REMOVAL OF AN ANGIOMA OF THE LIVER BY 
ELASTIC CONSTRICTION EXTERNAL TO THE 
ABDOMINAL CAVITY, WITH A TABLE OF S9 
CASES OF OPERATION FOR HEPATIC TUMORS. 
W. W. KEEN, M. D. 
BY 
Professor of the Principles of Surgery and of Clinical Surgery, 
Jefferson Medical College, Philadelphia. 
Read at the meeting of the Medical Society of the State of Pennsylvania, 
Pittsburg, May 19, 1897. 
Reprinted from the Pennsylvania Medical Journal, October, 
MURDOCH-KERR PRESS, 
PITTSBURG, PA. REMOVAL OF AN 
ANGIOMA OF THE LIVER 
By Elastic Constriction External to the Abdominal 
Cavity, with a Table of 59 Cases 
of Operation for Hepatic 
Tumors. 
Read at the Meeting of the Medical Society of the State of Pennsylvania, 
Pittsburg, May 19, 1897. 
W. W. KEENE, M. D., 
Professor of the Principles of Surgery and of Clinical Surgery, 
Jefferson Medical College, Philadelphia. 
Mrs. S. 8., aet. 53, Higins, Schuylkill co., 
Pa., was admitted to the Jefferson Hospital, 
February 19, 1897, at the instance of Dr. 
Hoffman. 
For the past five years her health has been 
failing. In January, 1894, she first noticed 
a tumor at the pit of the stomach. In July 
of that year it began to give her severe pain. 
These attacks of pain have been recurring 
at intervals of from one to three months, 
and have pulled down her health very much. 
They have been attended with nausea, but 
no vomiting. She has complained also of 
a burning pain in the right iliac fossa for 
ten years past; her bowels are very much 
constipated. Urine, amber color, acid, 
sp. gr. 1.028, no albumin or sugar, 
bile-pigment, sediment 
I A 1: V 
Her mother died of enteric fever at 60; 
father of apoplexy at 75. Of her brothers 
and sisters «the only noteworthy fact is that 
of three who died, one died of tuberculosis 
at 54; four others are living and in good 
health. As a girl she was delicate. She 
was married at 23 and has had four chil- 
dren. Her menstruation began at seven- 
teen and was always normal. During the 
past year it has become irregular, the last 
period occurring in October, 1896; “:~r~ 2 
very slight. Microscopic examination nega- tached. The size of the tumor was 7.5 cm. 
On examination, an elastic tumor is felt 
to the right of the median line, about mid- 
way between the level of the umbilicus and 
the ensiform cartilage. It is so superficial 
that on touching it I almost thought it was 
in the abdominal wall, but a more careful 
examination showed that it could be pushed 
under the abdominal wall in every direc- 
tion, but especially vertically. It was quite 
tender on pressure. It measured 7.5 cm. 
in diameter. It was slightly movable in 
respiration. It was dull on percussion, and 
two fingers breadth of tympany divided it 
from the hepatic dullness. A test meal was 
given and the result showed free Hydro- 
chloric acid. By a syringe the stomach was 
inflated with air through the stomach tube 
after it had been evacuated of the test meal. 
The dilatation of the stomach did not alter 
the position of the tumor, but it was not 
quite so prominent or well defined. In the 
left popliteal space, just external to the in- 
ternal hamstring muscles, is a small tumoi. 
The diagnosis lay between a tumor of the 
liver, of the stomach, of the colon, or of 
the omentum. In spite of the movement 
with respiration, the tympany between it 
and the liver, and the impression made by 
its palpation were against its being con- 
nected with the liver. The test meal and 
inflation of the stomach convinced me that 
it was not gastric; the absence of any dis- 
turbance of the bowels that it was not con- 
nected with the colon. I, therefore, rather 
by exclusion, than otherwise, thought it 
most likely connected with the omentum, 
though not excluding absolutely the liver 
as its origin. 
transversely, and it extended backwards in- 
to the liver for a space of about 6.5 cm. The 
tumor presented on the surface of the liver 
a rounded bosselated surface. It was ele- 
vated above the surface about a half inch. 
I was quite uncertain as to its character, 
and, therefore, as Prof. Coplin was present, 
asked him to look at it with me, and he 
suggested that it was an angioma. On fur- 
ther examination of the tumor by pressure 
I became convinced that he was quite right. 
The veins were nearly as large as my little 
finger. As it extended upward, evidently 
encroaching upon the body of the liver, and 
by the attacks of pain disabled the patient 
from any household work, and as no other 
similar tumors were to be seen, I deemed it 
best to operate. I did not think it wise to 
attack it with the knife or to attempt 
to amputate it completely, even by 
the Paquelin cautery, in view of the 
very large vessels evidently leading 
into it, nor did I think it was sufficiently 
well defined for enucleation. Accordingly, 
I cut down through the liver tissue into its 
substance, so as to make a sort of artificial 
pedicle for the tumor, the pedicle itself be- 
ing nearly 5 cm. in breadth. (Fig. 1.) Then 
Shows how by the cautery the artificial pedicle was 
formed and constricted by rubber tubing. 
I encircled its base with an elastic rubber 
tube, tying this as tightly as I could draw it. 
I afterward placed a second one just above 
it. I then closed the entire wound, packing 
around the tumor and below the elastic lig- 
atures a collar of iodoform gauze, the tumor 
itself being drawn outside the belly through 
the abdominal incision. No pins or su- 
tures were necessary to secure it to 
the belly wall, as its bulk prevented 
it falling back into the abdominal cav- 
ity. The wound was partly closed at each 
Operation, March 4, 1897. An incision 
was made from the border of the ribs to the 
level of the umbilicus in the middle of the 
right rectus. The liver at once presented. 
