LIVER AND GALL-BLADDER, DIS EASES OF THE.
Diseases of the Liver.
Malformations.—Abnormalities in the form of the liver are not common. They may be either acquired or congenital.
1. Corset-liver.—The constant press ure of the lower ribs against the liver as a result of tight lacing or the wearing of a tight waist-band may produce a deep, transverse furrow on the right lobe from atrophy of the parenchyma. The furrow usually corresponds to the margin of the ribs, and may be so deep that the liver becomes divided into a large upper and a small, lower, part connected together by a narrow isthinus or band composed chiefly of fibrous tissue, the larger blood vessels, and bile-ducts. The peritoneum in the groove is much thickened. The lower portion is usually rounded and may be freely movable as if hinged to the upper, and appear in the abdomen as a movable tumor.
This deformity is met with usually in elderly females. There are usually no symptoms resulting from the deformity; yet in some there is said to be a con stant sensation of pressure and weight in the hepatic region. In occasional cases, in consequence of venous stasis, there is a temporary swelling of the isolated por tion and violent pain and signs of irri tation of the peritoneum.
2. Tongue-like Lobes. — These are probably of much more frequent oc currence, and therefore of much more importance, than the corset-liver. They are both of importance chiefly on account of the difficulties they present in diag- nosis. Riedel met with twelve cases of tongue-like lobes in forty-two operations for I have met with nine in various conditions. In two the mass was thought to be a movable kidney, and in one, an infant with Inemorrhagic pan creatitis, it was thought that possibly the tongue-like lobe was an intussusception. They are met with at all ages, and are probably usually congenital rather than acquired from external pressure. The diagnosis of these malformations is usu ally easy if the abdominal wall is thin and lax, as the connection of the mass with the liver can be definitely traced; but if the abdominal wall is thick from the deposit of fat or its muscles tense it is often impossible to differentiate these from other masses met with in the ab domen. An effort should be made to
outline the mass and trace its connection to the liver. This is often impossible, as the base may be deeply furrowed and a loop of intestine may occupy the groove.
Treatment for these abnormalities is rarely called for. When the mass is troublesome from its mobility, and is not retained by a suitable bandage, it may be removed. Such has been done suc cessfully.
The chief interest in this subject is in connection with the diagnosis of ab dominal tumors. Unless fully alive to the great variety, as to shape and posi tion, in which these accessory lobes of the liver may present themselves, one will often be misled in the diagnosis of abdominal tumors. In not a few cases, even with the utmost care, a positive opinion as to the nature of these tumors cannot be given.
Riedel, who first drew attention to the importance of these abnormal lobes, be lieves them to be due usually to press ure on the liver, as in tight lacing, and to trattion, by an enlarged gall-bladder. They are met with usually in women. In nine of his twelve eases the gall-bladder was attached to the lower part of the process.
far as can be inferred from the nine eases which 1 have met, tight lacing has little to do with the production of the deformity, and the position of the gall bladder at the lower part of the mass is :I II occident rather than a cause of its formation. In many, if not almost all, eases tbe forrnation of these lobes seems to be developmental, having nothing to do with either pressure or traction.
Displacements.
Displacements of the liver may be either congenital or acquired. As in stances .of the former are hernia of the liver through the diaphragm and through the anterior abdominal wall. Interesting examples are also afforded by transposition of viscera, the liver being found to the left and the spleen to the right. As a rule, the other organs, both of the thorax and abdomen, are also transposed, tbe cardiac impulse being in the fourth or fifth intercostal space to the right: but the liver and spleen may be the only organs abnormally placed.