4 2o APPLIED ANATOMY. 



Wounds and Injuries of the Liver. The liver is frequently ruptured in 

 falling or by being struck by some body from without. The rupture may involve its 

 anterior edge or upper surface. In all examinations it should not be forgotten that 

 the right and left sides are separated completely by the falciform ligament.. On 

 account of the walls of the vessels being imbedded in the liver tissue they do not 

 readily collapse and hemorrhage is often fatal. Rupture of the posterior nonperi- 

 toneal surface is not so dangerous as elsewhere. 



Abscesses may be either one or two large ones or multiple small ones. 

 Pus on the upper surface of the liver, between it and the diaphragm, is called sub- 

 diaphragmatic abscess. It may originate either from the liver or other viscera below, 

 or the lung and pleura above. Maydl gives gastric ulcer as the most frequent cause 

 and then affections of the intestines and appendix : we have seen it arise from calculous 

 disease of the kidney. The pus may discharge outward between the ribs, or upward 

 into the pleural cavity, lung, or pericardial sac. In incising for subdiaphragmatic 

 abscess the tenth rib in the axillary line can be resected without opening the 

 pleura, but if the eighth or ninth is chosen the pleural sac may be opened and 

 the two layers of pleura should be stitched together before the incision through the 

 diaphragm into the abscess cavity is made. If the abscess points at the inferior 

 surface it may break into the stomach, duodenum, or colon. It may be reached by 

 an incision through the abdominal walls to the right of the median line. The posi- 

 tion of the falciform ligament, about 4 cm. ( i ^2 in. ) to the right of the median line, 

 should be remembered, and if the left lobe of the liver is to be treated the inci- 

 sion should be made to the left of the ligament. 



Multiple abscesses are started in the liver by conveyance of infection through the 

 portal vein, as occurs in appendicitis, or by direct extension up the common duct 

 from the intestine, or from an inflamed gall-bladder or bile-ducts through the hepatic 

 duct and its ramifications. 



Portal Obstruction. The veins of the portal system have no valves. The 

 portal vein is formed by the union of the splenic and superior mesenteric veins 

 and the gastric, pyloric, and cystic veins. The splenic receives the blood from the 

 spleen, the stomach, and pancreas, the descending colon, sigmoid flexure, and rec- 

 tum. The superior hemorrhoidal vein drains the rectum and empties into the inferior 

 mesenteric, which passes into the splenic and finally into the portal vein. The supe- 

 rior mesenteric vein drains the remainder of the large and small intestine. 



In cirrhosis, carcinoma, and occasionally gall-stones, the flow of blood through 

 the portal vein is interfered with ; hence arise congestions of the various parts which 

 it drains. In the abdomen ascites is produced ; the distended and varicose veins of 

 the stomach sometimes rupture, causing haematemesis ; diarrhoea may occur, and 

 dilatation of the hemorrhoidal veins produces hemorrhoids. 



Especially when there also is pressure on the vena cava the superficial and deep 

 veins of the abdominal wall become enlarged (see page 380). The main anasto- 

 moses are : ( i ) between the gastric (coronary) vein of the stomach and the cesopha- 

 geal veins which empty into the vena azygos major ; (2) between the epigastric^ 

 (superficial and deep) below and the terminal branch of the internal mammary 

 above; (3) between the epigastric veins and portal vein through the para-umbilical 

 vein (caput medusae, page 380); (4) through the thoracico-epigastrica between the 

 axillary and epigastric (see Fig. 392, page 380) ; (5) between the superior hemor- 

 rhoidal and the middle hemorrhoidal, emptying into the internal pudic. 



GALL-BLADDER AND BILIARY PASSAGES. 



The gall-bladder lies in the fissure of the gall-bladder, with its funclus just about 

 level with the edge of the liver and its body pointing inward, upward, and backward; 

 its neck, which is S-shaped, is near the right end of the portal fissure. It is 7.5 cm. 

 (3 in.) long and 2.5 to 3 cm. (i to i ^ in.) in diameter. It holds one to one and 

 a half ounces. Below, it rests on the transverse colon and first part of the duodenum. 

 It is attached to the liver, but not very strongly, by connective tissue and the 

 peritoneum. According to Brewer (Annals of Surgery, 1899, vol. xxix, page 723) 

 one-third to one-fourth of its surface is uncovered by peritoneum : in 5 cases in 100 



