The principles and practice of modern surgery

by Roswell Park

CHAPTER LII.
THE LIVER.

CONGENITAL DISPLACEMENTS OF THE LIVER.

The congenital defects and displacements of the liver which interest the surgeon are few. More or less transposition, sometimes complete situs transversus, is encountered. The same is true of more or less hernial protrusion into the chest, through a defect in the diaphragm, or such displacement as may be permitted by some defect of the abdominal walls or other viscera. Hammond has recently shown that the left lobe of the liver is sometimes congenitally enlarged to an extent sufficient to cause symptoms, a condition alluded to by very few writers. In this way the liver may cover the stomach and even extend over the spleen. Similarly the right lobe may be affected, but giving a different train of symptoms. Under these conditions mistakes may arise. Thus the left lobe might be mistaken for a large spleen, from which, nevertheless, it should be separated and differentiated by its free movement during respiration. Hammond even reports one case of this kind where, instead of removing the elongated portion of the liver, it was held up against the abdominal wall by sutures. For a similar condition Langenbuch has successfully resected a portion of this viscus. What is said here pertains to a true congenital variety, and not to acquired displacements or enlargements. In [Fig. 625] is represented the case of xiphopagous twins united by a band of liver tissue and operated (by division of the band) by Baudouin.

Fig. 625

Xiphopagous twins, separated by division of a band of common liver tissue. Case of M. Baudouin. (Pantaloni.)

WANDERING OR FLOATING LIVER.

The relations between congenital laxity of the natural supports of the liver and certain morbid conditions, especially those produced by marked enlargement followed by great reduction in size, to the so-called wandering or floating liver are very indefinite. The term “wandering” implies a mobility far beyond the normal, with more or less yielding of ligaments, especially the suspensory, which permits undue displacement. We often fail to realize that the liver, which is the heaviest of the viscera, is nevertheless, in man, placed at their top, and hence that it has, in at least some respects, very meagre support. This is one of the disadvantages of the upright position, and it does not prevail in animals. In addition to this may be mentioned the peculiar enlargement of the right lobe, very rarely of the left, so often seen in connection with biliary obstruction, and often spoken of as Riedel’s lobe. Floating liver is more common in women than in men by four to one, and is often ascribable to the ill effects of tight lacing. Repeated pregnancies, with the consequent relaxed and pendulous abdominal walls which often follow them, also conduce to the condition by weakening, in fact almost removing, its lower supports.

Symptoms.

—The symptoms produced are those of indigestion, dyspnea, perhaps with cyanosis, nausea, vomiting, and occasionally biliary obstruction and jaundice. In addition to these the patient will show the ordinary physical signs of a displaced or displaceable liver, noticeable in the upright or in the knee-elbow position.