Puncture of suspicious growths must have been undertaken by the medical masters of yester years. In this context, Moser [1] was at pains to stress that present medical truths must have historical perspectives. Therefore, it is salutary to consider the surgical process of puncture [2]. Here, attention is drawn to a remarkable case documented carefully in 1882 by Sidney Coupland of the Middlesex Hospital [3].

The patient was a woman aged 33 years. She presented with pain and enlargement of the liver. She was admitted under Dr. Greenhow of the Middlesex Hospital on September 16th, 1879. There was pain with abdominal swelling. Humane treatment of cancer patients was in vogue as author demonstrated elsewhere [4]. Thus, note the precise information as follows: “It was not until the 25th that she was in a condition to allow the abdomen being examined.” It was then found that the hepatic dullness reached from the fourth rib above to the iliac crest below. On the 28th, the left border of the swelling was found to be irregular. Aspiration by Mr. Hulke in the softest part of the tumor “yielded a drop of blood mingled with large multinucleated cells.” Some cutaneous extravasation occurred at the site of the puncture and spread in the abdominal wall. The left lower limb became oedematous. Slight icterus developed in the 1st October. The temperature varied from 99.20 to 97.40, and pulse from 108 to 128, and after a restless night she died on October 3rd. Post-mortem examination was carried out. There was a small quantity of dark, straw-coloured fluid. The liver had attained a “great size and weighed over 18 Ibs. The capsule was very vascular. The details continued thus:

On section the right lobe, especially its anterior two thirds, had a firm but resilient consistence, much like that of India rubber. Its anterior one-fourth was wholly replaced by new tissue, the cut surface of which had a strikingly marbled and variegated aspect, greyish and black areas being interspersed with pale and whitish lines.

The problems, which arose, became apparent and required the submission of some specimens to the Society’s Morbid Growths Committee. It concluded that “in parts more remote from the normal structures a perfect alveolar formation exists, the alveoli of which are filled with cells apparently derived from the liver-epithelium.” These findings where in consonance with the then state of knowledge about the localization of metastases within the liver [5].

Elsewhere, author had presented a related case of liver rupture. This was compared with a modern case [6,7]. On the whole, this case is reminiscent of the opinion of the great German Pathologist, Julius Cohnheim [8] that necropsies “are all in a manner experiments instituted by nature, which we need only rightly interpret to get a clear idea of the causes, laws of growth, and significance of the tumor.” In this context, author took time to recognize patterns such as those personally demonstrated elsewhere [9] (Figure 1). In other words, the present historical case is part of the ongoing advanced studies in the epidemiology of pigment cell biology from historical heights [10].

Figure 1: Section of the liver to show metastatic cancer nodules, this time preponderating in the upper part significantly.