[Written for the MEDICAL BRIEF.] Observations Concerning the Anatomy and Physiology of the

Gall Bladder and Ducts.

BY M. R. BARKER, M. S., M. D., Chicago, Ill.

Preliminary to the discussion of some of the surgical diseases of the gall bladder and ducts, and the surgical procedures adapted thereto, and for the purpose of elucidation, it seems wise to study, briefly, the anatomy, anatomical relations and physiology of these organs as they exist in the living organism. We are especially interested in the structure of the gall bladder and cystic duct, as from this we may draw some conclusions as to their functions. The gall bladder, in its structure, holds an anomalous position among the hollow viscera, having no distinct muscular coat, while the arrangement of the mucous membrane of the cystic duct is different from that of any other duct in the body. The frame of the gall bladder wall, to which the other structures entering into it are attached, is a fibro-muscular membrane, of which the fibrous tissues enormously predominate, the muscular fibers being sparsely distributed in the fibrous tissues, the greater number of which are distributed longitudinally, while a few are transversely placed. Spread over the outIside of this fibro-muscular membrane is the peritoneum, which covers all of the fundus, and all of the body and neck of the gall bladder, excepting a small portion, which lies next to the liver, the peritoneum being reflected from the body and neck of the gall bladder onto the liver on each side, forming the meso-cholocystis, which performs the same functions for the gall bladder that the meso-colon performs for the colon, among which it holds it in place. On the inside of this fibro-muscular membrane is spread the mucous membrane which, by continuity of tissue, is connected with the mucous membrane of the gall ducts and intestinal tract. mucous membrane of the fundus and body is arranged in rugæ, or ridges, with valleys between, while in the neck and cystic duct it is arranged in concentric folds in such a way that a fold fits in the valley between two other folds, thus forming a valve. In

The

the cystic duct there is a series of from eight to ten of these valves. These folds, or valves, are known as the folds of Heister, and guard the inlet and outlet to the gall bladder. These folds are so closefitting that it is with difficulty that a probe can be passed through the normal cystic duct. Some claim that it can not be done. The cystic duct, with the two hepatic ducts, form the common duct, which opens into the descending duodenum through an orifice on the summit of the papilla. This papilla is a valve-like contrivance which guards the mouth of the common duct, and through which the bile flows into the intestine. This apparatus is normally attached to other organs, as follows: The gall bladder is attached to the under side of the right lobe of the liver by the meso-cholocystis, and is connected with the common duct by the cystic duct, which passes slightly obliquely from right to left to its junction with the common duct, and is about an inch and a half long. The common duct is attached to the liver by the hepatic ducts, at its upper end, and to the descending portion of the duodenum at its lower end. It is about three inches long and passes almost directly downwards from its beginning to its termination.

The normal relations of the gall bladder and ducts, to other organs in the living subject, constantly change. In other words, the gall bladder may have certain definite relations to the pylorus one moment, while the next moment these relations will be changed, due to the normal and nearly constant movements of both pylorus and liver, to which the gall bladder is attached. This may be said of nearly all the organs that are located in the neighborhood of the gall bladder. They are all, except the head of the pancreas, constantly changing their positions, and the organ that is in the closest relation to the gall bladder one moment, may be farthest removed the next. Nevertheless, the gall bladder and ducts have a certain relation to other organs. The liver is anterior, or above the gall bladder, and as the two are attached to each other, their relations do not normally change; but as the liver moves with normal respirations, the relations of the gall bladder to other organs changes somewhat by reason of

former to the latter. The blood supply of the gall bladder is the cystic artery, which divides into two branches at the neck of the gall bladder. One of these passes along the border of the gall bladder, next to the liver, between the folds of the mesocholocystis, while the other branch passes along the free border of the gall bladder.

The lymphatics of the gall bladder form a very remarkable plexus about it. The whole of the organ is wrapped by these vessels, besides which a chain of them passes on either side of it, all anastomosing freely. Those on the right side enter the lumbar glands, those on the left enter the glands on the lesser curvature of the stomach, and the esophageal glands, while those that surround the gall bladder pass to the glands in the gastro-hepatic omentum. The principal nerve supply of these organs is the hepatic plexus of the sympathetic.

