1726 HUMAN ANATOMY. 



eighteenth of the entire body weight. The left lobe reaches across the stomach so 

 as to be in contact with the spleen. The tubercle at the lower extremity of the 

 Spigelian lobe and the caudate lobe are relatively large. In the infant there is little 

 connective tissue in the organ, which is very friable and also easily moulded on the 

 surrounding structures. At birth the weight of the liver is about i50gm. (5 oz. ). 



PRACTICAL CONSIDERATIONS : THE LIVER, GALL-BLADDER, 



AND BILIARY PASSAGES. 



The Liver. — Anomalies in the position of the liver occasionally occur, as in 

 " transposition," when the whole organ may be on the left side ; in such cases the 

 spleen and other asymmetrical abdominal viscera (and frequently, but not neces- 

 sarily, the thoracic organs) will also be found to be transposed. "Accessory" lobes 

 are not uncommon and have been mistaken for new growths. 



The shape of the liver may obviously be affected by compression exerted 

 through the parietes. The chief type of the so-called "lacing" or "corset" liver 

 is marked by a transverse groove separating the main body of the organ from a pro- 

 longation downward of the anterior portion, especially of the right lobe, which may 

 reach to below the umbilical level. This portion has been mistaken for a movable 

 right kidney. Knuckles of intestine may lie betweeri it and the anterior abdominal 

 parietes and prevent the recognition of its continuity with the liver by either palpa- 

 tion or percussion. 



•Movable liver (^hepatoptosis) is a condition in which, through stretching of the 

 tissues and structures which normally retain it in place beneath the arch of the dia- 

 phragm, it sinks by gravity to a lower level. It has then been mistaken for various 

 forms of abdominal or renal tumor and for movable kidney. Hepatoptosis is often 

 associated with displaceiiients or abnormal mobility of other abdominal viscera. 

 Traction of the liver on the suspensory ligament is said to produce a fold of skin 

 which hides the lower part of the umbilicus (Glenard). 



The structures most potent in holding it in its proper position are, in the order 

 of their importance : (a) the attachment of the hepatic veins to the inferior vena 

 cava, (^) the coronarv ligaments and the cellulo-vascular bands in and between its 

 layers, (r) the fibrous tissue near the vena cava and on the non-peritoneal posterior 

 surface of the right lobe, {d ) the muscular wall of the abdomen (keeping the in- 

 testinal mass pressed upward beneath the liver), and {e) the lateral and "suspen- 

 sory" ligaments. 



Coincidently with the descent of the viscus it undergoes a rotation or tilting 

 forward so that its diaphragmatic surface is in contact with the abdominal wall. 



Hepatopexy consists in suturing such a movable liver in its normal position by 

 stitches which may be variously placed, but the most useful of which seem to be 

 those which unite the round ligament and liver-substance with the anterior abdominal 

 wall near the xiphoid cartilage (Francke, Treves). 



The normal relations of the liver to the diaphragm and the abdominal parietes 

 cause it to be much influenced— especially as to its circulation — by the respiratory 

 and other movements associated with energetic exercise ; hence the congestion of 

 the organ resulting in "biliousness," or even in jaundice, seen in cases in which, 

 from accident or disease, persons who have led active lives are confined to bed. In 

 walking, and more markedly in horseback riding, the compression of the organ be- 

 tween the diaphragm and the upper — or respiratory — segment of the abdominal wall 

 which takes place during deep inspiration is aided by its downward movement from 

 gravity. It has been suggested (Jacobson) that such movement must slightly open 

 the inferior vena cava, which is then immediately compressed by the following up- 

 ward movement, — during expiration, — thus directly influencing the systemic venous 

 current and with almost equal directness that in the hepatic veins. 



In deep inspiration the anterior edge of the liver descends from under cover of 

 the lower ribs, and in very thin persons may be palpated. A similar descent occurs 

 when a reclining is exchanged for an erect position. 



The direct connection between the gastro-intestinal and the portal circulation 

 causes the latter to be markedly affected by the use of alcoholic or other irritants and 



