CANCER OF THE LIVER iS characterized by the increase in size of the organ, the presence of large nodules presenting um bilication, the absence of splenic enlarge ment, the cancerous facies, and, in gen eral, the presence of cancerous nodules elsewhere. Those cases in 1-vhich cancer of the organ is present without the de velopment of nodules upon the anterior surface of either lobe at times cause very great difficulty. Here the small size of the spleen, the character of the urine, the complexion, and other signs and symptoms, which ordinarily are regarded as of secondary importance, become of the highest value in diagnosis.
Attention called to the occasional re semblance between hypertrophic cirrhosis and hepatic carcinoma, and stress laid upon the difference in the stools, which are bilious in the former, clay-colored in the latter. Freyhan (Deutsche med. Zeit., May 8, '93).
In cases of SENILE, or MARANTIC, ATROPHY' the organ, if it can be pal pated, is smooth; there is absence of ascites and of jaundice.
The ATROPHIC NUTMEG LIVER (cya notic induration) and also the "hyper trophied" nutmeg liver are also charac terized by the smooth surface of the organ, as also by the prominent symp toms of obstructive disease of the heart.
Other forms of ascites and peritonitis are not infrequently mistaken for the results of cirrhosis; indeed, I think it may be said with confidence that the most frequent cause of false diagnosis of cirrhosis, is either CANCEROUS Or TUBER CULAR PERITONITIS. III such cases there may be present gastric and intestinal disturbances easily mistaken for those accompanying cirrhosis; the ascites may be of gradual development, as in portal cirrhosis; and the liver, being, by the accumulation of fluid, forced upward, may disappear behind the ribs and so be diagnosed as presenting great atrophy. Between cancerous and tubercular peri tonitis the distinction may be drawn that in the former the spleen is not enlarged, and in the latter the enlargement may be as extensive as in portal cirrhosis. In these cases, again, it is the secondary symptoms and signs which are of the areatest value in arrivin, at a decision: complexion, urine, etc., and, in addition to these, the character of the abdominal fluid when removed. Most important,
also are manifestations of disease else where, either cancerous or tubercular. In cases of doubt, to determine the tuber culous nature of the condition, it is well to inoculate a rabbit or guinea-pig, and, for the recognition of cancer, to make a careful search for cancer-cells in the re moved fluid.
Complications.—Leaving out of ac count the rare cases of development of a primary adenomatous or cancerous con dition, there may be other complicating conditions in the liver itself of the nature of degenerative changes; in advanced cases it is not infrequent to meet with evidence of fatty degeneration of the cells as distinct from the fatty infiltra tion seen in less advanced conditions; more rarely is amyloid degeneration present. Thrombosis of the portal vein occurs occasionally.
TUBERCULOSIS.—The naost frequent complication outside the liver is the de velopment of tuberculosis. Rolleston and Fenton find pulmonary tuberculosis in 32 out of 114 cases, tuberculosis being the direct cause of death in 17.ly flack, out of 121 cases, finds tuberculosis either active, latent, or obsolete in 25: i.e., 23 per cent. Of these 28, in 14 the condition was active in the lungs, in 12 in the peritoneum, and in 7 both in the lungs and peritoneum. Twelve, or about 10 per cent., of the cases died directly from tuberculosis; in S per cent. the condition was latent or obsolete.
Tuberculosis is a cause of cirrhosis of the liver. The liver becomes generally atrophied, indurated, and granular, like the cirrhosis which results from the abuse of alcohol, although in a less degree. More rarely, it becomes deeply furrowed and lobulated, as in syphilitic cirrhosis. Hanot and Gilbert (La Sem. Med., Feb. 3, '92).
A case of infectious cirrhosis of the liver, of unknown origin, in a rabbit that had been inoculated with a fragment of epithelioma of the kidney. Tuberculosis was not found in other organs, and tu bercle bacilli could not be found in the hepatic lesions. Psorosperms were like wise absent. The histological appear ances were unique, and indicated that the infection had spread from the centre to the periphery. Pilliet (Bull. de la Soc. Anat.. No. 17, '93).
Other frequent complications are: