The symptoms which ensue after a wound of the liver are those common to inflammation of the cavity of the abdomen, with the addition of those peculiar to the organ—pulse often smaller and less perceptible than in peritonitis; discoloration of the skin, eyes, and urine, amounting even to jaundice, although this is not an immediate symptom, neither is it always present. The pain is not confined to the part, but extends to the umbilicus, while the pain symptomatic of inflammation of the liver—viz., pain in the top of the right shoulder—is felt early, and is often accompanied by cramps of the muscles of the arms and numbness of the fingers. The usual symptoms of anxiety and depression are present, and the stomach shows by its irritability that it has partaken of the shock given to the system. The bowels are usually confined, but I have known blood passed from them when it was not supposed that the stomach or intestines had been wounded; the discharge from the wound is either of blood or bile, or both, mixed with a serous effusion which afterward becomes purulent. 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. If the gall-bladder be adherent to the peritoneum from any previous inflammation, a wound in it need not prove mortal, as the effusion would be avoided, and there is no reason to believe that an injury to this part would be otherwise more vital than that of any other of the viscera of the abdomen.
The late Lieut.-General Sir S. Barns, when Lieut.-Colonel of the Royals, was wounded at the battle of Salamanca by a musket-ball, which injured the cartilages of the false ribs, a portion of the rib being removed and passed out through the liver. A bilious discharge continued several weeks from the wound, and his life was saved with great difficulty. He returned to his duties, although suffering from a dragging pain and weight in the side, which any exertion increased. In the autumn of 1819 he was attacked by acute inflammation; the pain in the right side, extending over the stomach and umbilicus, was constant and acute, and increased on pressure; the pulse small, indeed scarcely perceptible; the extremities cold; the countenance depressed and anxious; bowels confined; stomach rather irritable. A number of leeches were applied, and other remedies administered. The constant pain, which was increased by pressure, could only be relieved by loss of blood, although every other symptom seemed to forbid depletion. Twenty ounces of blood were taken from the arm, which caused a diminution of the pain, and gave relief for an hour; the pain then returned, and twelve ounces more blood were taken away, with the most beneficial effect; a blister was applied over the part, and a dose of calomel and opium was repeated. Shortly afterward he became tranquil; the extremities lost their coldness; and, although the pain continued in a slight degree for several hours, and much soreness remained for many days, he quickly recovered. Two months afterward he had another and equally severe attack, in consequence of walking about two miles rather hastily; from that he was relieved in a similar manner. Whenever he bent his body, a portion of the rib appeared to press in upon the liver, and often gave him acute, darting pain; and one day, on pulling on his boot in haste with some bodily exertion, a third attack ensued. In order to prevent the bending of the body forward, and to confine the motion of the liver, which seemed liable to injury from the irregular points of bone which could be readily distinguished above it, stays, made with iron plates instead of whalebone, were adapted to his body, and from these he derived great comfort.
Corporal Macdonald, first battalion, 79th Regiment, was wounded on the 16th of June at Quatre Bras, by a musket-ball, which entered the abdomen, splintered the eighth rib on the right side, passed through the liver, and was supposed to have lodged on the opposite side, as he says he felt the ball strike the left side, on which he was not able to lie for a long time. Lost but little blood at the time; was dressed superficially, and arrived in Brussels on the 19th, laboring under considerable fever. Bleeding to thirty-six ounces. For seven successive days the bleeding was repeated, to from twelve to sixteen ounces each day, when a large, bilious, and purulent discharge took place from the wound, on which the inflammatory symptoms appeared to subside, until the 30th of June, when bleeding took place from the wound during the night to the extent of twenty ounces, and then ceased spontaneously. On the 15th of July the hemorrhage recurred with so much fever as to warrant twenty ounces of blood being taken from the arm, and this was repeated the next day. The bilious discharge ceased in the middle of August, and on the 2d of September he was discharged convalescent.
Lieutenant Edward Hooper, first battalion, 38th Regiment, was wounded by a musket-ball on the 9th of December, 1812. It passed through the anterior edge of the liver, and, glancing round the ribs, was cut out about two inches from the spine.
