CANCER OF THE LIVER CARCINOMA HEPATIS. 695 



3ases there is no jaundice. As icterus does not occur in most of the, 

 organic diseases of the liver, its presence with enlargement of the liver 

 is strong evidence that this is due to carcinoma rather than to other 

 diseases ; but its absence cannot be regarded as proof against carcino" 

 ma. Where the cancer of the liver is extensive, the urine shows the 

 peculiarities before mentioned, and appears peculiarly red or bluish 

 from the presence of abnormal coloring matter, resulting from the de- 

 struction of numerous liver-cells. 



While the above symptoms gradually occur, the diseases may gen- 

 erally be suspected from the . appearance of the patient, who looks 

 cachectic, is wasted away, has a relaxed skin, and oedema about the 

 ankles. In some patients the cancerous marasmus does not appear 

 till very late, and, even when large tumors may be felt in the liver, 

 they appear as well nourished and fresh as many patients with carci- 

 noma of the breast, before it has ulcerated. But even these patients 

 do not escape the injurious effects on the general health, which are 

 difficult to understand when the cancer does not suppurate. They 

 gradually become marasmic ; and, when the emaciation and exhaustion 

 have reached the highest grade, they generally die of dropsy. Among 

 the final symptoms we not uncommonly have thrombus of the fem- 

 oral veins, follicular catarrh of the large intestine, and shortly be- 

 fore death thrush not unfrequently comes in the mouth. 



Where there are large tumors in the liver, the physical examina- 

 tion not unfrequently gives important aid in diagnosis. In none of the 

 diseases of the liver, so far described, does the organ attain the size that 

 it may reach in carcinomatous degeneration. The liver, enlarged by 

 this disease, most frequently elevates the lower ribs, pushes them out- 

 ward, and forms a visible prominence in the abdomen, which often has 

 the outline of the liver, and may extend from the right hypochondrium 

 to below the navel and into the left hypochondrium. On palpation, 

 we usually distinctly feel the edge of the indurated organ, and on its 

 surface we find larger or smaller protuberances, which, are almost pa- 

 thognomonic of the disease. 



If the peritoneal covering of the tumor be the seat of a recent in- 

 flammation, we sometimes feel and hear a distinct friction from the 

 movements of the liver during respiration. If there be considerable 

 ascites, it may prevent exact examination of the surface of the liver ; 

 but if, by pushing the finger in quickly, we displace the fluid, we may 

 at least convince ourselves of its increased size and consistence. 



In most cases the above-described symptoms and course render the 

 diagnosis of cancer of the liver quite easy ; but, as we have before said, 

 it is occasionally difficult or even impossible. Where the cancer is in- 

 filtrated, or a few small cancerous nodules develop deep in the liver, 



