into the belly-cavity may take place. The individual becomes faint, and the faintness keeps on increasing; and there are pain and tenderness in the liver-region. The right thing to do is to open the belly in the middle line, search for a wound in the liver and treat it by deep sutures, or by plugging it with gauze.
Cirrhosis of the Liver.—As the result of chronic irritation of the liver increased supplies of blood pass to it, and if the irritation is unduly prolonged inflammation is the result. The commonest causes of this chronic hepatitis are alcoholism and syphilis. The new fibrous tissue which is developed throughout the liver, as the result of the chronic inflammation, causes general enlargement of the liver with, perhaps, nausea, vomiting and jaundice. Later the new fibrous tissue undergoes contraction and the liver becomes smaller than natural. Blood then finds difficulty in passing through it, and, as a result, dropsy occurs in the belly (ascites). This may be relieved by tapping the cavity with a small hollow needle (Southey’s trocar), or by passing into it a large sharp-pointed tube. This relieves the dropsy, but it does not cure the condition on which the dropsy depends. A surgical operation is sometimes undertaken with success for enabling the engorged veins to empty themselves into the blood-stream in a manner so as to avoid the liver-route.
Inflammation of the Liver (hepatitis) may also be caused by an attack of micro-organisms which have reached it through the veins coming from the large intestine, or through the main arteries. There are, of course, as the result, pain and tenderness, and there is often jaundice. The case should be treated by rest in bed, fomentations, calomel and saline aperients. But when the hepatitis is of septic origin, suppuration is likely to occur, the result being an hepatic abscess.
Hepatic Abscess is especially common in persons from the East who have recently undergone an attack of dysentery. In addition to the local pain and tenderness, there is a high temperature accompanied with shiverings or occasional rigors, the patient becoming daily more thin and miserable. Sometimes the abscess declares itself by a bulging at the surface, but if not an incision should be made through the belly-wall over the most tender spot, and a direct examination of the surface of the liver made. A bulging having been found, that part of the liver which apparently overlies the abscess should be stitched up to the sides of the opening made in belly-wall, and should then be explored by a hollow needle. Pus being found, the abscess should be freely opened and drained. It is inadvisable to explore for a suspected abscess with a hollow needle without first opening the abdomen, as septic fluid might thus be enabled to leak out, and infect the general peritoneal cavity. If an hepatic abscess is injudiciously left to itself it may eventually discharge into the chest, lungs or belly, or it may establish a communication with a piece of intestine. The only safe way for an abscess to evacuate itself is on to the surface of the body.
Hydatic Cysts are often met with in the liver. They are due to a peculiar development of the eggs of the tape-worm of the dog, which have been received into the alimentary canal with infected water or uncooked vegetables, such as watercress. The embryo of the taenia echinococcus finds its way from the stomach or intestine into a vein passing to the liver, and, settling itself in the liver, causes so much disturbance there that a capsule of inflammatory material forms around it. Inside this wall is the special covering of the embryo which shortly becomes distended with clear hydatid fluid. The cyst should be treated like a liver-abscess, by incision through the abdominal or thoracic wall, by circumferential suturing and by exploration and drainage.
Tumours of the Liver may be innocent or malignant. The most important of the former is the gumma of tertiary syphilis; this may steadily and completely disappear under the influence of iodide of potassium. The commonest form of malignant tumour is the result of the growth of cancerous elements which have been brought to the liver by the veins coming up from a primary focus of the large intestine. Active surgical treatment of such a tumour is out of the question. Fortunately it is, as a rule, painless.
The Gall-bladder may be ruptured by external violence, and if bile escapes from the rent in considerable quantities peritonitis will be set up, whether the bile contains septic germs or not. If, on opening the abdomen to find out what serious effects some severe injury has caused, the gall-bladder be found torn, the rent may be sewn up, or, if thought better, the gall-bladder may be removed. The peritoneal surfaces in the region of the liver should then be wiped clean, and the abdominal wound closed, except for the passage through it of a gauze drain.
Biliary concretions, known as gall stones, are apt to form in the gall-bladder. They are composed of crystals of bile-fat, cholesterine. Sometimes in the course of a post-mortem examination a gall-bladder is found packed full of gall-stones which during life had caused no inconvenience and had given rise to no suspicion of their presence. In other cases gall-stones set up irritation in the gall-bladder which runs on to inflammation, and the gall-bladder being infected by septic germs from the intestine (bacilli coli) an abscess forms.
Abscess of the Gall-bladder gives rise to a painful, tender swelling near the cartilage of the ninth rib of the right side. If the abscess is allowed to take its course, adhesions may form around it and it may burst into the intestine or on to the surface of the abdomen, a biliary fistula remaining. Abscess in the gall-bladder being suspected, an incision should be made down to it, and, its covering having been stitched to the abdominal wall, the gall-bladder should be opened and drained. The presence of concretions in the gall-bladder may not only lead to the formation of abscess but also to invasion of the gall-bladder by cancer.
Stones in the gall-bladder should be removed by operation, as, if left, there is a great risk of their trying to escape with the bile into the intestine and thus causing a blockage of the common bile-duct, and perhaps a fatal leakage of bile into the peritoneum through a perforating ulcer of the duct. If before opening the gall-bladder the surface is stitched to the deepest part of the abdominal wound, the biliary fistula left as the result of the opening of the abscess will close in due course.
“Biliary colic” is the name given to the distressing symptoms associated with the passage of a stone through the narrow bile-duct. The individual is doubled up with acute pains which, starting from the hepatic region, spread through the abdomen and radiate to the right shoulder blade. Inasmuch as the stone is blocking the duct, the bile is unable to flow into the intestine; so, being absorbed by the blood-vessels, it gives rise to jaundice. The distress is due to spasmodic muscular contraction, and it comes on at intervals, each attack increasing the patient’s misery. He breaks out into profuse sweats and may vomit. If the stone happily finds its way into the intestine the distress suddenly ceases. In the meanwhile relief may be afforded by fomentations, and by morphia or chloroform, but if no prospect of the stone escaping into the intestine appears likely, the surgeon will be called upon to remove it by an incision through the gall-bladder, or the bile-duct, or through the intestine at the spot where it is trying to make its escape. Sometimes a gall-stone which has found its way into the intestine is large enough to block the bowel and give rise to intestinal obstruction which demands abdominal section.
A person who is of what used to be called a “biliary nature” should live sparingly and take plenty of exercise. He should avoid fat and rich food, butter, pastry and sauces, and should drink no beer or wine—unless it be some very light French wine or Moselle. He should keep his bowels regular, or even loose, taking every morning a dose of sulphate of soda in a glass of hot water. A course at Carlsbad, Vichy or Contrexéville, may be helpful. It is doubtful if drugs have any direct influence upon gall-stones, such as sulphate of soda, olive oil or oleate of soda. No reliance can be placed upon massage in producing the onward passage of a gall-stone from the gall-bladder towards the intestine. Indeed this treatment might be not only distressing but harmful. (E. O.*)
LIVERMORE, MARY ASHTON [RICE] (1821–1905), American
reformer, was born in Boston, Massachusetts, on the 19th of
December 1821. She studied at the female seminary at Charlestown,
Mass.; taught French and Latin there, taught in a
