Liver

Liver (O. Eng. lifer; cf. cognate forms, Dutch lever, Ger. Leber, Swed. lefver, &c.; the O. H. Ger. forms are libara, lipora, &c.; the Teut. word has been connected with Gr. ἧπαρ and Lat. jecur), in anatomy, a large reddish-brown digestive gland situated in the upper and right part of the abdominal cavity. When hardened in situ its shape is that of a right-angled, triangular prism showing five surfaces—superior, anterior, inferior, posterior and right lateral which represents the base of the prism. It weighs about three pounds or one-fortieth of the body Weight.

Although the liver is a fairly solid organ, it is plastic, and moulds itself to even hollow neighbouring viscera rather than they to it. The superior surface is in contact with the diaphragm, but has peritoneum between (see Coelom and Serous Membranes). At its posterior margin the peritoneum of the great sac is reflected on to the diaphragm to form the anterior layer of the coronary ligament. Near the mid line of the body, and at right angles to the last, another reflection, the falciform ligament, runs forward, and the line of attachment of this indicates the junction of the right and left lobes of the liver. The anterior surface is in contact with the diaphragm and the anterior abdominal wall. The attachment of the falciform ligament is continued down it. The posterior surface is more complicated (see fig. 1); starting from the right and working toward the left, a large triangular area, uncovered by peritoneum and in direct contact with the diaphragm, is seen. This is bounded on the left by the inferior vena cava, which is sunk into a deep groove in the liver, and into the upper part of this the hepatic veins open. Just to the right of this and at the lower part of the bare area is a triangular depression for the right suprarenal body. To the left of the vena cava is the Spigelian lobe, which lies in front of the bodies of the tenth and eleventh thoracic vertebrae, the lesser sac of peritoneum, diaphragm and thoracic aorta intervening. To the left of this is the fissure for the ductus venosus, and to the left of this again, the left lobe, in which a broad shallow groove for the oesophagus may usually be seen. Sometimes the left lobe stretches as far as the left abdominal wall, but more often it ends below the apex of the heart, which is 3½ in. to the left of the mid line of the body. The relations of the lower surface can only be understood if it is realized that it looks backward and to the left as well as downward (see fig. 1). Again starting from the right side, two impressions are seen; the anterior one is for the hepatic flexure of the colon, and the posterior for the upper part of the right kidney. To the left of the colic impression is a smaller one for the second part of the duodenum. Next comes the gall bladder, a pear-shaped bag, the fundus of which is in front and below, the neck behind and above. From the neck passes the cystic duct, which is often twisted into the form of an S. To the left of the gall bladder is the quadrate lobe, which is in contact with the pylorus of the stomach. To the left of this is the left lobe of the liver, separated from the quadrate lobe by the umbilical fissure in which lies the round ligament of the liver, the remains of the umbilical vein of the foetus. Sometimes this fissure is partly turned into a tunnel by a bridge of liver substance known as the pons hepatis. The under surface of the left lobe is concave for the interior surface of the stomach (see Alimentary Canal: Stomach Chamber), while a convexity, known as the tuber omentale, fits into the lesser curvature of that organ. The posterior boundary of the quadrate lobe is the transverse fissure, which is little more than an inch long and more than half an inch wide. This fissure represents the hilum of the liver, and contains the right and left hepatic ducts and the right and left branches of the hepatic artery and portal vein, together with nerves and lymphatics, the whole being enclosed in some condensed subperitoneal tissue known as Glisson’s capsule. Behind the transverse fissure the lower end of the Spigelian lobe is seen as a knob called the tuber papillare, and from the right of this a narrow bridge runs forward and to the right to join the Spigelian lobe to the right lobe and to shut off the transverse fissure from that for the vena cava. This is the caudate lobe. The right surface of the liver is covered with peritoneum and is in contact with the diaphragm, outside which are the pleura and lower ribs. From its lower margin the right lateral ligament is reflected on to the diaphragm. A similar fold passes from the tip of the left lobe as the left lateral ligament, and both these are the lateral margins of the coronary ligament. Sometimes, especially in women, a tongue-shaped projection downward of the right lobe is found, known as Riedel’s lobe; it is of clinical interest as it may be mistaken for a tumour or floating kidney (see C. H. Leaf, Proc. Anat. Soc., February 1899; Journ. Anat. and Phys. vol. 33, p. ix.). The right and left hepatic ducts, while still in the transverse fissure, unite into a single duct which joins the cystic duct from the gall bladder at an acute angle. When these have united the duct is known as the common bile duct, and runs down to the second part of the duodenum (see Alimentary Canal).  
  
