Gallbladder

“ The small intestines should be appropriately washed before consumption.
10 Milk found on the gallbladder is prohibited by Torah law, and any milk found beneath it is prohibited by rabbinical decree.
11 To remove the milk from the gallbladder, one should squeeze it gently to find and remove the milk.
Note: One should take care not to break any of the three tubes attached to the bladder. If one breaks, it is necessary to extract it later.
12 The structure of the gallbladder involves two layers of fat. The upper layer is prohibited, and the fat and tubes attached to it are prohibited. ”

“ The right lobe is the larger, and is slightly notched on its outer free margin, to receive the well-developed gallbladder, which, though not mentioned in the text by Cuvier, is very imperfectly figured in one of the Plates; [2] when inflated, it is pyriform; in the empty condition, it assumes the outline of the liver (see Plate II, Fig. 3) . The biliary ducts open into the intestine, just where it is connected with the liver, by a common duct. ”

“ Biliary concretions, known as gall stones, are apt to form in the gall-bladder. They are composed of crystals of bile-fat, cholesterine. Sometimes in the course of a post-mortem examination a gall-bladder is found packed full of gall-stones which during life had caused no inconvenience and had given rise to no suspicion of their presence. In other cases gall-stones set up irritation in the gall-bladder which runs on to inflammation, and the gall-bladder being infected by septic germs from the intestine (bacilli coli) an abscess forms. ”

“ I must here mention, that jaundice does not necessarily follow upon absence of the gall-bladder; just as in the horse, the deer, the rat, and other animals that possess no gall-bladders, the biliary function is perfectly well carried on, so it may be in the human subject, labouring under a congenital or accidental deficiency of the gall-bladder. In such cases, the hepatic ducts are pervious, and consequently the secreted bile finds no difficulty in reaching the intestines. ”

“ Impaction of the bowel by gall-stones escaping from the gall-bladder into the bowel is by no means an unfrequent cause of fatal obstruction. Small gall-stones, after giving rise to intense pain and often grave symptoms during their passage through the bile-ducts, may escape into the duodenum and be discharged through the rectum, as any other small foreign body. If, however, there is constriction or stricture of the bowel at any point, the small gall-stone may lodge there, and if other stones follow and lodge, the collection may soon be great enough to produce obstruction. ”

“ Even death itself has resulted from the impaction of a gall-stone in the duodenum. When we have any suspicion that the stone is large, our treatment must therefore be continued until its extrusion by the mouth or rectum has been accomplished.
When the occlusion of the common bile-duct is caused by an organic tumour, no treatment of ours can be expected to remove the obstacle, and sooner or later the patient is carried to an untimely grave. Our efforts of relief in such a case ought therefore to be directed to another channel ”

“ Hepatic abscess may follow on an attack of amoebic dysentery, and is produced either by infection through the portal vein, or by direct infection from the adjacent colon. In general pyaemia multiple small abscesses may occur in the liver.
The Gall-Bladder.—The formation of biliary calculi in the gall-bladder is the chief point of interest here. At least 75% of such cases occur in women, especially in those who have borne children. Tight-lacing has been stated to act as an exciting cause, owing to the consequent retardation of the flow of bile. ”

“ In case of jaundice, the bile, which is perhaps not at all absorbed in a state of health, is taken up in large quantities, and mingled with the mass of blood, which proves a seasonable relief in the state of accumulation and distension occasioned by the obstruction. This may happen in cases of fever, not indeed as a relief to nature, but from a depraved state of irritability in the lymphatics, induced by disease. Though no increased quantity of bile, therefore, is found in the gall bladder, there may have been an increased excretion of it, a preternatural absorption having been excited. ”

“ If the stone happily finds its way into the intestine the distress suddenly ceases. In the meanwhile relief may be afforded by fomentations, and by morphia or chloroform, but if no prospect of the stone escaping into the intestine appears likely, the surgeon will be called upon to remove it by an incision through the gall-bladder, or the bile-duct, or through the intestine at the spot where it is trying to make its escape. Sometimes a gall-stone which has found its way into the intestine is large enough to block the bowel and give rise to intestinal obstruction which demands abdominal section. ”

“ Cholelithiasis, that is, stone in the bile duct, may not only cause severe pain, but may lead to rupture of the duct and a rapidly fatal termination. Owing to the practice of wearing corsets, gall-stones occur much more commonly in women than in men. Twenty-five per centum of all women over 60 years of age are found to have gall-stones. While these cases suffer from intense pain they are very seldom fatal. But it must not be forgotten that a fatal issue can take place either from collapse and stoppage of the heart, because of the intensity of the pain, or from perforative peritonitis. ”

“ In women gall-stone disease is more frequent than in men. This depends upon the greater frequency of diseases of the thyroid and sexual glands in women. Changes in the sexual organs produce an irritation of the splanchnic with checking of the peristaltic movements of the intestine and, at the same time, relaxation of the muscular coat of the bile-ducts. Thus there arises a deficient expression of bile, and stagnation follows, with invariable immigration of bacilli producing inflammation and precipitation of cholesterin and gall-stones. ”

“ The Gall-bladder may be ruptured by external violence, and if bile escapes from the rent in considerable quantities peritonitis will be set up, whether the bile contains septic germs or not. If, on opening the abdomen to find out what serious effects some severe injury has caused, the gall-bladder be found torn, the rent may be sewn up, or, if thought better, the gall-bladder may be removed. ”

“ When once a gall-stone has formed, and is blocking up the common bile-duct, thereby causing jaundice from obstruction, it is easy enough to understand why a substance like podophyllin, which increases the biliary secretion, is to be avoided. It is not, however, so easy to understand why the remedy is equally counter-indicated, either during the formation or sojourn of a gall-stone in the gall-bladder. ”

