When the abscess discharges directly into the pleural cavity the one rule of treatment is to make a free opening into the pleural cavity, removin,g a portion of the rib if necessary, and to establish efficient drainage. When the lung-tissue is involved and abscess-formation has taken place, the ease should be treated as one of lung-cavity and the exploration and incision made into the chest, and not by way of the liver. K. Macleod (Brit. Afed. Jour., Sept. 1, 1900).
In order to reach the liver the peri toneum must be freely opened up with out interfering, with the costo-diapbrag matic cul-de-sac. 'ibe liver, having been exposed, is carefully isolated from the rest of the peritoneal cavity by means of -terilized compre,,e,; the abseesA then opened and drainage established without uashing out. ln 72 personal operations t re \111.t. 42 cure,. The fatal result. in ino-t of the 30 other.: in which the ab scess recurred after operations was due to the fact that the latter had been too lour. delayed. Giordano k Inter. Congress of Med; Brit. :Med. Jour.. Oct. 13, 1900).
Nlan,on', method of treating deep ,eated liver-abscess is to tap the abscess hv a large trocar and et-mania, introduc im.. a large drainage tube stretched upon a metal rod through the cannula and ap plyimr siphon drainage to carry off the Uf 4 cases operated upon within the last year, 3 recovered and 1 died. These 4 cases complete a series of 2S operated upon by this method by the author, of which 4 died. Ile is more eonvinced than ever of the efficacy and ,alety of treating liver-abscesses by the trocar and cannula. and is still more ready to condemn operations by the knife. Ile believes that the operation ,hould be done a, soon as pus is sus pected, and that the surgeon should not wait until the abscess has pointed on the abdominal wall or the chest-wall. J. t'antlie (Brit. Med. Jour.. Sept. 14, 1901).
Tumors of the Liver.
Of these, secondary carcinomata are, by far, the most common. Primary car cinoma, sarcoma, angioma, and lym phadenoma also occur. 1\lyxoma, sarcoma, and fibroma are rare forms.
Cancer of the liver is met with in about 3 per cent. of death-s from all causes, and in all persons affected with cancer the liver is the scat in 50 per cent. of the cases, the liver being third in order of frequency of internal cancer.
Symptoms.—In many, perhaps half, of the eases of cancerous disease of the liver there are no symptoms by which the dis ease can be recognized during life. The symptoms of the primary growth usually overshadow' those caused by the liver dis ease. The stomach is the seat of the primary growth in more than a quarter of all cases; so that symptoms of ive disturbances are usually prominent, such as loss of appetite, distress after food, nausea, and vomiting. Progressive loss of flesh and strength is an early symptom. Pain and uneasiness in the hepatic region are common, but in many cases of even extensive disease of the liver neither is present. No doubt both are often due to local peritonitis.
Progressive enlargement in malignant disease is almost invariable. When ir regular, the growth is generally second ary. Tenderness and pain is usually experienced. When the growth is deep seated, pain may be but little marked or absent. Outlying secondary growths may form on the falciform ligament. Gastric derangements are frequent. limmorrhages into the skin may occur ith or without jaundice. Jaundice and aseites are accidental symptoms. They both occur in about half the cases. In rare cases the ascitic fluid may be chylous. Emaciation of a steadily pro gressive type is most characteristic. Death often occurs within three months of the onset of symptoms. Gachexia is an important diagnostic sign.
Primary malignant disease of the liver seems to be more frequent in men than in women. Secondary growths are usually carcinomatous. H. D. Rolleston (Cliii. Jour., Mar. 3, '97).
The liver is usually enlarged. Hepatic dullness may extend upward to the fifth rib in the midaxillary line, to the left as far as the spleen, and the lower edge may be felt at or below the umbilicus. The lower edge and anterior surface be low the costal margin are hard and often uneven on account of the nodular posits. The nodules in some cases are felt to be umbilicated: an absolutely diagnostic sign. In eases of diffuse in filtration the liver may be very large; occasional instances are met with in which it is smaller than normal. The surface is smooth and hard and usually tender.