Reprinted from the International Medical Magazine, April, 1892. 
REMOVAL OF A SMALL SOLID TUMOR 
FROM THE LIVER. 
BY LOUIS McLANE TIFFANY, M.D., 
Professor of Surgery in the University of Maryland. 
In the American Journal of the Medical Sciences for June, 1888, atten- 
tion was called to the fact that in certain cases of liver disease or injury an 
area of liver surface more or less extensive could be shut off by suture from 
the general peritoneal cavity while remaining exposed to the air, thus ena- 
bling the surgeon to operate for abscess, wound, etc., with but small risk of 
inducing septic peritonitis. Eighteen months ago it was my fortune to have 
recourse to this procedure when removing a small solid tumor of the liver. 
The history is as follows : 
J. M. H., aged twenty-five, occupation farmer, was admitted to the University Hos- 
pital May 17,1890, and was referred to me by Dr. Luther M. Hunley. He is married; 
family history is negative; he has always been healthy up to the commencement of 
the present illness, and never suffered from malarial fever, scarlet fever, or measles. He 
enies venereal troubles ; is temperate; does not use tobacco. His first knowledge of 
his present illness dates from a colicky pain in the left side at the margin of the ribs 
ten years ago. At first the pain was but momentary, and appeared but once in two or 
three weeks. In July, 1886, he had an attack of what was denominated bilious fever, 
and since then has had pain continuously in his left side up to one year ago. When 
the pain in the side ceased, he suffered pain in the epigastric region. Sixteen months 
ago he noticed a swelling to the left of the middle line in front, just below the carti- 
lages of the ribs, also at times slight pain in the lower part of the abdomen; bowels 
constipated. In consequence of the pain he has suffered for the past four years he 
has been unable to do farm work. He is well developed, of medium height, tongue 
slightly coated, chest expands normally. There is a slight swelling in the epigastric 
region, to the left of the middle line, about two inches below the xiphoid cartilage. 
This lump is extremely tender on pressure. The patient thinks that this swelling 
has increased in size since he first noticed it. Deep inspiration causes the tumor to 
descend two inches. On expiration, it resumes its former position. The tumor is 
hard and resisting, dull on percussion, and appears to be about one and a half inches 
in diameter. Area of splenic dulness not increased; kidneys act freely ; exami- 
nation of urine negative. Pain is caused at the seat of the tumor by very deep 
inspiration. 
The patient was prepared for operation in the usual way; and two days after ad- 
mission to the hospital he was operated upon as follows: An incision five inches long 
was made over the tumor through the left rectus muscle in the direction of its fibres. 
The wound edges were separated, the peritoneum was exposed, and all hemorrhage 
arrested. Bleeding was free. The apex of the tumor was adherent to the parietal 
peritoneum. The abdominal cavity was opened and the liver examined by touch. 2 
The tumor was found to be in the left lobe of the liver, about two inches from the 
lower free border. A finger passed beneath the liver found that the tumor did not 
extend through the viscus. A hypodermic needle passed into the tumor gave exit to 
no fluid. The peritoneum was stitched to the liver around the circumference of the 
growth, which was then excised with curved scissors and the Paquelin cautery applied. 
The cavity left in the liver substance was an inch deep by one and a half inches 
across. The wound was packed with iodoform gauze. Ether was the anaesthetic used, 
and a good deal of nausea followed. There was much bloody oozing through the 
dressing for twenty-four hours. Urine had to be drawn by a catheter for three days. 
With the exception of extremely constipated bowels, the patient’s recovery wa% 
uneventful. In three weeks the patient returned home well and without pain. The 
photograph was taken three weeks after operation, the wound being superficial but 
not healed. Within the past month 
(eighteen months since operation) I 
have heard from the patient as follows: 
He is in excellent health, suffers no 
pain, and attends to the necessary work 
on the farm of which he is the owner. 
Examination of the tumor which we 
removed showed that it 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. 
It will be found, probably, as 
clinical records accumulate, that the 
methods of operating on the liver 
more and more conform to methods 
applicable throughout the body, 
and as a necessary result the ex- 
treme hesitancy which now charac- 
terizes the undertaking of an hepatic 
operation by the surgeon will pass 
away, and as a sequence more favorable results may be expected. 
A glance at traumatisms of the liver is not uninteresting. 