Two fingers introduced into the abdomen 
showed that there was a tumor at the lower 
border of the liver, just to the left of the 
notch where the round ligament was at- 3 
end and an ample gauze dressing was then 
applied. The wound was dressed at inter- 
vals of two days. At the end of forty-eight 
hours the tumor was distinctly shrinking 
and showed the effect of strangulation. On 
the sixth day the rubber ligatures were re- 
moved, and as there was but a small pedicle 
left, this was divided by a pair of scissors 
nine additional cases. At the time of pub- 
lication of my first paper, my impression 
was that the case of Langenbuch in 1888 
was the first case reported. Dr. Spencer 
has, however, found an earlier case by Lius, 
dating back to 1886. This operation was 
for the removal of a constricted lobe of the 
liver. In addition to this, Von Hacker 
{Wien. med. Woch., 1886, Nos. 14 and 15) 
had already reported one case of constricted 
lobe of the liver, which was not removed 
but fixed to the abdominal wall, by Billroth, 
and Tscherning {Centralblatt f Chirurgie, 
1888, No. 23) had operated on a similar 
case. Both of these recovered and were 
cured. 
The number of cases in my combined 
tables, it will be observed, is not very large 
(59), but they are increasing somewhat in 
frequency, as surgeons become more and 
more aware of the possibilities of hepatic 
surgery. From 1886 to 1892—six years— 
twenty-one cases were operated on; from 
1892 to 1897—five years—we have thirty- 
eight additional cases. 
Fig 2. Shows the shrunken and mummified tumor and its ped- 
icle after removal. Natural size. 
without the loss of a drop of blood. Fig. 2 
shows the tumor shrunken and mummified 
of the natural size when removed. The 
constricted pedicle is well seen. The 
remaining portion of the pedicle slowly 
sloughed off and became detached at the 
end of ten days. A small amount of bile 
escaped from the liver stump. The stump 
remained adherent to the abdominal wall. 
The wound contracted slowly. It was skin- 
grafted by Reverdin’s method once. Cica- 
trization proceeded, becoming complete by 
the 25th of April (52 days). Her highest 
temperature after the operation only once 
reached 100 degrees, on the fourth day af- 
ter the operation. She suffered almost no 
pain. Fig. 3, from a photograph, shows the 
scar. 
In my former table, two of the cases were 
In the Boston Medical and Surgical Jour- 
nal, for April 28, 1892, I published a case 
of resection of the liver for an adenoma of 
the bile ducts and with it a table of twenty 
cases, compiled by Dr. T. S. Westcott. This 
first case, after five years and a half, is still 
entirely well. The present paper contains 
the only case I have had since 1892, and 
Dr. George W. Spencer has tabulated thirty- 
Fig. 3. The resulting scar. From a photograph. 
American and 18 European; in my present 
table seven are American and the others 
(thirty-two) European. Combining now the 
two tables together, we find the following 
facts: 
I. Mortality. Of the 59 cases reported, 4 
the termination of one (No. 12) is uncertain, quent; especially should the suspicion of the 
Of the other fifty eight, 49 recovered and 9 
died, a mortality of 15.5 per cent. Consider- 
ing the novelty of such operations and the 
great vascularity of the liver, as well as the 
fact that the abdomen has to be opened, 
this is quite a gratifying result. The cause 
of death of the 9 cases has been shock ; 
hemorrhage, and exhaustion, 7; septicemia, 
hepatic origin of the tumor be entertained 
if the tumor rises and falls with the respira- 
tory movements of the diaphragm. 
V Duration. The long duration of the 
tumor, even in some of the malignant cases, 
is striking. In 14 cases it is placed statis- 
tically at less than a year. After that, in 
the non-malignant cases, a number of them 
existed for several years, one (No. 48), an 
adenoma, for twenty years, which then be- 
came cancerous, presumably after an acci- 
dent. Another (No. 34), a cystoma, existed 
for fifteen years. A third (No. 32), a car- 
cinoma, was said to have existed for ten 
years; eighteen years earlier a cancerous 
cervix uteri had been operated upon. The 
autopsy eighteen years later showed the 
uterus free from disease, but the liver and 
right kidney were involved in the cancer. 
Another case of carcinoma (No. 25) had 
existed for several years. 
11. Age. The extremes were days 
and 67 years. The baby of 2,\ days (No. 
50) was operated on for an umbilical hernia 
of the left lobe. By decades, the cases oc- 
curred as follows: 
Under twenty 4 
Twenty-one to thirty 12 
Thirty-one to forty 10 
Forty-one to fifty 12 
Fifty-one to sixty 8 
Sixty-one to seventy 2 
Total 48 
Showing that age seems to have no spe- 
cial influence. 
Even more surprising is the survival of 
the patients a long time after operation, 
even for what was believed to be a cancer- 
ous growth. 
111. Sex. The influence of sex on the 
contrary is very striking; 42 were women, 
as against 9 men. That this disproportion 
is due to the constriction of the chest in 
women from their clothing is, I think, al- 
most certain. 
Eiselsberg {Wien. klin. Woch. 1893, P- 
-2) states that Hochenegg’s case (No. 13 of 
former table) was alive three years after the 
operation. V. Bergmann’s case (No. 35) 
was well after a year, and Lucke’s case (No. 
18 of the former table), a case of carcinoma 
as large as a fist, was well two years after 
operation {Centralblattf. Chirurgie, 1892, p. 
844). Schrader’s case (No. 53), a carcinoma, 
was well seven years later. Such clinical re- 
sults should encourage us certainly to radi- 
cal interference even in malignant growths. 
Wolfler’s recent report of the excellent final 
results after enterectomy for cancer give us 
exactly the same encouragement. He 
has shown that four cases of resection of the 
intestine for malignant growths have sur- 
vived from 6 to 19 years {Annals of Surgery, 
May, 1897, 646). 
