Carcinoma of the liver is a disease of much greater importance than tubercular deposition, as it occurs very frequently and is often a primary affection.

Although we do not coincide with Cruveilhier, as to the frequency of its occurrence, it still must be considered as a common affection, and we would give its numerical relation to carcinoma of other organs as one to five. The greater frequency of its occurrence, as compared with tubercle of the liver, and considered in reference to the frequency of both affections in other organs, and especially in the lungs, and to the facts connected with the formation of cysts in the lungs and the liver, is a matter of particular interest.

These remarks apply to carcinoma of the liver generally, but not to its different varieties; of these, some are frequent, some occur less frequently, some very rarely.

Four varieties of carcinoma are found in the liver, which we will examine in succession.

Aa. Areolar Cancer

This form occurs so rarely, that it is never described among hepatic affections. One case of very extensive areolar cancer has come under my notice.

Bb. Carcinoma Fasciculatum Sive Hyalinum (Muller)

Although not as frequent as the following, it undoubtedly occurs often. It is generally taken for medullary carcinoma, and the mistake is accounted for by the fact that the two often coexist. It forms masses of the size of a filbert to that of a man's fist, which are surrounded by an investment of delicate cellular tissue; though the surface is uneven and lobulated, the general outline is round; its consistency varies, being sometimes but slight, at others almost cartilaginous; its color a pale yellowish-red, and generally of almost vitreous transparency. The carcinomatous masses are commonly found in considerable numbers, and like medullary cancer, they cause rounded protuberances of the viscus, and produce an increase in its weight and size.

Rr Medullary Carcinoma

This is the most common form of hepatic cancer, and almost all investigations that have hitherto been made in reference to this subject, treat of this variety only. It occurs either in the shape of detached masses, or as an infiltration of the hepatic parenchyma.

aaa. The detached masses occur as tumors, which offer many peculiar features.

Their general form is spherical, though their surface not unfrequently is slightly racemose or lobulated. Those which have been developed in the peripheral portion of the organ, and are therefore in contact with the peritoneum, present a flattened, or even an indented surface, and the indentation may extend to the very nucleus of the morbid growth. The peritoneal lamina in the indentation is opaque and thickened, owing, not as is commonly thought, to cartilaginous induration, but to an homologous cancerous degeneration of the serous and subserous tissue. This condition of the peritoneum is analogous to the relation the common integument bears to subjacent cancerous growths.

In size the medullary cancer varies from that of a millet- or hemp-seed to that of a man'6 fist, a child's head, and more. In most instances morbid growths of various sizes are found in the same individual. The larger those are which occupy the peripheral portion of the organ, the more prominent will be the protuberances on the surface.

The number of these adventitious products varies equally; sometimes there are but few, or even only a solitary one is found; at others they are very numerous. The greater the number of those occupying the peripheral portion of the organ, the more numerous will be the protuberances on the surface. When the morbid growths are numerous and large, two or more often coalesce.

We are unable to discover any peculiarity in reference to their position; they commence equally in the peripheral and in the deeper-seated portions of the intestine. They commonly make their first appearance in the right lobe.

As regards consistence, we find two varieties which have also been considered as differing in texture. They do not, however, constitute essential distinctions, but are merely different degrees of development of the same morbid growth.

One is of the consistency of bacon, and presents on section a smooth homogeneous, shining surface, of a dull white color, and without a trace of bloodvessels. On pressure, a small quantity of a thick creamy fluid exudes from the meshes of a dense fibrous structure. These growths are not detached from the adjoining hepatic tissue without considerable difficulty; and a distinct cellular investment can scarcely be demonstrated. The growths belonging to this variety, when coexisting with the second, are always the smaller of the two.

The second presents the physical characters of true encephaloid disease; its general color is milk-white, it is more or less vascular, and consequently in part gray, yellow, brownish, red, or even dark red; it is very spongy, and on pressure yields a large quantity of a thin milky fluid, which is contained in the meshes of a friable, fibrous tissue. The tumors are invested by a delicate cellulo-vascular sheath, and are easily detached from the hepatic parenchyma. When occurring simultaneously with the first variety, they generally form the large morbid growths.

The latter evidently represent an advanced stage of the morbid growth, as appears not only from the foregoing remarks, but also from the relations of the primary cell. (Vide vol. i).

/3/3/3. Infiltrated medullary cancer is analogous to the other infiltrations of the hepatic tissue, which we have already discussed. It always contains obliterated and obsolete bloodvessels and gall-ducts, which are gradually absorbed. The infiltration attacks larger or smaller segments of the viscus; it does not present distinct boundaries, but insensibly passes into the normal parenchyma. It rarely occurs without nodulated cancer. The carcinomatous mass presents the same two varieties in reference to consistence and to its elementary constitution. We find a transition from the diffused to the circumscribed form in the fact, that the nucleus of the latter is sometimes infiltrated hepatic tissue, which becomes endowed with independent growth, and merely forces the parenchyma out of its place.

The larger and the more numerous the carcinomatous masses are, the more extensive the cancerous infiltration, the more does the viscus increase in size and weight. The extracancerous tissue presents the nutmeg and adipose degeneration.

Medullary cancer is here, as elsewhere, the seat of hemorrhages, which are proportioned to the rapidity of its growth and the looseness of its texture. In rare cases it penetrates through the peritoneal investment of the liver, its development then proceeds with extreme energy, and it induces exhausting hemorrhages. In other cases it perforates the coats of large gall-ducts within, or of the biliary passages external to the liver, and grows into their cavities. In the infiltrated form we not unfrequently find extravasations of bile to a greater or less amount.

Medullary cancer rarely passes into suppuration, as it generally terminates fatally by inducing universal cachexia and exhaustion. Its fusion is still more rarely found to take place within a fibrous sheath, as is comparatively oftener the case in the spleen. Occasionally nature seems to attempt an arrest of the morbid growth, by a conversion into fat or adipocire.

Hepatic cancer undoubtedly very often occurs as the first of a successive series of cancerous deposits; yet, in the dead subject, it is commonly found combined with carcinoma of the lymphatic glands, that are seated near the biliary passages and in the lumbar region, with cancer of the stomach, of the intestine (especially of the rectum), of the peritoneum, of the kidneys, and with universal cancerous infection. It is often developed with remarkable rapidity after the extirpation of cancerous growths, and is then generally accompanied by cancer in the lungs.

rrr Medullary carcinoma not unfrequently occurs in the liver in the shape of cancer melanodes (melanosis), and equally as an infiltration, or in circumscribed masses. We find the most varied combinations of its elementary molecules with those of pure medullary cancer.

A common result of hepatic cancer making its way outwards, is inflammation of the peritoneum; the carcinomatous liver is consequently often found agglutinated to neighboring parts by means of cellular or cellulo-fibrous tissue, which may in its turn be subjected to cancerous degeneration.