In the “ Medical and Surgical History of the War,” second surgical 
volume, p. 130, are recorded twenty-six recoveries from punctured or incised 
wounds of the liver, gathered from various authors. Of these cases, in 
three, portions of the liver were cut off at the time of the injury; in two 
instances, portions of the liver were torn away; in three instances, portions 
of liver were tied and divided distal to the ligature; in one case a portion 
of liver is recorded as protruding, and “ came away” on the fifth day ; while 
as showing what might occur while the world was still wrapped in septic 
darkness, Theden, in the year of grace 1782, records a case of self-inflicted 
wound of abdomen, followed by escape of small intestines, removal of piece 
of diaphragm and liver one-half inch by three inches, and complete division 
of ileum. As the man was not expected to live, the protruding portions 
were returned pell-mell, and the wound in the abdominal wall was sutured ; 
LOUIS MCLANE TIFFANY, M.D., ON REMOVAL OF A SMALL SOLID TUMOR FROM THE LIVER. 
3 
escape of fecal matter for four weeks took place; the patient recovered and 
lived seven years. 
Sufficient has been learned by experience, in gunshot and other surgical 
wounds of the liver, to justify the opinion that hemorrhage is not to be greatly 
feared. Hemorrhage stops spontaneously, without doubt, in many cases, 
even in grave wounds perhaps, either punctured or gunshot. Pressure 
direct or with gauze suffices in the great majority of cases to bring about 
cessation of bleeding. In hemorrhages from deeper and larger vessels, a 
thread passed through the liver substance and then tied more or less tightly 
around the bleeding point arrests blood pretty thoroughly. In wounds 
resulting from resection of liver substance, if hemorrhage is not arrested 
spontaneously, sutures, Paquelin cautery, or the tampon leave little to be 
desired. Bleeding from the very large vessels of the liver, or even the 
inferior cava, will of course not be arrested by the method stated, but, so 
far, such accidents are not recorded as needing treatment. It is presumable 
that death occurs before surgical interference could be obtained. Ligature 
of individual vessels does not seem to be possible in this respect, the liver 
substance behaving in the same manner as kidney substance. 
In Langenbuch’s well-known case of resection, the pedicle was tied in 
sections, hemorrhage following the same evening, which necessitated re- 
opening the abdomen. Hochenegg1 records a method of pressure by gauze 
which is worthy of note, and seems of general utility,—a wedge of liver sub- 
stance had been excised. 
“ The severe hemorrhage ensuing after the excision of the wedge-shaped portion 
should have been stopped by the sutures, but they did not succeed in doing so, for 
all the stitches made in the parenchyma of the liver tore out again. 
“ The wound, therefore, had to be cared for in the following manner: The 
angular wound caused by the excision of the wedge was clapped together and covered 
with iodoform gauze, which was fixed in place by knotted sutures, and then the 
parietal peritoneum was attached to the visceral peritoneum by means of fine catgut 
sutures. The bleeding ceased entirely. The further progress of the case has been 
entirely uneventful up to the present time; the patient has continued free from fever 
and is to-day (first day after operation) doing well. The speaker will not fail to 
report the final result.” 
The arrest of bleeding after removal of a solid tumor presents rather a 
different view of the question; hence the importance of the following, which 
I quote at length.2 
“ Male, aged fifty, came to hospital to be treated for a hard tumor in the abdomen 
and great consequent debility. Diagnosis, carcinoma of the peritoneum. On account 
of the great suffering of the patient, laparotomy was performed at his request. A 
large tumor was found extending from the parietal peritoneum, but the point of its 
1 Wiener Medicinische Blatter, 1889, No. 25, p. 391. 
2 Prof. Bruns, reported by Garr6, in Beitrage zur Klin. Chir., Tlibingen, 1888-89, 
iv. 181 et seq. (in extenso). (Case on page 188.) 4 
REMOVAL OF A SMALL SOLID TUMOR FROM THE LIVER. 
origin could not be accurately ascertained. Moreover, a yellowish lump the size of a 
pea was found adhering to the margin of the right lobe of the liver near the incisura 
hepatis. A piece of liver the size of a hazel-nut, attached to the lump, was excised 
with the knife for microscopic examination, and the thermo-cautery was applied to 
the wound. 
“ The examination revealed the little tumor to be a metastatic carcinoma of the 
liver. The extirpation of the tumor was therefore desisted from, and the wound 
closed. Healing of the abdominal wound occurred without reaction.” 
These cases seem to indicate that hemorrhage after excision of the liver 
substance may be definitely arrested by ligature, cautery, or pressure. 
The influence which may be induced by bile when poured into the 
peritoneal cavity is not yet to be stated definitely; the serous membrane 
is unquestionably more tolerant of its presence than has been supposed ; but 
any discussion of the question is outside the limits of this brief paper.