IV. Diagnosis. Most of the cases re- 
ported, as pointed out in my former paper, 
have been with a wrong diagnosis. The 
omentum, the ovary, the abdominal wall, 
the colon, the kidney and the mesentery 
have all been supposed to be the origin of 
thetumor. Itis a striking fact in both tables 
that in a large number of the cases there 
was an area of tympany between the tu- 
mor and the hepatic dullness, which, nat- 
urally, led to the conclusion that the tumor 
was not connected with the liver. In both 
of my own cases the diagnosis was incor- 
rect, one being thought to be a tumor of 
the kidney the other of the omentum. Sim- 
ilar errors of diagnosis, now that this fact 
has been pointed out, should be less fre- 
VI. Varieties. The following various 
forms of tumor are mentioned; 5 
Removal of constricted or herniated left 
lobe 4 
ods have been employed, so that it is impos- 
sible to draw any conclusions from a tabula- 
tion showing the relative frequency with 
which each method has been used. 
Syphiloma n 
Carcinoma 10 
Adenoma 6 
Sarcoma 4 
Angioma. 4 
Caveroma i 
(1) The Ligature. Kousnetzoff and Pen- 
sky {Rev. de Chir., 1896, pp. 501 and 954) 
have considered the methods quite exhaus- 
tively both from the clinical and the experi- 
mental point of view. They have shown un- 
questionably that the individual vessels of 
the liver can be successfully ligated and 
that their walls are sufficiently strong to 
sustain a weight running from 290 grams 
to 1,600 grams (p. 966) in most cases with- 
out rupture. It is rather surprising to see 
that the isolated hepatic veins are on the 
whole stronger than the isolated arteries. 
A later article by Auvray in the same jour- 
nal (1897, p. 319) confirms the result of these 
authors. In my first case, I was able, though 
using the Paquelin cautery, to tie several 
large vessels before severing them. This 
was also Elliot’s experience (No. 54). When 
the vessels are tied, these authors have 
pointed out the importance of tying the knot 
firmly, but slowly. If drawn quickly, the 
ligature will cut through the hepatic tissue; 
if drawn slowly it will not. Possibly a flat 
ligature, such as kangaroo tendon or floss 
silk will answer better than the narrower 
twisted or braided silk. Sometimes by a 
continuous double thread the liver has thus 
been tied by a row of ligatures. In doing 
this, the authors referred to have suggest- 
ed, and it seems to me wisely, that a blunt 
needle be employed instead of a sharp point- 
ed one, so as to avoid perforation of any 
vessels. 
Cystoma I 
Angio-fibroma x 
Small calculi x 
Endothelioma i 
Echinococcus and hydatid cysts 14 
Total 58 
Perhaps the only striking fact in connec- 
tion with the varieties of tumor is that there 
are so many. 
VII. Size and number. The size varied 
from very small ones up to those of the size 
of an adult head. 
Only single and primary growths should 
be attacked. When malignant disease is 
secondary or exists as multiple tumors it 
should be let alone. 
VIII. Technique of removal. One of 
the most important and certainly one of the 
most encouraging points is the improve- 
ment in the technique. Until ten years ago 
the liver was not deemed amenable to sur- 
gical attack on account of its vascularity. 
This is still the one great danger as is shown 
in the history of almost all the cases, and in 
the fact that six of the eight deaths are at- 
tributable to shock,hemorrhage and exhaus- 
tion. The small mortality shows that this 
is not by any means an unsurmountable 
danger. The danger of hemorrhage, even 
after small punctures, is such that on no 
account should the liver be punctured, ex- 
cept after coeliotomy, so that if hemorrhage 
occurs it can be effectually dealt with. The 
cases of fatal hemorrhage after aspiration, 
reported by Ricard and Broca {Rev. *de 
Chir., March, 1897, 25°)> should warn us 
against similar misfortunes. 
(2) Gauze and Hot Water. This method 
will be of service occasionally, but on the 
whole is inferior to the other methods. 
Four methods of checking hemorrhage 
have been employed. First, the ligature: 
second, packing with gauze wet with hot 
water; third, the cautery; fourth, the elastic 
ligature. Not uncommonly, and very 
wisely, two or more of these various meth- 
(3) The Paquelin Cautery. This is one 
of the most valuable means, and I would 
draw attention especially to the method of 
its employment in the case I have reported 
in this paper, namely: by cutting obliquely 
into the liver substance in such a manner 
as to make an artificial pedicle. It should 6 
be employed at the lowest heat which will 
cut the liver substance, a dull red, and by 
repeated applications will control almost any 
hemorrhage. In many, if not in most cases 
not suited to enucleation, the tumor may be 
entirely removed by this means with little 
or no hemorrhage. 
In all cases in which it is possible to treat 
the stump by the intra-peritoneal method, 
this should be done. It was the method 
adopted in my first case, and I believe is 
by far the best; but where there is danger 
of recurrent hemorrhage, or where an elas- 
tic ligature is used, it is, of course, impossi- 
ble to treat the stump intra-peritoneally. If 
treated intra-peritoneally, the stump, if pos- 
sible, should be constructed in the form of 
flaps, as in my first case, and the flaps su- 
tured together as after an amputation. If 
not so treated, the stump should be seared 
with the Paquelin cautery, as was done by 
Elliot, and the stump walled off by gauze. 
The peritoneum will care for and absorb 
the aseptic slough caused by the cautery. 
(4) The Elastic Ligature. This method 
has been employed by Terrillon (No. 19), 
Kiister (No. 27), Schmidt (No. 36), Czerny 
(No. 23), Israel (No. 38), Tricomi (No. 40), 
Mayo Robson (No. 47), Rosenthal (No. 55), 
DTJrso (No. 56), Watson (No. 57), and 
myself (No. 59). It proved most reliable 
in all these cases. It is to be noted, how- 
ever, that Kiister’s case died from sep- 
ticemia. That this had its origin in the 
gangrene produced by the elastic ligature 
there can be little doubt. Its use may 
be, therefore, somewhat questionable, but 
in a case like my own, it was hardly avoid- 
able. I think that the danger from pri- 
mary hemorrhage by any other method 
would have been greater than the dan- 
ger from possible infection. The collar of 
iodoform gauze was a valuable means of 
preventing infection of the peritoneum. 
