944 THE ORGANS OF DIGESTION. 



distended and the Diaphragm descends very low, the liver is pushed down ; in some other 

 diseases, as phthisis, where the Diaphragm is much arched, the liver rises very high up. Pres- 

 sure from without, as in tight-lacing, by compressing the lower part of the chest, displaces the 

 liver considerably, its anterior edge often extending as low as the crest of the ileum ; and its 

 convex surface is often at the same time deeply indented from the pressure of the ribs. Again, 

 its position varies greatly according to the greater or less distension of the stomach and intestines. 

 When the intestines are empty the liver descends in the abdomen, but when they are distended 

 it is pushed upward. Its relations to surrounding organs may also be changed by the growth of 

 tumors or by collections of fluid in the thoracic or abdominal cavities. 



Surgical Anatomy. On account of its large size, its fixed position, and its friability, the 

 liver is more frequently ruptured than any of the abdominal viscera. The rupture may vary 

 considerably in extent, from a slight scratch to an extensive laceration completely through its 

 substance, dividing it into two parts. Sometimes an internal rupture without laceration of the 

 peritoneal covering takes place, and such injuries are most susceptible of repair ; but small tears 

 of the surface may also heal; when, however, the laceration is extensive, death usually takes 

 place from haemorrhage, on account of the fact that the hepatic veins are contained in rigid 

 canals in the liver-substance and are unable to contract, and are moreover unprovided with 

 valves. The liver may also be torn by the end of a broken rib perforating the Diaphragm. 

 The liver may be injured by stabs or other punctured wounds, and when these are inflicted 

 through the chest-wall both pleural and peritoneal cavities may be opened up and both lung and 

 liver be wounded. In cases of wound of the liver from the front, hernia of a part of this viscus 

 may take place, but can generally easily be replaced. In cases of laceration of the liver, when 

 there is evidence that bleeding is going on, the abdomen must be opened, the laceration sought 

 for, and the bleeding arrested. This may be done temporarily by introducing the forefinger 

 into the foramen of Winslow and placing the thumb on the gastro-hepatic omentum and com- 

 pressing the hepatic artery and portal vein between the two. Any bleeding points can then be 

 seen and tied and the margins of the laceration, if small, brought together and sutured by 

 means of a blunt curved needle passed from one side of the wound to the other. All sutures 

 must be passed before any are tied, and this must be done with the greatest gentleness, as the 

 liver substance is very friable. When the laceration is extensive it must be packed with iodofprm 

 gauze, the end of which is allowed to hang out of the external wound. Abscess of the liver 

 is of not infrequent occurrence, and may open in many different ways on account of the relations 

 of this viscus to other organs. Thus it has been known to burst into the lungs and the pus 

 coughed up, or into the stomach and the pus vomited ; it may burst into the colon, or into the 

 duodenum ; or, by perforating the diaphragm, it may empty itself into the pleural cavity. 

 Frequently it makes its way forward, and points on the anterior abdominal wall, and finally it 

 may burst into the peritoneal or pericardiao cavities. Abscesses of the liver frequently require 

 opening, and this must be done by an incision in the abdominal wall, in the thoracic wall, or in 

 the lumbar region, according to the direction in which the abscess is tracking. The incision 

 through the abdominal wall is to be preferred when possible. The abdominal wall is incised 

 over the swelling, and unless the peritoneum is adherent, sponges are packed all around the 

 exposed liver surface and the abscess opened, if deeply seated preferably by the thermo-cautery. 

 Hydatid cysts are more often found in the liver than in any other of the viscera. The reason 

 of this is not far to seek. The embryo of the egg of the taenia echinococcus being liberated 

 in the stomach by the disintegration of its shell, bores its way through the gastric walls and 

 usually enters a blood-vessel, and is carried by the blood -stream to the hepatic capillaries, where 

 its onward course is arrested, and where it undergoes development into the fully formed hydatid. 

 Tumors of the liver have recently been subjected to surgical treatment by removal of a portion 

 of the organ. The abdomen is opened and the diseased portion of liver exposed ; the circula- 

 tion is controlled by compressing the portal vein and the hepatic artery in the gastro-hepatic 

 omentum and a wedge-shaped portion of liver containing the tumor removed ; the divided 

 vessels are ligated and the cut surfaces brought together and sutured in the manner directed 

 above. 



When the gall-bladder or one of its main ducts is ruptured, which may occur independently 

 of laceration of the liver, death usually occurs from peritonitis. If the symptoms have led to 

 the performance of a laparotomy and a rent is found, it should be sutured if small, or the gall- 

 bladder removed if it is extensive. If the cystic duct is torn, its intestinal end must be closed 

 and the gall-bladder removed. In rupture of either of the other ducts, the only thing which 

 can be done is to provide for free drainage, in the hope that a biliary fistula may form. 



The gall-bladder may become distended with bile in cases of obstruction of its duct or the 

 common bile-duct, or from a collection of gall-stones within its interior, thus forming a large 

 tumor. The swelling is pear-shaped, and projects downward and forward to the umbilicus. It 

 moves with respiration, since it is attached to the liver. To relieve this condition the gall-bladder 

 must be opened and the gall-stones removed. The operation is performed by an incision two or 

 three inches long in the right semilunar line, commencing at the costal margin. _ The peritoneal 

 cavity is opened, and, the tumor having 1 been found, sponges are packed round it to protect the 

 peritoneal cavity, and it is aspirated. When the contained fluid has been evacuated the flaccid 

 bladder is drawn out of the abdominal wound and its wall incised to the extent of an inch ; any 

 gall-stones in the bladder are now removed and the interior of the sac sponged dry. If the case 

 is one of obstruction of the duct, an attempt must be made to dislodge the stone by manipulation 

 through the wall of the duct ; or it may be crushed from without by the fingers or carefully 



