and that it is only when the contents of this latter organ have passed the duodenum that the liver"pours its chyle into it." Yet we were before told that the liver was designed to animalize the fluids; and we are immediately afterwards informed, that the same pressure discharges the cystic bile, whose use is to separate the faecal matters from the chyle. It is singular that pressure should stop one fluid, and promote the discharge of another, when their orifices are the same. We have always declined engaging in controversy, and can now only add, that, on a careful consideration of the facts and arguments adduced by Dr. Rush, we do not find them applicable to this system, and, of course, they contribute nothing to its support. The facts and experiments which we have collected from different authors, in the present article, seem not to have occurred, to this respectable veteran in the moment of writing, and his system appears neither probable nor consistent.
We own, however, that the consideration of Dr Rush's system, and the facts which the examination has-now led us to review, suggest some doubts whether the bile may not acquire additional properties in the gall bladder. When we reflect that the gall bladder is wanting in herbivorous animals, that it is always found in carnivorous, that the gall of children is sweet, that the hepatic bile is comparatively, if not really, mild and sweet, we are led to suspect that the follicles of cyst may furnish the bitter resinous part of the bile, and that, of course, the gall bladder is a supplementary oxgall, a glandula succenturiata, subservient to the pro cess of digestion. It is sufficient to state the doubts, with a general view of the facts, which lead to them; but this is neither place nor have we room for more minute discussion. Yet we think we could support this idea from some of the phenomena of digestion, and from some, analogous phenomena in the animal machine.
The liver is the seat of various disorders, viz. inflammation, abscess, scirrhus, hydatids, etc. Sec Hepati tis; Icterus; Biliosa febris; Cholera morrus; hepatalgia; and in most of these the countenance is yellow, with a greenish cast. Besides those disorder.-generally known, Mr. Crawford mentions one, which he denominates an enlargement of the liver. (See his Essay on the Nature of a Disease incident to the Liver.) The principal signs of it are, a great and sudden swelling and hardness of the belly, with a difficulty of breathing; the only very troublesome symptom. Previous to these, a general weakness, a sense of tightness about the breast, and a giddiness of the head on the slightest motion, are perceived; then an oedematous swelling appears in the legs, with pains in the back, thirst, and loss of appetite; the pulse is small and weak, but on, bleeding it becomes more full and distinct; the countenance is florid; as the belly enlarges, the breathing is more difficult, and a sense of oppression is then felt about the praecordia; and a stricture about the cartilago ensiformis becomes almost insupportable, soon terminating in a complete suffocation. A violent vertigo and troublesome palpitation of the heart are occasionally observed. Some symptoms of this disorder resemble those of the scurvy; but the sore spongy gums attendant on scurvy are not observed in this complaint.
These symptoms show that an infarction of the liver has, at least, begun, and that it must be quickly obviated. With this view, bleeding, with a mild, nourishing, and somewhat generous diet, has been recommended, followed by active laxatives, with calomel. In a disease where we have no pretensions to experience, we ought not to blame; but unless the symptoms are violent, the bleeding may be, perhaps, dispensed with, or a small quantity only taken. The laxatives are undoubtedly necessary and proper. The formula recommended we add.
Aloes socotr. ss. rad. jalap, pulv. 3 i. ca-iomelan, sap. Venet. aa 3 ii. bals Locatel. q. s. ut £
.massa, ex cujus, singulis drachmis formentur pilulae N° xii.
The patient is greatly relieved, it is said, a few hours after bleeding; and by means of these pills, repeated at proper intervals, the complaints gradually abate, and the cure is generally completed in the space of nine or ten days.
People who return from warm climates are subject to an increased secretion of bile in the primae viae, attended with general languor, nausea, foul tongue, loss of appetite, indigestion, frequently diarrhoea, a yellow skin, with a very unhealthy aspect. Bath waters are in these cases of service, though the Cheltenham spring has lately become more fashionable.