Krister’s method of passing the ligature was 
ingenious. A canula was first passed, and 
through this two elastic ligatures were in- 
troduced through the substance of the liver. 
In some cases the constricted tumor was 
removed immediately. In others it was se- 
cured to the abdominal wall by pins or su- 
tures, or, as in my own case, simply held in 
place by the partial closure of the abdominal 
wound above and below the tumor. The 
utmost care was used to have the pedicle, 
the tube and the dressing aseptic. If this 
is done, and the iodoform collar used, I do 
not think that the danger of elastic con- 
striction, and allowing the tumor to remain 
for several days till adhesions between the 
stump and the abdominal wall have taken 
place, is at all great. The absolute avoid- 
ance of hemorrhage is of the utmost im- 
portance. 
When the tumor has sloughed off in the 
cases in which the elastic ligature has been 
used, the pedicle heals very slowly. In my 
own case it required six weeks before the 
wound was entirely cicatrized, and even 
then with the assistance of small skin grafts. 
The same expedient of skin grafting was 
adopted by Czerny (No. 23) and Schmidt 
(No. 36). 
Occasionally the operation will be best 
done in two stages, but where possible this 
should be avoided. 
The conclusions that I have reached are 
as follows: 
First. Experiments upon animals and op- 
erations on man have shown that tumors 
of the liver and even large portions of the 
liver can be removed without undue dis- 
turbance of its function. Experimental evi- 
dence in animals and clinical evidence in 
man go to show that the liver tissue is re- 
generated and the loss made good (Pon- 
fick). 
Secondly. That the escape of bile into the 
peritoneal cavity is not usual after such an 
operation, that by searing the raw surface, 
by ligation, by walling off with gauze, and 
by securing the stump in the abdominal wall, 
it is prevented, and even if it occurs, fresh 
bile is not infective, and, therefore, does not 
produce peritonitis. 
In two cases (Nos. 44 and 50) the gall 
bladder was removed along with the tumor. 7 
Thirdly. The two dangers of hepatic op- in which an abdominal section revealed the 
erations are sepsis and hemorrhage, espe- 
dally the latter. The former can be prevent' 
syphilitic nature of the large tumor, is most 
instructive. The operation was at once ter- 
Ed by modern antiseptic methods; the lattei 
minated; the abdomen was closed and the 
can be mastered by ligation, by the cautery, 
by the elastic ligature or by pressure, or still 
patient entirely recovered under suitable 
treatment. 
better, by a combination of these means. 
Fourthly. The removal of a tumor can be 
Sixthly, 
. In all cases of doubt, and after 
done by ligation, by blunt dissection, by the 
a fair trial of anti-syphilitic treatment, pro- 
videcf time allows, an exploratory coeliot- 
cautery, or by the knife or scissors, or by 
omy should be done. If the case is unsuit- 
able for operation, because it is syphilitic or 
by reason of its size, adhesions, multiplicity 
combination of these methods. If the base 
is very large or the tumor very vascular, an 
artificial pedicle can be made by the cautery 
and an elastic ligature applied. 
Fifthly. In case a syphilitic tumor is sus- 
of tumors, or for any other similar reason, 
the abdomen is simply closed and very rare- 
ly will any mischief be done. 
On the other hand, if, as will very fre- 
quently be the fact, the case proves to be 
operable, suitable surgical measures can be 
immediately instituted. 
pected, no operation should be done until 
after a full trial of anti-syphilitic treatment 
has been made and failed. The case of 
Ahlenstiel (Archiv klin. Chir., 211, 902), 
Demonstrator of Surgery, Jefferson Medical College. * 
Table of 59 Cases of Resection of the Liver for Tumors 
, compiled by Dr. G. W. Spencer 
1 
NO. 
REPORTER AND 
REFERENCE. 
SEX. 
AGE. 
DURATION, NA- 
TURE AND SIZE. 
METHOD OF 
REMOVAL. 
TREATMENT OF LIVER 
STUMP. 
RESULT. 
REMARKS. 
21 
Lius. 
Revue de Chir- 
urgie, 1896, No. 
12, p. 977. 
F. 
67 
Six months. 
Constricted lobe 
o' liver. 
Size of a man’s 
head. 
Ecraseur and 
cautery. 
Attempted to stitch 
stump to abdominal 
wall but sutures 
tore out, so liver, no 
longer bleeding,was 
returned into abdo- 
men. 
D. 
Six hours 
after oper- 
ation from 
h e m 0 r - 
rhage. 
Part removed was 
similar to normal liver 
tissue. 
22 
Koenig. 
Revue de‘ Chir- 
urgie, 1896, No. 
12, p. 986. Lehr- 
buch d. Speci- 
ellen Chirurgie, 
1889, II. 223. 
F. 
II 
Six months. 
Cystic adenoma 
of bile ducts. 
Liver wound closed 
by sutures of hep- 
atic peritoneum. 
R. 
Three liters of fluid 
evacuated. 
23 
Czerny. 
Wratsch, 1890, 
No. 27. 
Large syphilo- 
ma of the right 
lobe. 
Tumor was 
brought out of 
the abdominal 
wound, c 0 n- 
stricted with an 
elastic ligature 
and excised with 
bistoury. Veins 
and arteries 
were tied. 
The stump was 
cleaned and thermo- 
cauterized. Edges 
of liver sutured to 
the edges of the ex- 
ternal wound. 12 
days after oper- 
ation the stump was 
skin grafted. 
