In all cases of doubt in neoplasms of the liver, it is advised to explore the hilurn of the liver to see if there are any enlarged glandq present; if present, they show a metastasis from a malignant growth, and puncture is unnecessary; but their absence does not exclude a malignant growth. for if it is a second ary growth the metastasis would not be through the lymphatics, but through the venous channels, and the glands would not be enlarged. Primary cancer of the liver shows metastasis in the glands situ ated at the hilum. Tuffier (Gaz. lIebd. de Mkl. et de Chir., Jan. 2S, '97).
A very handy and accurate method of recording the size and position of ab dominal organs or tumors has been called the Keith method. It consists in first carefully percussing out the organ,—say, the liver. The limits of percussion-dull ness are then marked on the skin by black paint (Indian ink). Then with red paint the ribs are mapped out by a broad band drawn on the skin over each rib. When the coloring fluids have dried, a piece of thin, transparent nmslin is placed over the front of the body, large enough to cover the body from the clavi cles to the pubes. With red paint the red lines over the ribs, the arch of the subcostal angle, the nipples, and the um bilicus are then traced on the muslin, and finally the brush is drawn along the black outlines of the liver as they are seen through the muslin. On the muslin the patient's name and the date of draw ing, as -well as the disease should be painted for future reference and compari son with notc-book. By this method one preserves a life-sized drawing of the liver, and a permanent record. James Cantlie (Clin. Record, June 22, '9S).
Etiology.—Cancer of the liver is most frequently secondary to cancerous dis ease in the organs connected with the portal circulations. Hence it occurs secondarily to cancer of the stomach, rectum, colon, cesophagus, gall-bladder, bile-ducts, and pancreas. It also follows cancer of the uterus and ovaries and the mammary gland.
Tumors of the liver occurring as primary growths are very uncommon. They may spring from the epithelial structure, adenomata and carcinomata representing, this type, or from the con nective tissue, as represented by flbro neuromata and sarcomata. Secondary
carcinoma follows a primary growth in the stomach in about 25 per cent. of the cases. G. R. Fowler (Medical News, Feb. S. 1902).
It occurs usually in late adult life, especially between the fortieth and tieth years. but may occur in children.
The relative frequency of its occurrence in the sexes is doubtful; some observers state that it is more frequent in males, others in females. My own experience coincides with the former. Inquiry is a doubtful cause and cancer of the ducts is frequently associated with gall stones, but whether as a canse or a result is uncertain.
Morbid Anatomy. — As the primary growth is situated in some organ whose blood is carried to the liver by the portal vein, the liver becomes early affected, and often is the seat of large deposits at the time of death. The deposits are in the form of whitish nodules scattered irregularly throughout the liver just as we would expect, in view of infection through the blood of the portal vein. The nodules vary in size from a micro scopical point up to a mass occupying a large portion of the organ. As they grow in the direction of least resistance they appear early beneath the capsule, and if the abdominal wall is thin they may be felt and even seen through it. They may be firm from fibrosis or soft from degeneration; the former shows umbilication on the surface, owing to contraction of the fibrous tissue. The masses are globular, but coalescence may result in the formation of large irregular masses presenting, on section, a striking contrast to the liver-tissue. Their color may be a bright yellow, from bile-stain ing; dark-red, due to hemorrhage; or pale yellow, from fatty degeneration.
The secondary cancers are of the same structure as the primary one from which the infection was derived: usually alveo lar or cylindrical carcinoma. The peri toneum over them may be thickened and strong adhesions formed with the abdominal wall or diaphragm. Usually some of the bile-ducts are compressed, obstructing the flow of bile.