Postempski mentions a case of suture of the liver after a stab-wound. Six sutures of chromicized cat-gut were carefully tightened and fastened with a single loop. The patient left his bed on the sixth day and completely recovered. Gann reports a case of harpoon-wound of the liver. While in a dory spearing fish in the Rio Nuevo, after a sudden lurch of the boat, a young man of twenty-eight fell on the sharp point of a harpoon, which penetrated his abdomen. About one inch of the harpoon was seen protruding from below the tip of the ensiform cartilage; the harpoon was seven inches long. It was found that the instrument had penetrated the right lobe of the liver; on passing the hand backward along the inferior surface of the liver, the point could be felt projecting through its posterior border. On account of two sharp barbs on the spear-point, it was necessary to push the harpoon further in to disengage the barbs, after which it was easily removed. Recovery followed, and the patient was discharged in twenty-one days.
Romme discusses the subject of punctured wounds of the liver, as a special text using the case of the late President Carnot. He says that in 543 cases of traumatism of the liver collected by Elder, 65 were caused by cutting or sharp-pointed instruments. Of this group, 23 recovered and 42 died. The chief causes of death were hemorrhage and peritonitis. The principal symptoms of wounds of the liver, such as traumatic shock, collapse, local and radiating pains, nausea, vomiting, and respiratory disturbances were all present in the case of President Carnot. From an experience gained in the case of the President, Romme strongly recommends exploratory celiotomy in all penetrating wounds of the liver. Zeidler reports three cases of wound of the liver in which recovery ensued. The hemorrhage in one case was arrested by the tampon, and in the other by the Pacquelin cautery.
McMillan describes a man of twenty who was kicked by a horse over the liver and rupturing that organ. A large quantity of offensive fluid was drawn off from the liver, and the man recovered. Frazer reports a case of rupture of liver and kidney in a boy of thirteen who was squeezed between the tire and driving chain of a mill, but who recovered despite his serious symptoms. Allen mentions recovery after an extensive incised wound of the abdomen, liver, and lung. Massie cites an instance of gunshot wound of the right hypochondrium, with penetration and protrusion of the liver. The patient, a boy of seven, recovered after excision of a small part of the protruding liver. Lawson Tait has incised the liver to the extent of three inches, evacuated two gallons of hydatids, and obtained successful recovery in ten weeks.
There are several cases of wound of the liver followed by recovery reported by surgeons of the United States Army. Whitehead mentions a man of twenty-two who on June 3, 1867, was shot in the liver by a slug from a pistol. At the time of the injury he bled freely from the wound of entrance continuing to lose blood and bile until daylight the next morning, when the hemorrhage ceased, but the flow of bile kept on. By June 10th there was considerable improvement, but the wound discharged blood-clots, bile, and serum. When the patient left the hospital on July 15th the wound was healthy, discharging less than 1 1/2 ounces during the twenty-four hours, of a mixture of free bile, and bile mixed with thick material. When last heard from—July 27, 1867—the patient was improving finely in flesh and strength. McKee mentions a commissary-sergeant stationed at Santa Fe, New Mexico, who recovered after a gunshot wound of the liver. Hassig reports the case of a private of twenty-six who was wounded in a fray near Paducah, Kentucky, by a conoid ball, which passed through the liver. The ball was cut out the same day. The patient recovered and was returned to duty in May, 1868. Patzki mentioned a private in the Sixth Cavalry, aged twenty-five, who recovered from a gunshot wound of the abdomen, penetrating the right lobe of the liver and the gall-bladder.