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From A. Birmingham Cunningham’s Text-book of Anatomy.  
Fig. 1.—The Liver from below and behind, showing the whole of the visceral surface and the posterior area of the parietal surface. The portal fissure has been slightly opened up to show the vessels passing through it; the other fissures are represented in their natural condition—closed. In this liver, which was hardened in situ, the impressions of the sacculations of the colon are distinctly visible at the colic impression. The round ligament and the remains of the ductus venosus are hidden in the depths of their fissures.  
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Fig. 2.—Transverse section through the hepatic lobules. | Fig. 3.—Vertical section through two hepatic lobules of a pig.  
  
i, i, i, Interlobular veins ending in the intralobular capillaries.

c, c, Central veins joined by the intralobular capillaries. At a, a the capillaries of one lobule communicate with those adjacent to it.

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c, c, Central veins receiving the intralobular capillaries.

s, Sublobular vein.

ct, Interlobular connective tissue forming the capsules of the lobules.

i,i, Interlobular veins.  
  
Minute Structure of the Liver.—The liver is made up of an enormous number of lobules of a conical form (see fig. 3). If the portal vein is followed from the transverse fissure, it will be seen to branch and rebranch until minute twigs called interlobular veins (fig. 2, i) ramify around the lobules. From these intralobular capillaries run toward the centre of the lobule, forming a network among the polygonal hepatic cells. On reaching the core of the conical lobule they are collected into a central or intralobular vein (fig. 2, c) which unites with other similar ones to form a sublobular vein (fig. 3, s). These eventually reach the hepatic radicles, and so the blood is conducted into the vena cava. In man the lobules are not distinctly separated one from the other, but in some animals, e.g. the pig, each one has a fibrous sheath derived from Glisson’s capsule (fig. 3, ct.).

Embryology.—The liver first appears as an entodermal hollow longitudinal outgrowth from the duodenum into the ventral mesentery. The upper part of this forms the future liver, and grows up into the septum transversum from which the central part of the diaphragm is formed (see Diaphragm). From the cephalic part of this primary diverticulum solid rods of cells called the hepatic cylinders grow out, and these branch again and again until a cellular network is formed surrounding and breaking up the umbilical and vitelline veins. The liver cells, therefore, are entodermal, but the supporting connective tissue mesodermal from the septum transversum. The lower (caudal) part of the furrow-like outgrowth remains hollow and forms the gall bladder. At first the liver is embedded in the septum transversum, but later the diaphragm and it are constricted off one from the other, and soon the liver becomes very large and fills the greater part of the abdomen. At birth it is proportionately much larger than in the adult, and forms one-eighteenth instead of one-fortieth of the body weight, the right and left lobes being nearly equal in size.

Comparative Anatomy.—In the Acrania (Amphioxus) the liver is probably represented by a single ventral diverticulum from the anterior end of the intestine, which has a hepatic portal circulation and secretes digestive fluid. In all the Craniata a solid liver is developed. In the adult lamprey among the Cyclostomata the liver undergoes retrogression, and the bile ducts and gall bladder disappear, though they are present in the larval form (Ammocoetes). In fishes and amphibians the organ consists of right and left lobes, and a gall-bladder is present. The same description applies to the reptiles, but a curious network of cystic ducts is found in snakes and to a less extent in crocodiles. In the Varanidae (Monitors) the hepatic duct is also retiform (see F. E. Beddard, Proc. Zool. Soc., 1888, p. 105). In birds two lobes are also present, but in some of them, e.g. the pigeon, there is no gall-bladder.  
  