Having thus briefly discussed the anatomy, and some of the anatomical relations of the gall bladder and ducts in health, we may here, with propriety, and briefly, discuss their physiology, realizing that we are now entering upon a subject about which there has been much speculating and theorizing, but out of which there has emanated little bearing the evidences of truth. It is an old and familiar teaching, that the gall bladder is a reservoir for bile. To the thoughtful, nothing is more erroneous. The normal human liver excretes from thirty to sixty ounces of bile daily. The normal gall bladder holds about an ounce. How long would this reservoir of an ounce meet the demands of the system for bile, if the liver supply should be shut off? We understand that a reservoir is a place where a liquid is stored, from which supply there may be drawn sufficient to take the place of the regular supply of that liquid should it fail. Clearly, Nature would not supply a reservoir holding only an ounce from which to draw in case of emergency a secretion which is so essential to the system that from thirty to sixty ounces of it are required daily. While this theory is old, and widely accepted, it is so far from true that it is not even plausible. Dr. Murphy has advanced the theory that the function of the gall bladder is to regulate the tension in the biliary passages, the same as an air cham

ber regulates the tension in the pipes of a steam pump. On the face of this it seems more plausible than the reservoir theory, yet closer thought must condemn this also. If this theory be true, the eight or ten valves, which close the cystic duct, must yield when a certain amount of hydrostatic pressure is present in the common duct, and the bile flow into the gall bladder. The outlet of the common duct, into the duodenum, is guarded by a single valve in the papilla. The cystic duct is provided with eight or ten valves, each one of which is as potent, so far as we know, as the valve in the papilla. Is it

Tig. 2

not a reasonable conclusion that long before sufficient hydrostatic pressure had developed in the common duct to open the ten valves in the cystic duct, the bile would have been forced into the duodenum and all tension relieved? We do not believe sufficient hydrostatic pressure could be developed in the common duct to open a normal cystic duct. It is well known that air can be forced through the cystic duct under an anesthetic, but it requires a considerable pressure to do it. It is also well known that a normal gall bladder can be emptied under an anesthetic by squeezing it with the hand, but it requires a good deal of pressure to do it; much more, I am sure, than all the hydrostatic

pressure that could be produced in the common duct.

We believe the folds of Heister are for the purpose of preventing just what Murphy believes happens, viz., the opening the cystic duct by hydrostatic pressu the common duct.

the manifold needs of the system, or from external impressions. The mucous membrane of the gall bladder secretes a certain substance. Let us now suppose this sub

Dace Sary for the perfect opera

tion of the The need of the system, then, for this substance, or the lack of

Let us reason from analogy. The action of a certain kind of vitiated blood upon the centers for respiration, causes dyspnea. In other words, a certain abnormality of the system so changes the blood that it causes an abnormal stimulus to the respiratory centers and this, in turn, causes dyspnea. We cite this phenomenon to illustrate what we wish to elucidate. We believe every physiological and psychological phenomenon is controlled by nerve stimulæ acting upon nerve centers. These stimulæ are, or result from,

this substance in the system modifies the blood in such a way that it acts upon these nerve centers in a similar manner that the vitiated blood acts upon the respiratory centers. By reason of this stimulus, however conveyed, the nerve centers controlling the folds of Heister act, causing these folds, or valves, to relax. Now, the bile, possibly by reason of hydrostatic pressure in the common duct, flows into the gall bladder, and is mixed with its secretion. When this is accomplished, the mixture of bile and secretion serves as a

nerve stimulus, which acts upon the nerve centers that control the contractile power of the gall bladder, and its contents are forced through the open cystic duct into the common duct and thence into the general system. The need of the system

Fig. 4

а

folds must be opened in some other way. We understand that the secretion of the gall bladder is not necessary to the life of the general system, neither does the system seem to be impaired when it is removed, but we can not say that it is not in some degree impaired. Surgeons do not, as a rule, remove the gall bladder until long after it has been functionally removed by disease; and the evidence of such a patient that he feels as well as when he possessed a normal gall bladder may not be reliable, as he may not know just how he felt when he possessed a normal gall bladder. Just why the secretion of the gall bladder is mixed with bile before it is introduced into the system, and why this secretion is introduced into the system periodically, instead of continuously, is not known. There is a good reason for it, however, and some day, when we know more, we will find this out. We do not assume, in this paper, to give the exact modus operandi of the gall bladder and ducts, but we believe their operation is carried on in some such manner as we have suggested, and that the normal secretion of the gall bladder, while not essential to the life of the system, is essential for the perfect operation of it.

a. Folds of Heister. b. Gall bladder. now being satisfied, for the time, the folds of Heister close and the cycle is at an end, only to be repeated when the system again demands the secretion of the gall bladder. From our study of the anatomy of the gall bladder, we know that its contractile pow. ers are very feeble and totally inadequate to force the folds of Heister; hence these

4625 Greenwood Avenue.

[Written for the MEDICAL BRIEF.] Epilepsy.

BY A. NOXON, M. D., Toronto, Canada.

Agnes K., age fifteen, has been subject to epilepsy for the last six years. Had convulsions in infancy, when teething. Had good health until six years ago when, one day, she became very much excited, which was followed by an attack of epilepsy, since which time she has had attacks quite frequently, at times three in a single day, and then again would be free for several days. General health in every respect good. Attacks occur mostly during the day. The usual treatment has been followed without any appreciable benefit. I hope the BRIEF family, with their varied experiences in such cases, will be able to give me a line of treatment that will prove a success in the case of this poor girl.

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