On his being wounded, he could scarcely believe his shoulder was not the part affected. His pulse was intermitting; the breathing hurried and laborious, and in a short time the tunicæ conjunctivæ became yellow. He was very largely bled, and warm fomentations were applied to the abdomen, from which, and the bleeding, he received some temporary relief; but, in consequence of his removal that night to the rear, the symptoms were much aggravated on the morning of the 10th. He complained of acute pain over the whole abdomen, increased on pressure; vomiting; quick, hard, and wiry pulse, (no pain referred to the wound.) The bleeding was repeated ad deliquium, warm fomentations and an enema also repeated, and a saline mixture, with a very few drops of tincture of opium, to allay the irritability of the stomach. On the following evening the vomiting had ceased; his pulse was less frequent and hard; pain less. On the 11th, after passing a very restless night, the pulse again rose; the abdomen became tense but not very painful, and he made ineffectual efforts to stool. He was again bled, a large blister was applied over the abdomen, and an ounce of castor-oil was given immediately. The blister acted well, and the purgative gave him three copious stools of dark and fetid feces. On the 12th he complained of twitching pains, referred to the right shoulder, and was ordered one grain of calomel, with two of antimonial powder, three times a day.
Jan. 13th.—Was free from pain; pulse fuller and less frequent; urine clear; tension of abdomen subsided. The calomel and antimony were continued, and some light nourishment was allowed. From this day a gradual amendment took place. The calomel was continued until his mouth became slightly affected; and, as his bowels were in general torpid, from the deficient secretion of bile, a mild purgative was given every two or three days, as occasion required, and an ounce of the infusion of calumba, with quassia, three or four times daily.
A soldier of the 48th Regiment was struck by a musket-ball at Albuhera, on the upper part of the right hypochondrium, over the liver; it came out behind, at a point immediately corresponding to that in front. Blood and bile were discharged from the wounds in considerable quantity, and his case was considered to be hopeless. Brought to me at Valverde, the next day, he was bled largely several times; the wounds were dressed simply, and he was kept perfectly quiet, and his bowels gently open. The skin became of a yellow color, his strength failed under the treatment, and he became thin, and looked ill. At the end of three weeks he was sent to Elvas, where he gradually improved, and was forwarded thence to Lisbon and to England, with his wounds healed.
An officer was wounded in one of the battles in the Pyrenees, by a musket-ball, which penetrated the outer part of the right hypochondrium, at the edge of the false ribs, and lodged. Blood and bile flowed in considerable quantity; the skin became yellow, the pain and swelling of the abdomen were considerable, and he was given over as lost. Under a vigorous and careful treatment he gradually recovered, so as to be sent to England, with a fistulous opening at the orifice of entrance. I examined the wound in 1817, three years afterward, and found that a large blunt probe passed inward toward the stomach and liver for the distance of five inches, where it ended apparently in a sort of sac. Purulent and bilious matters were constantly discharged from the wound; his countenance was sallow; his digestion bad; he suffered from constant uneasiness, if not pain, and was altogether out of health. I saw him once annually for several years, and found that I could sometimes strike the ball with the probe; that he frequently, after an attack of pain and derangement, passed matter by stool, after which the pain and uneasiness about the wound ceased. I had hopes the ball would some day pass through the opening thus made, and had thoughts of enlarging the external wound, and of endeavoring to extract the ball with a long pair of forceps. He ceased at last to pay his annual visit, and I suspect he died in one of the attacks I have alluded to. This ball must have passed very close to, if it did not penetrate, the gall-bladder.
I have never had an opportunity of extracting a ball from the liver during life, although I have seen persons live many weeks into whose livers balls had penetrated; and I have been acquainted with three persons who had been wounded through the liver, to whom little subsequent inconvenience was occasioned.
406. Portions of the liver have been removed in some instances; in one case, related by Blanchard, a small piece of liver was removed with the forceps. The patient dying of fever three years afterward, a small piece of the liver near the external wound was found wanting. Dieffenbach gives a case in which a small protruded portion was cut off with scissors, without any bad consequence. Dr. Macpherson, in the ‘London Medical Gazette’ for January, 1846, has related the case of a Hindoo, a large piece of whose liver protruded through a wound an inch in length, made by a spear in the right hypochondriac region. A ligature was applied tightly around its base, and the piece cut off, rather than make such an enlargement of the wound as might allow the restoration of the protruded liver. The arteries bled from the cut surface, and required to be tied, and a double ligature was put through the stump of liver and tied on each side. The part was not pushed back into the abdomen, but allowed to remain in the wound. The symptoms were mild, the ligatures came away on the ninth day, and the man returned to his home in three weeks.