Reprinted from the Occidental Medical Times, February, 1891. 
PRIMARY CARCINOMA OF THE LIVER. 
By D. W. Montgomery, M. D., Professor of Pathology, and Clinician 
fat.,.diseases of the Skin”,'Medical Department University of Cali- 
fornia; Clinician for Diseases of the Skin, San Francisco Polyclinic. 
Like all other organs of the body, the liver is at first a mass of 
embryonic tissue, composed of round cells. Out of this plastic 
mass either the simple tubular liver of the reptiiia or the very com- 
plicated liver of the higher mammalia may be developed. In the 
normal human liver there are sometimes found nodules more or 
less accurately circumscribed, consisting of cells somewhat larger 
than hepatic cells, with better defined margins, and arranged 
around a central lumen like the arrangement met with in the more 
simple tubular glands.1 No traces of bile are ever found in these 
cells, and in all probability they do not functionate. They seem 
to be groups of cells which have stopped in the course of their de- 
velopment at a stage represented by the reptilian liver, instead of 
going on to form the more complicated liver of the higher verte- 
brates. These nodules may remain wholly inert throughout the 
course of a long lifetime, or they may take on a sudden growth 
through the intervention of some unknown cause, or combination 
of circumstances, possibly from some slight but long continued 
irritation, or from some unusual flow of blood to the part. This 
new growth may consist either of connective tissue alveoli, con- 
taining cells arranged regularly around a central lumen, in which 
case it is called an adenoma, and is almost always a benign growth. 
The cells may be irregularly scattered in the alveoli like dice shaken 
up in a box, in which case it is called a carcinoma, and is a malig- 
nant growth, destructive in the locality in which it grows, and 
forming metastases in far distant organs. An adenoma of the 
1Article on Adenoma by Wm. T. Councilman, in Reference Hand- 
book of Medical Sciences. 2 
liver has been known to form a metastasis, as if to show our pow- 
erlessness to make a classification where Nature has drawn no dis- 
tinct lines of demarcation.2 
The only rule we can go by in these cases, in attempting to form 
a judgment ot their malignancy or innocence, is that the nearer 
they approach the type of a normal gland, and the more regular 
and orderly the arrangement of their elements, the greater likeli- 
hood of innocence. On the other hand, the more thev deviate 
from the normal type, the more certainly will they act as cancers. 
The truth seems to be that these cells are dangerous individuals 
in the community; they have been erratic from the beginning, and 
the best to be expected from them is that they may remain stunted 
and useless members, or, if they grow, that their only crime will 
be the room occupied, for on apparently slight cause they may 
break out into the most terrible and destructive form of malignancy. 
The foregoing process may, I believe, have been the origin of 
the cancer I shall now describe. 
On March 20, 1888, Dr. F. B. Carpenter, who was then mak- 
ing the autopsies at the city morgue, sent me a tumor of the liver 
for examination, with the following history : 
“ Body of well-nourished man, 38 years of age, right heart filled 
with dark fluid blood, heart muscle soft, lower lobe of left lung 
solid from lobar pneumonia; both kidneys large, having appear- 
ance of chronic nephritis; bladder contracted, walls very much 
thickened from chronic cystitis; spleen soft, liver large and yellow, 
and in the middle of the right lobe, directly above the gall bladder, 
but entirely unconnected with it, a tumor the size of a small orange. ’ ’ 
The tumor was a node lying in the depth of the right lobe. 
When cut into it looked like a perfectly round, ripe, succulent 
fruit let into the liver substance; there was a glistening callous rind, 
about an eighth of an inch in thickness, surrounding a purple, 
hemorrhagic, reticulated centre. There were no satellites in the 
neighborhood, nor were any other tumors found in the liver or in 
any part of the body. An oblong block of tissue was cut out of 
the tumor, including the advancing callous margin, and also the 
purple hemorrhagic centre. Sections from this block showed, ad- 
mirably, the nature of the growth. The callous margin was seen 
to consist of a dense connective tissue stroma, including in its al- 
veoli, cells, showing an attempt at a tubular arrangement; farther 
2Perls, Virchow’s Archiv, vol. 56, p. 436. 3 
in. the alveoli became much larger, the tumor lost all resemblance 
to a tubular gland, and there were abundant hemorrhages into the 
alveoli. It looked as if the connective tissue partitions between 
large groups of alveoli had broken down, forming much larger 
alveoli. The diagnosis was primary hemorrhagic adeno-carci- 
noma of the liver. There was extensive fatty infiltration of the 
liver, and the interlobular tissue in the neighborhood was densely 
infiltrated with round cells—an interlobulitis, in fact, probably from 
the irritation of the advancing tumor. 
Carcinoma originating in the liver is not by any means frequent, 
although, as long ago pointed out by Virchow, secondary depos- 
its, or metastases, occurring from cancer in some other part of the 
body are very frequent, and often grow to a very great size, far 
outstripping at times the primary growth, Haasemann has gone 
over the records of cases occurring in the Berlin Pathological In- 
stitute from 1870 to 1889 inclusive, and finds in all 258 cases. 
Only six were primary in the liver, and two of these are rather 
doubtful, the notes not being full enough to permit of certainty. 
He found that men and women were affected in about equal pro- 
portion. Age, however, plays an important role, for much the 
larger number occur in old age, though some undoubted cases 
have been observed in children.3 
Primary cancer of the liver occurs in three chief forms; as large 
nodes, sometimes a solitary node, or a large node with a few satel- 
lites in the neighborhood; as a diffuse infiltration, which, before 
microscopical examination, may easily be mistaken for ordinary 
cirrhosis of the liver; or, lastly, as nodules, following the course 
of the portal vessels. The present is of the first variety. As for 
diagnosis, none could have been made in this case; it is even 
very doubtful if the disease had given rise to any symptoms. If 
his life had not been cut short by an intercurrent, lobar pneu- 
monia symptoms, of course, would naturally have come with the 
development of the disease. Even in cases far advanced, where 
symptoms are very pronounced, the diagnosis of cancer of the 
liver is so surrounded with difficulties as to render it little more 
than a guess—a guess which we often hazard only to the relatives, 
and not to the patient. 
It must be admitted that the future holds out very little hope of 
3Ueber den primaren Krebs der Leber, Hafisemanu, Berlin, klin. 
Wochenschrift, November i6, 1890. 4 
making an early diagnosis in this class of cases. A great advance 
has been made of late years in our ability to recognize cancers 
at an early period of their history in situations where we are able 
to see them, and, if necessary, remove a piece for histological 
analysis; but cancer of the liver is very often a riddle, the first 
satisfactory solution of which takes place on the post-mortem 
table. 
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