[Reprinted from the Transactions of the Philadelphia County Medical Society.] 
TUMOR OF THE LIVER IN WHICH REMOVAL WAS 
ATTEMPTED. 
JOHN B. ROBERTS, M.D. 
[Read September 28, 1892.] 
M. F., aged'sixty years, was admitted to the Woman’s Hospital 
May 24, 1892, with the following history ; 
From girlhood she had enjoyed almost uninterrupted health until a com- 
paratively recent time, when she suffered a good deal with indigestion and 
pain under the right shoulder and left breast. She was a married woman 
and had borne six children. About four months before applying for treat- 
ment she noticed, when undressing at night, a lump in the right side of the 
abdomen about as large as a fist, which seemed very hard. This growth had, 
she thought, increased very rapidly, and had extended somewhat to the left 
side of the abdomen ; it was the seat of some tenderness on pressure. The 
notes, however, do not seem to indicate that she suffered any very great incon- 
venience from this abnormal condition. 
The physical examination of the patient showed nothing abnormal in the 
lungs or in the heart, except that the latter was rather weak. The urine con- 
tained no albumin or sugar; was acid in reaction; had a specific gravity of 
1015, and was voided to the amount of thirty ounces in twenty-four hours. It 
contained amorphous phosphates and uric acid. She had no jaundice. 
Examination of the pelvic organs showed nothing especially wrong. Palpa- 
tion of the abdomen disclosed a hard, smooth mass in the right hypochon- 
drium, which did not seem to extend back into the kidney region, and was 
so prominent anteriorly that it made a distinct elevation of the abdominal 
parietes, which was evident on mere inspection. The abdomen was not 
tympanitic, and showed no evidence of intra-peritoneal fluid. The tumor 
was localized and moved upward and downward during the respiratory act. 
It seemed, on careful investigation, to be probably connected with the liver, 
though this diagnosis was not definitely determined. An exploratory incision 
was recommended and carried out on June 3d, with the ordinary aseptic pre- 
cautions observed in laparotomy cases. 
An incision in the middle line was made, and extended for about seven 
inches, one-half of which was above and the other half below the umbilicus. 
Upon opening the peritoneal cavity I found in the right lobe of the liver a 
tumor resembling in shape a flattened cobble-stone, circular in outline and 
about three inches in diameter. It was perhaps an inch and a half thick, 2 
ROBERTS, 
and located in the anterior portion of the right lobe of the liver, involving 
the edge, which was thickened by the infiltrated growth. The mass lay 
directly above the gall-bladder. There were no adhesions between the tumor 
and the intestines, omentum, or abdominal wall. The limit of the healthy 
liver tissue surrounding the tumor was readily discernible, because the 
growth, though not incapsulated, had a distinct outline where it came in con- 
tact with the uninfiltrated liver tissue. The surface of the growth was of a 
dirty brownish-white color, and showed irregular puckerings of the perito- 
neal investment of the liver, as though the peritoneum was thickened by 
chronic interstitial inflammation. jSTo other growth was found in any part of 
the liver which could be reached by careful exploration with my hand. 
Although I believed the tumor to be a malignant one, I considered it a proper 
case for excision, because there was no infiltrated tissue beyond the immediate 
seat of the tumor. 
My intention was to excise the mass with a Paquelin thermo-cautery knife, 
and I began by separating the gall-bladder from the under surface of the 
tumor by means of the hot knife. Before I had dissected the gall-bladder loose 
a quite free hemorrhage occurred from the surface of the liver from a vein 
the size of a goose quill, which was opened by the cautery. Just at this 
time one of the rubber bulbs of the thermo-cautery burst and destroyed the 
instrument for further use. Not expecting to use the Paquelin cautery I did 
not have a second instrument in readiness; I was, therefore, obliged to abandon 
the operation because of the evident risk from profuse hemorrhage, which 
would probably be uncontrollable without the use of the cautery. It did 
not seem wise to allow the patient to wait under ether with the abdomen 
opened until another instrument could be obtained. I was also deterred from 
proceeding by the fact that the operation was, under the best circumstances, 
grave, and the permission of her friends had been given somewhat unwil- 
lingly. To arrest the hemorrhage from the large vein I stitched the gall- 
bladder in its former position against the liver, so as to close the opening in 
the vein by pressure. This was done with several silk sutures, and answered 
admirably. I intended, after the patient recovered from the immediate effects 
of the operation and gained strength, to reopen the abdomen and, with two 
thermo-cauteries at hand, make a second attempt at removal of the growth. 
The patient was put to bed, did well, and the temperature remained about 
normal. During the time of convalescence, however, she was quite weak, 
complained occasionally of pain in the abdomen, and had a little irritation 
of the bladder, causing her urine to dribble. The stitches in the belly wall 
were removed in a few days, but the patient was not discharged until July 12. 
