PRACTICAL CONSIDERATIONS : THE LIVER. 1727 



by the amount and character of food taken. Drinking and overeating thus exaggerate 

 the periodic physiological congestions of the liver and often result ultimately in organic 

 changes. Of course, passive congestion is likely to follow valvular disease of the 

 heart, emphysema, pulmonary cirrhosis, or any condition in which the right heart is 

 engorged, the backward pressure through the vena cava reaching the hepatic veins 

 and their sublobular tributaries. The thin interlobular and perihepatic connective 

 tissue, known as Glisson's capsule, which closely invests the ducts and vessels, is 

 commonly affected in chronic irritation of the liver, especially that form due to al- 

 coholic excess, and in some infectious diseases, notably the specific fevers and 

 syphilis. Its anatomical relations explain the usual sequence of phenomena. Pro- 

 liferation of the portions surrounding the terminal branches of the portal vein causes 

 obstruction which, either alone or aided by the concurrent toxaemia, results in con- 

 gestion and catarrh of the stomach and intestines, in enlargement of the spleen and 

 pancreas, and later in ascites. 



As the obstruction increases, a collateral circulation is often established to re- 

 lieve the portal congestion by means of communication between () the accessory 

 portal veins (particularly those in the falciform ligament) and the diaphragmatic, 

 para-umbilical, and epigastric veins ; (<) the veins of Retzius and the retroperitoneal 

 veins ; (c) the hemorrhoidal and the inferior mesenteric veins ; (X) the gastric and 

 the cesophageal veins. An operation has been employed to establish a better and 

 more satisfactory compensatory circulation in cases of cirrhosis by effecting adhesions 

 between the surfaces of the liver and the spleen and the diaphragmatic peritoneum, 

 on the one hand, and the parietal peritoneum and omentum, on the other. 



When compression of the liver is carried beyond physiological limits, as from 

 contusion or from forced flexion, rupture results. This is more frequent in the 

 liver than in the other abdominal viscera on account of its size, its friability, its 

 fixity, its close diaphragmatic and parietal relations, and its great vascularity. A 

 similar disjunction of liver-substance may occur from a fall on the feet from a height. 

 It is grave in proportion to the extent of the rupture and to its involvement or non- 

 involvement of the peritoneal covering. Ruptures confined to the liver-substance, 

 i.e. , not reaching the surface, and moderate in extent, are not infrequently recovered 

 from. The commonest seat of rupture of the liver is near the falciform and coro- 

 nary ligaments, with which the rupture is apt to be parallel. If they are extensive 

 enough to reach the surface of the organ, death often results from hemorrhage, the 

 intimate association of the hepatic substance with the thin-walled vessels preventing 

 their retraction or collapse. Hemorrhage is also favored by the direct connection 

 of the valveless hepatic veins with the vena cava and by the absence of valves in 

 the portal veins. According to the situation of the rupture, the blood may be poured 

 into the general peritoneal cavity ; into that portion of it known as the subhepatic 

 space, and bounded below by the transverse mesocolon ; or into the retroperitoneal 

 space behind the liver and ascending colon. The local symptoms will vary with the 

 situation of the collected blood. 



Wounds of the liver should be considered with reference to its relations to the 

 parietes, especially on the right side, where, on account of its greater bulk, it is 

 more often injured. Except at the subcostal angle, where a small part of the anterior 

 surface lies against the abdominal wall (the lower edge being on a line between the 

 eighth left and the ninth right costal cartilages), the lower ribs and costal cartilages 

 surround the liver. Thus stab wounds must pass between them, while fracture of 

 the ribs with depression may penetrate the interposed diaphragm and then the liver- 

 substance. Anteriorly, a little internal to the mammary line, the liver may reach to 

 the fourth intercostal space or even quite to the level of the nipple, and may be 

 directly wounded throughout that area. Laterally it is not usually found above the 

 sixth interspace. Posteriorly a stab wound through the sixth, seventh, or eighth 

 intercostal space, or even down to the level of the tenth dorsal spine, would pene- 

 trate four layers of pleura, the thin concave base of the right lung, and the dia- 

 phragm before reaching the liver. Still lower, the base of the lung may escape, 

 but a wound of the liver may involve the two layers of pleura of the costo-phrenic 

 sinus and the diaphragm. Of course, the alterations in position of the liver during 

 inspiration and expiration, and according to the position of the body, must be 