“ How often, among the symptoms of that disease, do we see it ourselves, and find it confirmed by others, that the bile is unnatural, either in quantity or quality? Green bile is often found in the gall bladder and ducts, and the action of a brisk purgative, especially of calomel, will often dislodge morbid secretions from the liver, and from the bowels, and the consequence of such free evacuations, is seen in the restoration of the healthy functions of the liver, and along with it a frequent disappearance of that formidable array of symptoms which so closely simulate hydrocephalus. ”

“ In jaundice from suppression the liver does not secrete bile; consequently no bile-acids being formed, none can enter the circulation, and they are therefore not to be detected in the urine. In jaundice from obstruction, on the other hand, bile is secreted, and absorbed into the blood; and the bile-acids not being all transformed in the circulation, as Frerichs supposed, are eliminated by the kidneys, and appear in the urine, where they can be detected by Hoppe's method, or even, with proper precautions, by simply adding sulphuric acid and sugar. ”

“ The whole duration of the disease was merely six days, and the more urgent symptoms only manifested themselves two days before the fatal termination.
After death the liver was found to be very small in size, not exceeding, as was supposed, 11⁄2 pound in weight. It was deeply stained yellow, and its cells were found to be small, and broken up; not an entire cell could be detected by either Dr. Wilks or myself—nothing, indeed, but a quantity of débris of hepatic tissue, and fat. The gall-bladder was contracted, and contained only a little mucus; the urinary-bladder was empty. ”

“ It is generally a tedious and chronic disease, and may continue many years; often thro’ life. It is seldom immediately dangerous, unless, as in nephritis, inflammation is kindled, or during pregnancy. When chronic and inveterate, it may terminate in jaundice, cachexy, dropsy. The symptoms of calculi in the gall-bladder are obscure; such as weight, uneasiness, dull heavy pain at intervals, sometimes temporary jaundice, cachexy, and diseases of the stomach. The causes, hereditary, viscid, tenacious bile, sedentary life, depressing passions, spirituous liquors ”

“ If the spleen become affected with any disorder, so that it cannot separate the black bile from the blood, such diseases as leprosy, insanity, inflammation of the spleen and remittent fever are the consequence. If any derangement happen to the gall-bladder so that it cannot secrete the bile, bilious disorders follow. If the kidneys get disordered, so that they cannot abstract the water from the blood, dropsy and similar diseases are the result. It all depends, however, on the will of God. In the same manner, all the organs of the body have a specific function. ”

“ Jaundice may also exist during the presence of simple constipation, hepatitis, biliary calculi, abscesses, hardening of the liver, etc.
Treatment.—When jaundice exists we must endeavor to rid the system of the excess of bile, and this is best accomplished by giving purgatives that act upon the liver. Calomel, 2 drams, with aloes, 7 drams, should be given. Glauber's salt in handful doses once or twice a day for a week is also effective. May apple, rhubarb, castor oil, and other cathartics that act upon the first or small bowels may be selected. ”

“ The patient dies of dropsy but not of "liver complaint."
Some people act as if they thought bile were a poison. On the contrary, it is a very useful digestant; it aids in keeping down the number of harmful bacteria and helps to carry the food from intestines to blood. Every day the liver manufactures at least a pint of this important fluid. The body uses what it needs and stores the surplus for reserve in the gall-bladder. The flow is continuous and, despite all appearances to the contrary, there is no such thing as a torpid or an over-active liver. ”

“ A gentleman, aged fifty, who had been a remarkably healthy man, observed, within eighteen months of his death, that his skin gradually assumed a more and more jaundiced tint without any assignable cause. The stools were clay-coloured, the urine loaded with bile pigment. Soon afterwards, the patient began to lose flesh. The liver became enlarged, and somewhat tender to the touch; the gall-bladder being at the same time so distended that it could be seen, as well as felt, projecting from under the false ribs. ”

“ The affection is not accompanied with any constant lesion. Pascal21 made post-mortem examinations in six cases and found the mucous membrane of the duodenum a little reddened: the gall-bladder contained thick bile, and in a few cases there was congestion of the sympathetic ganglia. The attack is usually marked by certain prodromic symptoms. The patient complains of malaise, loss of appetite, a load in the epigastrium, embarras gastrique, dull pains in the colon, borborygmi, and cramps or tingling in the limbs. For the first few days the bowels generally move several times daily. ”

“ Wounds of the gall-bladder are, as far as is known, fatal—the effusion of bile which immediately takes place giving rise to inflammation which, with other causes, destroys the sufferer at the end of a few days. ”

“ Though both liver and gall-bladder must be very much affected in this disease, yet Dr. Moseley is of opinion that nothing can be depended upon from an inspection of them after death. Some symptoms there are in common with inflammations of the liver, but none of those which distinguish it from other diseases. It never terminates in suppuration of the liver as the hepatitis sometimes does, though it is frequently carried off by an enormous secretion of bile. ”

“ If the main hepatic duct or the common duct were obstructed, there would of course be paleness of the feces, as the bile would be prevented from entering the duodenum. But when a large amount of highly-colored bile is being secreted, as in relapsing fever, it seems clear that the obstruction of a certain number of minute ducts would cause sufficient resorption of the bile to induce jaundice of varying degrees of intensity, while at the same time allowing a flow of bile through the patulous ducts. ”

“ THO’ it is now pretty well known, that colicky and icteric diseases often arise from gall-stones generated in the bilious receptacle, and obstructing its canals; yet an example of one, of such enormous size, voided into the duodenum from the ductus communis, as happened in the first of the following cases, is a very rare, if not intirely an unexampled occurrence. It will encourage us not too easily to despair of the expulsion of the largest calculi from the gall-bladder ”