There was no marked change in the liver growth that could be appreciated 
through the flaccid abdominal wall. Her detention in the hospital for so long 
a time was due to her feebleness and to the fact that in the latter part of 
June she had what appeared to be a slight attack of pleurisy. This, how- 
ever, did not cause her temperature to rise much over 100°. She was feeble 
during the whole time of her stay in the hospital, her pulse varying from 100 
to 112 ; even when she was discharged the pulse counted over 100. 
The condition found by the exploratory incision was described to her and 
to her friends, and an effort made to obtain their consent to a second opera- 
tion definitely planned for the radical removal of what was believed to be a TUMOR OF THE LIVER. 
3 
malignant growth, which could only have a final fatal issue. The feeble con- 
dition of the patient, however, did not permit me or Dr. Fullerton to urge 
the operation as much as we would have done had the patient been younger 
and in vigorous health. It was impossible to obtain the consent of her friends 
to the operation, and the case, therefore, passed out of my hands. 
It seemed to me that hemorrhage would be greatly diminished by encircling 
the growth, before excision, by a series of interlocking sutures of strong silk 
carried through the entire thickness of the liver. This, as I told the hospital 
class, would probably be my method of guarding against bleeding. The 
excision would then have been made with the cautery. There would have 
been left, of course, a large hemispherical wound in the anterior portion of 
the liver. 
The patient died September 17, 1892, but I was ignorant of the fact until 
after she had been buried. Her physician, Dr. C. K. Rowe, writes that before 
death the patient’s skin became of a decidedly yellow hue, that the tumor 
had increased somewhat in size, and that two or three small tumors were dis- 
covered on the back and neck. She became very much emaciated, and ap- 
parently died from exhaustion. 
At the time that the patient whose history is recorded was under 
my care I was not familiar with the report of Dr. L. McL. Tiffany1 
on his case of removal of a small tumor of the liver, or of the details 
of Dr. W. W. Keen’s case of excision of a cystic adenoma from the 
liver.2 I had heard that Dr. Keen had successfully removed a growth 
from a liver, but I had not seen the report. These two cases, so far 
as was known to Dr. Keen at the time his paper was written, were 
the only instances of resection of the liver for the removal of tumor 
that had occurred in America. 
Dr. Tiffany’s patient was a man, aged twenty-five years, from whom 
a small tumor was taken from the left lobe of the liver, leaving a 
cavity in the surface of the liver an inch in depth and an inch and a 
half in diameter. Previous to the removal of this growth the parietal 
peritoneum was stitched to the liver around the area to be operated 
upon. Excision of the tumor was then performed by means of scis- 
sors, and the Paquelin cautery wras applied to the bleeding surface. 
The tumor, which had been a painful one, “ was composed of liver 
tissue in which there was much exudation, while scattered through the 
growth were many fine grains of sand—no doubt, minute calculi.” 
The patient operated upon by Dr. Keen was a woman, aged thirty- 
one years, who had suffered with a slowly-growfing lump in the right 
side of the abdomen for about two years’ time. The tumor proved to 
be a cystic adenoma of the bile ducts; it was three and a half inches 
1 International Medical Magazine for April, 1892. 
2 Boston Medical and Surgical Journal, April 28, 1892, p. 405. 4 
TUMOR OF THE LIYER. 
vertically and nearly of the same dimensions transversely; at its base 
where it joined the liver substance it was two and a half inches thick. 
Its internal border lay next to the gall-bladder, which had to be dis- 
sected loose for one-half inch, in order to afford access to the growth 
in the operation of removal. Dr. Keen’s first idea was to ligate the 
thick border of attachment before applying the cautery to cut through 
the liver tissue ; he, therefore, put one stitch directly through the liver 
substance near to the gall-bladder. After this was tied he used the 
cautery. The cautery knife acted so satisfactorily that he found no 
necessity for further ligation of the liver substance surrounding the 
tumor, but removed the growth partly by the use of the cautery and 
partly by enucleation with the finger-nail. The large veins that he 
met with while making the incision with the hot metal were ligatured, 
as they were discovered, before the cautery divided them. * The two 
flaps of liver tissue left by the removal of the growth were then sutured 
together, very much as flaps are stitched after amputation of a limb. 
The cases of Drs. Tiffany and Keen both recovered, and were in 
good health months after the operation. Dr. Keen’s paper includes a 
list of twenty reported cases of removal of hepatic tumors, which was 
compiled by Dr. T. S. Westcott after thorough search through a large 
mass of literature. 
Consideration of these cases induces Dr. Keen to believe that 
quite a large portion of the liver can be removed without extreme 
danger to the patient; that the entrance of bile into the peritoneal 
cavity is not necessarily fatal; and that bleeding can be managed by 
searing the surface of the liver, by ligation, or by fastening the stump 
to the abdominal wall in a manner similar to that used by Dr, Tiffany 
in his case to which I have just referred. Hemorrhage need not be 
great, as the divided vessels can be tied separately or in mass, or 
treated by pressure, by the cautery, or by a combination of all of these 
hemostatic measures. The mortality shown by the cases tabulated by 
Dr. Westcott is about ten per cent.