Hydatid cyst of the liver appears as a tumor, evidently cystic or fluctuating, growing painlessly and attaining considerable size. It may usually be excluded from abscess, cancer, dilated gall-bladder, aneurysm, gumma, hydronephrosis, renal cysts, or tumors of unknown origin. A tumor peculiar to the liver will move with that organ. The aspirating needle will probably need to be used before diagnosis is complete, the fluid withdrawn being clear unless suppuration has begun.
Treatment.
—Hydatid cysts require radical treatment. Aspiration does not remove the mother-cyst nor any of its semisolid contents. Even the injection of iodine and resort to electrolysis hitherto in vogue have been abandoned. Open incision, first, of the abdomen, and then, after careful protection of the abdominal cavity, of the cyst itself, with scrupulous attention to prevention of escape of its contents save externally, is the only radical and promising procedure. These precautions should be taken because of the possibility of implantation of some living fragment of the parent organism, or its offspring, elsewhere in the abdomen and the growth of the same in this new location. After free evacuation of such a cyst it should be explored and thoroughly cleaned out, after which its edges are to be affixed to those of the parietal peritoneum if practicable, a large tube inserted and suitably connected up for drainage, while the opening around it is closed with sutures or packed with gauze. This connection of an interior cavity with the exterior of the body is called marsupialization.
SYPHILIS OF THE LIVER.
The operating surgeon as such is only concerned with gummatous tumors, not with diffuse expressions of syphilis which produce interstitial hepatitis or cirrhosis. The latter are often met in cases of general syphilis, and yield to suitably directed treatment. Either the diffuse or the gummatous form may produce enormous enlargement of the liver, with suspicion at least of an abscess. In one case of this kind, known to the writer, the lower border of the liver extended below the crest of the ilium, and yet within a short time, under vigorous treatment, the liver resumed its normal size. Gummas have, then, an interest for the surgeon, as no other similar enlargement ever reduces its volume so speedily under any other circumstances. Moreover gummas may occasionally break down and produce abscesses requiring incision and drainage. If syphilis can be recognized as the etiological factor prognosis is satisfactory in nearly every instance.
ACTINOMYCOSIS OF THE LIVER.
The specific fungi of this disease may be easily carried from the alimentary canal to the liver through the portal circulation, and its peculiar granulomas, appearing first here, may spread to the diaphragm, to the abdominal wall, or in any other direction. Unless aided by the presence of other distinctive lesions diagnosis is rarely made until the presence of a granulating tumor and its ulceration, with the escape of the distinctive calcareous particles, makes it recognizable to touch as well as to sight. This often might be secured by an exploratory operation, which circumstances might justify. (See chapter on [Actinomycosis].)
TUMORS OF THE LIVER.
Benign tumors in the liver are rare. So-called adenomas of somewhat indistinct type, and fibromas, have been described as occurring here. The former are of uncertain origin and probably do not deserve the name given here. Nevertheless they have a structure more or less simulating true gland tissue. Fibromas may spring from any of the fibrous structures. Other benign tumors occur here so rarely as to scarcely warrant mention. Aneurysms and large venous dilatations also occur occasionally in the liver. Any of these lesions may justify exploration, and those favorably situated may be enucleated or excised, with subsequent suture of the liver and drainage of any remaining cavity.
Of the malignant tumors the sarcomas and endotheliomas may arise in almost any part of the organ. Primary carcinomas have their origin only about the gall-bladder and its ducts, from whose epithelial lining they may spring; otherwise they are products of extension or metastasis. By far the larger proportion of cancers arise from the gall-bladder, within which they begin to grow, either as the expressions of irritation or of parasitism. The presence of gallstones in the gall-bladder is now known to be an extremely common provocation of cancer, and the relation obtaining between the two is certainly more than accidental or casual. (See [Cancer of the Gall-bladder].)