Resection of the Liver.—It is remarkable to what extent portions of the liver may be resected by the knife, cautery, or ligature, and the patient recover. Langenbuch records a case in which he successfully removed the greater portion of the left lobe of a woman of thirty. The lobe had been extensively deformed by tight lacing, and caused serious inconvenience. There was considerable hemorrhage, but the vessels were secured, and the woman made a good recovery. McWhinnie, in The Lancet, records a case of dislodgment of an enlarged liver from tight lacing. Terrilon mentions an instance in which a portion of the liver was removed by ligature after celiotomy. The ligature was removed in seven days, and the sphacelated portion of the liver came off with it. A cicatrix was completed at the end of six weeks, and the patient, a woman of fifty-three, made an excellent recovery. Bastianelli discusses those cases in which portions of the liver, having been constricted from the general body of the organ and remaining attached by a pedicle, give rise to movable tumors of the abdomen. He records such a case in a woman of thirty-seven who had five children. A piece of liver weighing 500 grams was removed, and with it the gall-bladder, and the patient made an uninterrupted recovery. Tricomi reports a case in which it was found necessary to remove the left lobe of the liver. An attempt had been made to remove a liver-tumor the size of a fist by constricting the base with an elastic ligature. This attempt was a failure, and cure was also unsuccessfully attempted by wire ligature and the thermocautery. The growth was cut away, bleeding was arrested by the thermocautery and by iron-solution, the wound entirely healed, and the patient recovered. Valerian von Meister has proved that the liver has marvelous powers of regeneration, and that in rabbits, cats, and dogs, even three-fourths of the organ may be reproduced in from forty-five to sixty-five days. This regeneration is brought about chiefly by hypertrophy of the lobules.
Floating liver is a rare malady in which the liver forms an abdominal prominence that may be moved about, and which changes its situation as the patient shifts the attitude. The condition usually arises from a lax abdominal wall following repeated pregnancies. The accompanying illustration exhibits a typical case verified by postmortem examination.
Hypertrophy of the Liver.—The average weight of the normal liver is from 50 to 55 ounces, but as noted by Powell, it may become so hypertrophic as to weigh as much as 40 pounds. Bonet describes a liver weighing 18 pounds; and in his "Medical and Surgical Observations," Gooch speaks of a liver weighing 28 pounds. Vieussens, the celebrated anatomist, reports an instance in which the liver weighed 20 pounds, and in his "Aphorisms," Vetter cites a similar instance. In 1811 Kraus of Germany describes a liver weighing 25 pounds; modern instances of enlarged liver are too numerous to be quoted here.
Rupture of the gall-bladder, although generally followed by death, is not always fatal. In such cases bile is usually found in the abdominal cavity. Fergus mentions a case in which, after this accident, the patient was considered convalescent and was walking about, when, on the seventh day, peritonitis suddenly developed and proved fatal in two days. Several cases of this accident have been reported as treated successfully by incision and drainage (Lane) or by inspiration (Bell). In these cases large quantities of bile escaped into the abdominal cavity. Peritonitis does not necessarily follow. Cholecystotomy for the relief of the distention of the gall-bladder from obstruction of the common or cystic duct and for the removal of gall-stones was first performed in 1867 by Bobbs of Indianapolis, but it is to Marion Sims, in 1878, that perfection of the operation is due. It has been gradually improved and developed, until today it is a most successful operation. Tait reports 54 cases with 52 perfect recoveries. Cholyecystectomy, or excision of the gall-bladder, was first practiced in 1880 by Langenbuch of Berlin, and is used in cases in which gall-stones are repeatedly forming. Ashhurst's statistics show only four deaths in 28 cases.
At St. Bartholomew's Hospital, in London, is a preserved specimen of a gall-bladder which had formed the contents of a hernial sac, and which, near the fundus, shows a constriction caused by the femoral ring. It was taken from a woman of forty-five who was admitted into the hospital with a strangulated femoral hernia. The sac was opened and its contents were returned. The woman died in a few days from peritonitis. The gall-bladder was found close to the femoral ring, and showed a marked constriction. The liver was misshapen from tight lacing, elongated and drawn downward toward the ring. There was no evidence that any portion of intestine or other structure besides the gall-bladder had passed through the ring.
The fatality of rupture of the spleen is quite high. Out of 83 cases of injury to this organ collected by Elder, and quoted by MacCormac, only 11 recovered; but the mortality is less in punctured or incised wounds of this organ, the same authorities mentioning 29 recoveries out of 35 cases. In his "Surgery" Gooch says that at the battle of Dettingen one of Sir Robert Rich's Dragoons was left all night on the field, weltering in his blood, his spleen hanging out of his body in a gangrenous state. The next morning he was carried to the surgeons who ligated the large vessels, and extirpated the spleen; the man recovered and was soon able to do duty. In the Philosophical Transactions there is a report of a man who was wounded in the spleen by a large hunting-knife. Fergusson found the spleen hanging from the wound and ligated it. It separated in ten days and the patient recovered.