R. 
The hemorrhage was 
not severe. 
24 
Albert. 
Wien. k 1 i n. 
W 0 c h e n s hr., 
1890, No. 52. 
Syphiloma of 
the right lobe, 8 
cm. in diameter. 
Opened a layer 
of normal liver 
tissue with the 
cautery. Extir- 
pated with blunt 
instruments. 
Bleeding cavity 
packed with iodo- 
form gauze. The 
gauze was applied 
in rolls to the edges 
of the wound and 
held in place by 
means of sutures. 
The capsule was 
sutured over the 
tampon. Edges oi 
the liver fixed to ex- 
ternal wound by a 
steel needle. 
R. 
After the operation 
the patient was free 
from pain. 
25 
Jacobs. 
Revue de Chir- 
urgie, 1896, No. 
12, p. 992, Arch, 
de Tocol. et de 
G y n e c. de 
Bruxelles, 1891, 
No. 10, p. 742. 
F. 
5° 
Several years. 
Size of orange. 
Cancer of the 
liver. 
Section by the 
thermo - cautery 
and drain. 
R. 
Diagnosis: Fibroma 
of abdominal wall. 
Recurrence in seve 1 
months. 
*For the first 20 cases, see the Boston Medical and Surgical Journal, April 28th, 1892. 8 
NO. 
REPORTER AND 
REFERENCE. 
SEX. 
AGE. 
DURATION, NA- 
TURE AND SIZE. 
METHOD OF 
REMOVAL. 
TREATMENT OF LIVER 
STUMP. 
RESULT. 
REMARKS. 
26 
Mueller. 
Revue de Chir- 
urgie, 1896, No. 
12,p. 985. 
XX 1 1. K di- 
gress der Deut- 
schen Chirur- 
gen, 1892. 
F. 
Three years. 
Tumor compos- 
ed of dilated 
biliary vessels. 
Tumor was 
brought out of 
abdominal 
wound. Pedi- 
cle ligated. 
R. 
Diagnosis: Cyst oi 
the ovary. 
27 
Kuester. 
Revue de Chir- 
urgie, 1896, No. 
12,p.986. XXII. 
Kongress der 
Deutscben 
Chirurgen, 1892, 
I. 12. 
Carcinoma of 
the liver, begin- 
ning in the gall 
bladder. 
Two elastic lig- 
atures passed 
through a can- 
ula and tied, 
leaving tumor 
outside abdom- 
inal wall. 
D. 
From sep- 
ticaemia. 
28 
Schmidt, F. 
ditto, I. 9. 
F. 
60 
Adenoma. 
Cavity curret- 
ted with a sharp 
spoon and pack- 
ed. 
R. 
29 
Bardeleben. 
ditto, I. 10. 
M. 
Sarcoma of the 
liver, size of 
child’s fist. 
Sutures passed 
around it, but 
did not hold. 
Cavity then 
packed. Chiefly 
blunt dissection. 
R. 
Well after two years. 
3° 
Doyen, 
Revue de Chir- 
urgie, No. 12, 
1896, p. 980, Ar- 
chives Provin- 
ciates de Chir., 
Paris, 1892, No. 
2, p. 149. 
F. 
23 
Several months. 
Size of child’s 
head on the left 
hepatic lobe. 
Ligated pedi- 
cle. An at- 
tempt was made 
to remove the 
tumor with the 
cautery, but 
this caused pro- 
fuse hemor- 
rhage. 
Stump was returned 
to the abdominal 
cavity. 
R. 
Diagnosis: Ovarian 
cyst. Liver in a con- 
dition of fibrou de- 
generation. 
31 
Martin (c). 
Bir m i n g h a m 
Med. Rev., 1892 
XXXII., p. 292 
F. 
21 
Six months. 
Cystic. The tu- 
mor bulged out 
between the 
lo er ribs and 
the iliac crest. 
Liver substance 
was incised to a 
depth of about 
hall an inch. 
The cyst was 
tapped and enu- 
cleated. A huge 
raw bleeding 
cavity was left. 
The margins of the 
liver incision were 
stitched to the mar- 
gins of the abdom- 
inal incision. The 
hemorrhage from 
the stump was 
checked by a firm 
abdominal com- 
press, which was 
applied in such a 
way that the walls 
of the hepatic cavity 
were pressed against 
each other. 
R. 
One month 
after oper- 
ation. 
At the time of the 
operation the wound 
was drained with a 
glass tube, which was 
removed on the sixth 
day and replaced on 
the ninth day by a 
rubber tube. This tube 
was removed on the 
thirteenth day, and by 
the nineteenth day the 
temperature had risen 
to 1040. A rubber 
tube was reintroduced 
and a large quantity 
of pus evacuated. 
32 
Ludlam. 
Clinique, Chi- 
cago,1892. Xl II, 
39- 
F. 
S1 
Duration ten 
years. 
Cancerous 
growth of the 
right lobe. Size 
of the adult 
head. 
Excised. Hem- 
orrhage checked 
by forceps. No 
large vessels ex- 
posed, 
D. 
F i f t e e n 
hours after 
0 p e r a t i on 
from shock. 
Eighteen years before 
this operation, the 
cervix uteri was ampu- 
tated for a cancerous 
growth. Autopsy: 
Whole liver involved 
in the cancerous infil- 
tration. Uterus was 
normal. Right kidney 
was involved. 
33 
Hanks. 
Am. J. Obs., 
1892, XXV., p. 
229. 
F. 
Angioma of 
lower lobe, 
which extended 
three inches be- 
yond the me- 
dian line. 
Punctured the 
tumor. Closed 
abdomen and 
treated the pa- 
tient by galvan- 
ism. 
R. 
The tumor decreased 
two-thirds in size. 
Once used galvano- 
puncture. Tumor de 
creased two-thirds. 
34 
Eiselsberg. 
