Treatment.
—The treatment of milder cases will consist of support from below by suitably adapted and well-fitting abdominal binders or supports. Serious cases may necessitate surgical relief. This consists of hepatopexy, i. e., fixation of the liver to some of its upper surroundings. The operation is performed through an incision such as that used for exposure of the gall-bladder. The lower surface of the diaphragm and the upper surface of the liver are scarified until they ooze perceptibly. The anterior edge of the liver is then fastened to the abdominal walls, as also the gall-bladder, if it can be utilized for the purpose. The patient is then placed in bed with as much compression of the abdomen below the liver as can be tolerated, in order that the scarified surfaces may be kept in contact until adhesions result.
INJURIES OF THE LIVER.
By its size and construction the liver is made peculiarly liable to certain injuries, while from others it is made more or less exempt by its protected situation, especially by the ribs, which nearly enclose it. From contusions it may undergo different degrees of laceration, sometimes even to the degree of fragmentation and pulpifaction. Again it is frequently involved in punctured wounds (stab, gunshot, etc.), which may be inflicted from any possible direction, perforation sometimes taking place from above and through the chest, and involving the tissues beneath.
General indications of injury to the liver will be furnished by its nature and location, the degree of collapse, and the consequent abdominal rigidity, with the common signs of internal or intra-abdominal hemorrhage. There is no doubt but that minor injuries of the liver are nearly always repaired, and that they occur much oftener than is generally appreciated; but a severe tear of the liver is a source of great danger because of hemorrhage. In general, of these injuries it may be said that any traumatism which produces profound or increasing symptoms should be regarded as indicating a careful exploration, done with every precaution at hand for carrying out any possible indication. What the liver may safely bear in the way of ligatures, sutures, and operative disturbance will be indicated later. Many fatal cases show a period of a few hours of temporary amelioration of symptoms which may have lulled to a sense of false security, and during which internal mischief is still increasing. Moreover, any blow sufficiently severe to rupture the liver may do other harm. In such instances, then, it becomes a simple question of whether there can still be sufficiently early intervention to save life. To what extent this intervention may be required in stab and gunshot wounds it is difficult to state. If hemorrhage and puncture of any hollow viscus can be excluded and if no other serious symptoms be present, it may be advisable to wait; otherwise the possible harm of a judicious early exploration is so small, while the prospective benefits are so great, that it is far the wiser course. Here, again, the general rule may be applied. When in doubt operate. Further details of operative procedures will be given below.
ABSCESS OF THE LIVER; HEPATIC ABSCESS.
While abscess of the liver is, like all other abscesses, due to germ activity, it may yet definitely follow injury or be the result of a primary disease, or an extension from some one of the adjacent tissues or organs; as from above (empyema, pyopericardium, subdiaphragmatic, spinal), from below (gall-bladder and ducts, pancreas, stomach), from the portal circulation (superficial or ulcerating piles, typhoid and other intestinal ulcers, peculiar or tropical parasites like amebas), from the appendix, from the general circulation (pyemic, metastatic), through the lymphatics (mesenteric nodes), from the intestinal tube (ordinary round-worms and various parasites), from cancer breaking down, as well as from degenerating gumma or granuloma and from hydatid cyst.
Hepatic abscess may be acute or chronic, small or large, solitary or multiple. The tendency is to enlarge and finally to kill. This they do usually by rupture, e. g., either into the pleural cavity or the lungs, after adhesions have been contracted, the pericardium, the mediastinum, the peritoneum, any part of the upper alimentary canal, or the biliary passages. Finally they may open externally and perhaps be followed by spontaneous recovery.
A certain convenience of description is afforded by dividing these cases into the so-called solitary abscesses and the multiple forms, the latter being more commonly associated with tropical diseases of the amebic type or with pyemic processes. In most solitary cases the abscess is located in the right lobe, its extent varying within wide limits, especially when the subphrenic space has been involved. Its contents may be of almost any color and the pus is often thick and foul in odor. (See [Subphrenic Abscess].)