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Fig. 4.—Diagrammatic Plan of the Inferior Surface of a Multi-lobed Liver of a Mammal. The posterior or attached border is uppermost.  
  
u, Umbilical vein of the foetus, represented by the round ligament in the adult, lying in the umbilical fissure.

dv, The ductus venosus.

vc, The inferior vena cava.

p, The vena portae entering the transverse fissure.

llf, The left lateral fissure.

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rlf, The right lateral fissure.

cf, The cystic fissure.

ll, The left lateral lobe.

lc, The left central lobe.

rc, The right central lobe.

rl, The right lateral lobe.

s, The Spigelian lobe.

c, The caudate lobe.

g, The gall bladder.  
  
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Fig. 5.—Human Liver showing a reversion to the generalised mammalian type.  
  
In mammals Sir William Flower pointed out that a generalized type of liver exists, from which that of any mammal may be derived by suppression or fusion of lobes. The accompanying diagram of Flower (fig. 4) represents an ideal mammalian liver. It will be seen that the umbilical fissure (u) divides the organ into right and left halves, as in the lower vertebrates, but that the ventral part of each half is divided into a central and lateral lobe. Passing from right to left there are therefore: right lateral (rl), right central (rc), left central (lc), and left lateral (ll) lobes. The gall-bladder (g), when it is present, is always situated on the caudal surface or in the substance of the right central lobe. The Spigelian (s) and caudate lobes (c) belong to the right half of the liver, the latter being usually a leaf-shaped lobe attached by its stalk to the Spigelian, and having its blade flattened between the right lateral lobe and the right kidney. The vena cava (vc) is always found to the right of the Spigelian lobe and dorsal to the stalk of the caudate. In tracing the lobulation of man’s liver back to this generalized type, it is evident at once that his quadrate lobe does not correspond to any one generalized lobe, but is merely that part of the right central which lies between the gall bladder and the umbilical fissure. From a careful study of human variations (see A. Thomson, Journ. Anat. and Phys. vol. 33, p. 546) compared with an Anthropoid liver, such as that of the gorilla, depicted by W. H. L. Duckworth (Morphology and Anthropology, Cambridge, 1904, p. 98), it is fairly clear that the human liver is formed, not by a suppression of any of the lobes of the generalized type, but by a fusion of those lobes and obliteration of certain fissures. This fusion is, probably correctly, attributed by Keith to the effect of pressure following the assumption of the erect position (Keith, Proc. Anat. Soc. of Gt. Britain, Journ. Anat. and Phys. vol. 33, p. xii.). The accompanying diagram (fig. 5) shows an abnormal human liver in the Anatomical Department of St Thomas’s Hospital which reproduces the generalized type. In its lobulation it is singularly like, in many details, that of the baboon (Papio maimon) figured by G. Ruge (Morph. Jahrb., Bd. 35, p. 197); see F. G. Parsons, Proc. Anat. Soc., Feb. 1904, Journ. Anat. and Phys. vol. 33, p. xxiii. Georg Ruge “Die äusseren Formverhältnisse der Leber bei den Primaten,” (Morph. Jahrb., Bd. 29 and 35) gives a critical study of the primate liver, and among other things suggests the recognition of the Spigelian and caudate lobes as parts of a single lobe, for which he proposes the name of lobus venae cavae. This doubtless would be an advantage morphologically, though for human descriptive anatomy the present nomenclature is not likely to be altered.

The gall-bladder is usually present in mammals, but is wanting in the odd-toed ungulates (Perissodactyla) and Procavia (Hyrax). In the giraffe it may be absent or present. The cetacea and a few rodents are also without it. In the otter the same curious network of bile ducts already recorded in the reptiles is seen (see P. H. Burne, Proc. Anat. Soc., Journ. Anat. and Phys. vol. 33, p. xi.).

(F. G. P.)

Surgery of Liver and Gall-bladder.—Exposed as it is in the upper part of the abdomen, and being somewhat friable, the human liver is often torn or ruptured by blows or kicks, and, the large blood-vessels being thus laid open, fatal haemorrhage 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.*)