Revue de Chir- 
urgie, 1896, p. 
510, Wien. klin. 
Wo ch e nschr., 
1893, No. 1. 
F. 
59 
Duration fifteen 
years. 470 
grammes. Ca- 
vernoma right 
lobe, size of 2 
fists. 
By blunt dissec- 
tion at first, then 
on account of 
hemorrhage, the 
excision was 
done with the 
cautery through 
sound liver tis- 
sue; stitched 
capsule. 
Liver wound was 
packed with iodo- 
form gauze held by 
the threads. The 
gauze was then 
brought out through 
the abdominal 
wound. 
R. 
In 7 weeks. 9 
NO. 
REPORTER AND 
SEX. 
AGE. 
DURATION, NA- 
METHOD OF 
TREATMENT OF LIVER 
RESULT. 
REMARKS. 
REFERENCE. 
TURE AND SIZE. 
35 
Bergmann. 
M. 
6l 
Adenoma. 12 
Tumor was 
Stump was returned 
R. 
Diagnosis of echino- 
Arch. f. klin. 
cm. broad, 2 cm. 
brought out the 
into the abdominal 
In 6 weeks. 
COCCUS. 
Chirurg., 1893, 
thick. 
abdominal 
cavity. 
Bd. XLVI., p. 
wound and ex- 
400. 
cised. Hemor- 
rhage was treat- 
ed by placing 
deep sutures in 
the wound,these 
sutures cut 
through. Ves- 
sels were ligat- 
ed. Cautery was 
used. Wound 
was packed with 
iodoform gauze, 
and gauze was 
brought out 
lower end of ab- 
dominal inci- 
sion. 
36 
Schmidt, G. B. 
F. 
37 
Syphiloma, 8 
Elastic ligature 
Edges of liver cavity 
R. 
The diagnosis was be- 
Deutsche medi- 
cm. long, 6 cm. 
was applied 
secured in abdom- 
One 
month 
tween a tubercular 
cin. Woe hen- 
broad, cm. 
around the base 
inal incision. 12 days 
after 
oper- 
, 
ulcerated tumor of 
schr., 1893, No. 
thick. Under 
of the tumor. 
after the operation 
atiox 
the transverse colon 
19, p. 175. 
the 10 b u 1 u s 
Tumor was re- 
the wound was skin 
and a carcinoma. 
quadratus. 
moved by knife. 
grafted by the 
Four arteries 
and six veins 
were caught by 
forceps and lig- 
ated. 
Thiersch method. 
37 
Rosenthal (J). 
F. 
41 
Angio fibroma. 
Tumor was 
Five days after the 
R. 
Many adhesions. Not 
Cen tralblatt 
Size of child’s 
brought out of 
tumor was removed 
In 6 weeks. 
much hemorrhage. 
fixer Chirxxrgie 
head situated in 
the abdominal 
the elastic ligature 
XXI. 1894, 237. 
the lobus spi- 
incision and 
began to cut through 
gelii. 
supported by a 
steel rod. Elas- 
the pedicle. This 
was then divided 
tic ligature on 
base. Excised. 
with a cautery and 
the cavity was pack- 
ed with iodoform 
gauze. 
38 
Israel. 
F. 
15 
Sarcoma on free 
Elastic ligature 
Stump returned to 
R. 
Diagnosis; Renal 
Revue de Chir- 
edge of right 
around base. 
abdominal cavity. 
But 
patient 
tumor. 
urgie, 1896, No. 
lobe. Base 15 
Ther m o-cau- 
covered with iodo- 
died 
4 mon- 
VII., p. Si2, 
cm. in diameter. 
lery. 
form gauze which 
ths 
later 
ditto. No. XII., 
Weight 1225 
was brought out at 
from 
metas- 
p.990, Central- 
grammes. 
the lower angle of 
tasis 
blatt fixer Chir- 
the skin incision. 
(sarcoma.) 
urgie, 1894, No. 
XXX., 714. 
39 
Jones (R.) 
F. 
21 
Six months. 
Cyst incised. 
Sides of the cyst- 
R. 
London Lancet, 
Hydatid cyst. 
Portion of the 
wall stitched to the 
Four 
mon- 
1894, I, 860. 
contained 124 
cyst wall excis- 
abdominal incision. 
ths 
after 
cyst-wall came away 
ounces. 
e d. Cavity 
drained. 
operation. 
through the abdom- 
inal wound. 
4° 
T r i c 0 m i (Pa- 
M. 
27 
One year. 
Elastic ligature 
Stump sutured to 
R. 
dua), 
Adenoma of 
was placed 
the abdominal wall. 
In 10 weeks. 
Centralblattfuer 
b i 1 e d u c t s. 19 
around the en- 
ation was performed 
Sublimate injection 
Chirxxrgie, 1894, 
No. 21, p. 936. 
cm. long, 14 cm. 
tire left lobe. 
thick, circum- 
ference at the 
lumor was 
brought out of 
and potassium iodide 
were used. The oper- 
base 49 cm. 
the abdominal 
wound and fast- 
ened by sutures. 
Liga m e n t 0 u s 
connections 
were divided. 
the growing of the 
tumor to the belly 
wall will hurt the pa- 
tient. 
On the four- 
teenth day the 
elastic ligature 
operation in two 
stages for similar 
cases. 
tore. A metal 
wire was placed 
around the tu- 
mor and the 
cautery was 
tried; but on 
account of hem- 
orrhage this 
was given up. 
Three days later 
isolated one- 
half and ampu- 
tated it with a 
chain suture, 
and the next day 
removed the 
rest. Weight, 
one kilogr. NO. 
REPORTER AND 
SEX. 
AGE. 
DURATION, NA- 
METHOD OF 
TREATMENT OF LIVER 
RESULT. 
REMARKS. 
REFERENCE. 
TURE AND SIZE. 
REMOVAL. 
4T 
Ditto. 
Echinococcus, 
R. 
42 
Ditto. 
Syphiloma. 
D. 
Twenty- 
four hours 
from shock. 
43 
Morgan, J. 
F. 
38 
Four years. 
Cyst wall was 
Hemorrhage was 
R. 
The diagnosis was 
London Lancet, 
Hydatid cysts. 
teased away 
stopped by ligatures 
In 3 weeks. 
malignant tumor. 
1895. L, 344. 
Enough small 
with forceps. A 
and hot sponges. 
cysts to fill a 
portion of the 
pint bowl. 
wall was excised 
with scissors ex- 
posing a bleed- 
ing surface. 
44 
Bastianelli. 
F. 
37 
Nine months. 
Tumor was re- 
R. 
Diagnosis: Displaced 
Brit. Med. Jl. 
Epit., 1895, I., 
69. (II. Poli- 
clinico, April, 
i895-) 
Gumma. 500 
grammes. 
moved together 
with the gall 
bladder. 
cancerous kidney. 
4S 
Dennis. 
F. 
Spherical gum- 
Excised a wide 
The stump was re- 
R. 
Diagnosis of hepatic 
Syst. Surg., 
' 
ma, one inch in 
V-shaped piece 
tunred with its large 
abscess. Iodides and 
P h i 1 a., i8g6. 
diameter, near 
of the liver, in- 
notch enclosed. 
mercury after oper- 
IV., p. 530-555. 
edge of the liver. 
eluding the gum- 
ation. 
ma. Before the 
growth was re- 
moved it was 
sorrounded by a 
series of chain 
stitches of silk. 
46 
Abbe, R. 
F. 
40 
Multiple gum- 
Excised a 
R. 
Diagnosis of hepatic 
Med. Rec., 1896, 
XLIX., p. 205. 
mata, varying 
in size from a 
bean to a wal- 
wedge-shape 
piece of the 
liver tissue one- 
abscess Iodides and 
mercury after oper- 
ation. 
nut. 
inch by one- 
inch and a half. 
This piece incl- 
uded one of the 
gummata. 
; 
47 
F. 
54 
Epithelioma. 
Encircled the 
The pedicle was as 
R. 
In 6 weeks. 
Weighed one- 
growth with an 
thick as the wrist. 
1896, L, 658. 
half pound. 
elastic ligature. 
After separation of 
Brought the 
tumor out of the 
the slough a granu- 
lating surface was 
abdominal in- 
exposed. 
cision and trans- 
fixed it with 
needles. Re- 
moved it by cut- 
ting through the 
liver tissue half 
an inch from the 
growth. 
48 
Goube, 
M. 
55 
Twenty years. 
Incised cap- 
The cavity in the 
R. 
Old and very feeble. 
Adenoma in the 
side of tumor 
depths of the liver 
Recurrence 
No pain in region of 
left lobe. Cav- 
with a bistoury. 
was forcibly packed 
11 months 
tumor until he fell 
Si3- 
ity left was the 
and removed the 
with gauze and the 
after oper- 
against the tongue of 
size of a child’s 
friable paren- 
ends were brought 
ation with 
a coach; since then 
I 
head. 
chyma with a 
curette. Hem- 
orrhage was 
managed by 
packing and lig- 
ating. 
out of the external 
wound. The exter- 
ior wound was par- 
tially closed. Anti- 
septic dressings 
were held in place 
by a sand bag. 
symptoms of 
c i n c e r of 
the liver. 
great pain and he lost 
flesh rapidly. 
Seventh and eighth 
ribs were broken in 
the accident. 
49 
Mikulicz. 
F. 
29 
Six months. 
Ablation with a 
Returned to abdom- 
R. 
Diagnosis: Syphil- 
Revue de Chir- 
Syphiloma of 
sharp curette. 
inal cavity. 
oma or adenoma. 
urgie, 1896, No. 
lelt lobe, size of 
I amponed with 
12, p. 991. 
fist. 
iodoform gauze. 
Kept in place by 
cat gut sutures; 
gauze brought 
out the skin in- 
cision. 
5° 
Girard. 
Infant. 
2% days 
Two and a half 
Remove the 
D. 
Diagnosis : Congen- 
ditto, p. 992. 
days. 
entire left lobe 
Next day. 
ital umbilical hernia. 
Hernia of left 
lobe, through 
umbilical open- 
with cautery. 
Cat gut around 
the pedicle. 
Left lobe, protruded 
with the small intes- 
tines. 
ing. 
Removed the 
gall bladder. 
Si 
M. 
5° 
Six months. 
Excised with a 
The stump was re- 
R. 
Diagnosis; Cancer of 
Cancer of right 
bistoury. T h e 
turned to the ab- 
omentum. Tumor 
lobe. Size of a 
surface of the 
dominal cavity. 
wa- adherent to the 
1896, p. 976. 
Beitraege kiin. 
walnut. 
wound was 
peritoneum. 
passed over with 
Chirurgie, 1888. 
a cautery. 11 
NO. 
REPORTER AND 
reference. 
SEX. 
AGE. 
DURATION, NA- 
TURE AND SIZE. 
METHOD OF 
REMOVAL. 
TREATMENT OF LIVER 
STUMP. 
RESULT. 
REMARKS. 
52 
Ditto. 
F. 
44 
Seven months. 
Echinococcus 
cyst. Size of a 
child’s head on 
lobus quadratus 
Removed by the 
cautery after li- 
gating the pedi- 
cle by several 
silk ligatures. 
Hemorrhage 
was stopped by 
ligatures and 
sponges, which 
were steeped in 
boric acid. 
The stump, 12 cm. 
long and 13 cm. 
wide was disinfect- 
ed with HgCl.z 
and returned to the 
abdominal cavity. 
R. 
In 19 days. 
Diagnosis; Tumor of 
mesentery or omen- 
tum. 1 
53 
Schrader, 
D e u t. med. 
Woe h., 1897, 
No. 11, p. 173. 
F. 
30 
Uncertain. 
Carcinoma, 4 
cm. by 3.5 cm. 
A wedge-shaped 
incision, follow- 
ed by Paquehn 
Ciutery. 
Suture of the liver 
stump and fixation 
in the abdominal 
wound. 
R. 
Wound healed in 
eight to ten weeks. 
Operation April 25, 
1890; still alive and 
well in March, 1897. 
54 
Eliot. 
Personal com- 
munication. 
F. 
40 
Six months. 
Two fists. Al- 
veolar sarcoma 
in fissure for 
gall bladder. 
Therm o-c a u- 
tery. Large ves- 
sels ligated. 
Stump four or five 
inches long, two in- 
ches thick. Dropped 
into abdomen and 
walled off by gauze 
packing. 
R. 
Disease returned in 
intestine which was 
adherent. Died four 
months after oper- 
ation. 
55 
Rosenthal. 
Deutsch. med. 
Woe h., 1897, 
No. 4. 
F. 
41 
Six weeks. 
Size of head. 
Angioma fibro- 
atodes of lobe 
of spigelius. 
Elastic ligature. 
Tumor removed 
by knife beyond 
the ligature. 
Stump touched with 
zn. cl. edges sutured 
and fastened to ab- 
dominal wall by a 
needle passed trans- 
versely a d then by 
sutuies. 
R. 
Well after fifteen 
months. Tympany be- 
tween tumor and liver. 
Thought to be an 
ovarian, omental, or 
hepatic tumor. 
56 
D’Urso, 
Centralbl.Chir., 
1897, p. 397- 
Size of head. 
Endothelioma. 
Attempted to 
shell out the pe- 
dicle but on ac- 
count of hem- 
orrhage placed 
an elastic lig- 
ature on it and 
treated it extra 
peritoneally by 
suture. 
Extra-periton eal. 
D. 
In 2 days. 
Exhaustion. 
Tympany between the 
tumor and liver. Un- 
certain diagnosis. 
57 
Watson, 
Boston Med. & 
Surg. Journal, 
Sept., 1896, p.63. 
F. 
Cancerous dis- 
ease of the gall 
bladder and low- 
er anterior por- 
tion of the right 
lobe of the liver. 
Three rubber 
ligatures were 
passed through 
sound liver tis- 
sue and the dis- 
eased area was 
removed in 
three separate 
pieces. 
The ligatures were 
left in situ and 
came away at the 
end of three weeks. 
D. 
Sixty days 
after oper- 
ation. 
Gall bladder contain- 
ed 102 stones. Dis- 
ease recurred in two 
months. 
58 
Landouzy and 
Segond, 
Bulletin de la 
Societe de Chir- 
urgie de Paris, 
1887, No. 13. 
M. 
is 
Three months. 
Echinococcus 
cysts. 
Abdominal sec- 
tion. Aspirated. 
Fastened the 
liver to the ab- 
dominal wall 
with two silver 
sutures. Re- 
moved the cyst 
wall also the 
liver tissue that 
covet ed the cyst. 
Bleeding surface 
packed with 
sponges. 
Fixed the stump 
to the abdominal 
wall with suture and 
drained. 
R. 
59 
Keen, 
Present paper. 
F. 
S3 
Three years. 
Angioma of the 
left lobe. Three 
by two and a 
half inches. 
Artificial pedi- 
cle made by two 
oblique lateral 
incisions by Pa- 
quelin cautery; 
then elastic con- 
striction of pe- 
dicle by rubber 
drainage tub- 
ing 
Tumor fixed outside 
abdominal wall. 
Removed by scissors 
on sixth day. No 
hemorrhage. 
R. 12 
Upon removing the gauze we found a large 
quantity of bile. The patient died in forty- 
eight hours. 
The President: A case of tumor of the 
liver came under my observation some time 
ago. The tumor was situated in the me- 
dian line, quite prominent. Diagnosis 
made was cyst of the pancreas. The abdo- 
men was opened and the cyst found to have 
originated in the left lobe of the liver. This 
entire lobe of the organ was occupied by the 
cyst. It was removed after ligation of the 
peritoneum above it. The left portion of 
the liver was raised out of the wound and 
ligated, but the ligature cut through. The 
catgut ligatures cut through the blood ves- 
sels, Such changes had taken place in the 
liver structure in this region as to make the 
portion near the cyst much softer. The 
area was seared with thermo-cautery, and in 
this way haemorrhage was pretty effectually 
controlled. There was some discharge of 
bile. The bile duct leading to the left lobe 
was secured with ligature and the wound 
closed, with the exception of gauze pack- 
ing. The patient did well for the first 
tweny-four hours. During the second 
twenty-four hours there was a marked de- 
cline and general condition of collapse. 
DISCUSSION. 
Dr. Evan O’Neill Kane (Kane): The 
matter of secondary haemorrhage, after the 
removal of a tumor of the liver, is of consid- 
erable importance. In a case I operated on 
last winter, for Drs. Stonecipher and Tow- 
ler, I removed a tumor the size of the head 
of a six months child. It grew from the 
base of the liver well in at the back. In this 
case there was a great deal of haemorrhage 
during the detachment of the growth—an 
alarming amount of haemorrhage; but it 
was quite readily controlled, first, by pack- 
ing, and then by hot water. But after- 
wards, I think about six days, secondary 
haemorrhage commenced, and continued 
about five or six days, during which the pa- 
tient gradually sank. I was not there, but 
the attending physician made every attempt 
to control it, but could not. 
Another thing I want to mention. Dr. 
Keen spoke of tympanites on percussion 
above the growth. I noticed the colon was 
pushed well up between the liver and the 
top of the growth.