Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 139

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189

USA > Ohio > Hancock County > Findlay > Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens > Part 139

Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).

FIG. 4 .- The plication modification of the method is here shon Owing to an almost total absence of fat between the peritoneal leaves of the mesentery in some cases, it is unsafe and impract cable to attempt their separation. In such cases neither lest i incised, or separated from its bowel attachment, but both kaum are grasped together at the proper distance from the bowel bar der, lifted over the raw surface and fixed by silk sutures ! amounts to a plication of the mesentery, or a partial enveloy ment of the bowel within both layers of its mesentery. Now that care has been taken to place the sutures between the vast lar trunks. This simple modification renders the method app cable to all cases, is even more quickly executed, and is eminent !! safe and satisfactory.

7. Stability and permanence of the coaptation is readily secured through intelligent disposition of the sutures.

SUMMARY.

Certain anatomical and physiological characteristics of từ- peritoneum have an important bearing on the problem ! peritoneal adhesions. Notably its area, its absorptive powe. the variable sensitiveness to pain of different portions, to continuity of its epithelial surface, the rapidity with whi :: it can form adhesions, and the completeness with which it c3: later absorb them.

Digitized by Google

which terminates in dense adhesions with scar tissue mation.

Etiologically there are a number and variety of factors in- Ived, but they can all be grouped under the two heads, psis and Trauma.

As prophylactic and curative measures, emphasis should given to rigid asepsis, the use of moist hot gauze, careful vering of all raw surfaces, avoiding unnecessary exposure, stricting trauma and spreading out of the omentum over e visceral surfaces before closing the abdomen.

A number of additional safeguards are available which have

cants, viable grafts of peritoneum, or omentum and judicious ante- and post-operative therapy.

The field of specific chemo-therapy offers the brightest hopes for future progress.

In properly selected cases the use of adjacent mesentery for covering raw bowel surfaces possesses distinct advantages over all methods hitherto proposed.

I desire to express my thanks to the pathological depart- ment of The Johns Hopkins Hospital for giving me the oppor- tunity of testing, on the fresh cadaver, the method above described.

PRIMARY CARCINOMA OF THE PLEURA.

By T. P. SPRUNT, M. D., Instructor in Pathology, The Johns Hopkins University.

The primary malignant tumors of the pleura, although rare, ve considerable interest for the clinician on account of the ficulty encountered in attempting an accurate differential ignosis. They have their principal interest, however, from : point of view of their pathology; and not only does this erest attach to the question of histogenesis but to their ulti- te nature and origin. Doubts have been expressed as to ether we are dealing here with a true tumor in the narrower se of that term or whether the lesion may not be the result the chronic inflammatory process which so uniformly ac- npanies it.

The classical pleural tumor was first described by Wagner 1 later by his pupil Schulz, and called by them endothelial icer. The pleura was much thickened and somewhat rough- d, resembling the appearance seen in the mucosa of the dder with prominent, hypertrophic musculature. Histo- ically the growth in the thickened pleural tissues consisted numerous alveolar and tubular structures separated from hi other by a connective tissue stroma and filled with large helial-like cells. They considered the endothelium of the ph vessels the point of origin of the growth.

number of cases have since been reported. Glockner, in 7, collected 42 cases from the literature and added 7 of his . Gutmann, in 1903, found 9 additional cases. In 1905 ch collected 47 endotheliomata and 16 sarcomata.

he individual authors, as a rule, compare their cases with classical Wagnerian tumor which most of them closely mble. The tubules and alveoli are sometimes filled with , at other times the spaces are lined by cubical or cylindri- tells in one or many layers. Practically all agree that the strongly resemble epithelial cells and that the histologi- picture is that of carcinoma, but the great diversity of ion as to the nature of the affection may be easily appre- ed after a mere enumeration of the names, which have given it. Among these designations we may mention that idothelial cancer (Schulz, Wagner, et al.), lymphangitis

prolifera (Fraenkel, Schweninger), lymphangitis carcinoma- todes (Neelsen), sarcocarcinoma (Boehme), alveolar endothe- lial sarcoma (Padock), endothelioma (Eppinger and many others), carcinoma (Lepine, Pitt, Benda, Dreesen, Ribbert, Orth).

In most of these reports the lining membrane of the pleura was either entirely lost or its cells, if present, only slightly changed. The great majority of the authors refer the point of origin of the tumors to the endothelial lining of the lym- phatics.

Benda reports a case in which the principal growth occurred on the pleural surface which was covered with numerous villi. The picture reminded him of the formation of papilli in cer- tain ovarian cystomata. These villi were covered by cylindrical cells and possessed a stroma of connective tissue and blood ves- sels or occasionally granulation tissue. In the depth, there were many alveoli and strands of epithelial cells or else glandu- lar formations and even small cysts which occasionally showed papillomatous projections from their walls. He considers as true epithelium the cells covering the pleura and his tumor, therefore, as a true carcinoma. He could come to no decided opinion as to the participation of the lymph vessel endothelium, but was inclined to regard the tumor masses in the subpleural tissues as extensions downward from the growth on the pleural surface.

Dreesen reports a similar case and reaches similar conclu- sions. They are both of the opinion that many of the reported cases had a like origin.

In connection with tumors of the serous surfaces there has been much discussion concerning the embryological develop- ment of the serous lining membranes, and concerning the classification of their cells. In the older literature the term endothelium is used almost exclusively, but in recent years many authors consider these cells more closely allied to epi- thelial structures than to the endothelium and consequently prefer to speak of them as epithelium. Malignant tumors aris-

Digitized by Google

290

JOHNS HOPKINS HOSPITAL BULLETIN.

ing from these cells therefore, they say, should be called car- cinomata.

It is now generally held that in their embryology these cells have nothing in common with the endothelial lining cells of the blood and lymph vascular systems. In addition, it has been shown that in certain of the lower vertebrates, the body cavity originates as an invagination of the hypoblast, but there is no sign of such an invagination in the higher vertebrates, in which the body cavities seem to originate by a splitting of the mesoblast with subsequently a differentiation of some of its cells into a lining membrane.

From studies of their behavior under pathological condi- tions, Mönckeberg, Büttner, Hinsberg, Herxheimer, v. Brunn, and others conclude that the lining cells of the body cavities have more in common with epithelium than with endothelium and the connective tissues. Opposite opinions are expressed by Ranvier, Roloff, and others who conducted somewhat simi- lar experiments. Beitzke, Orth, and Ribbert among other eminent pathologists speak for their epithelial nature.

If then we choose to speak of these cells as epithelium we must regard them as epithelial cells of mesoblastic origin, and related in this respect to the epithelium of the adrenals, kid- neys and other organs of the urogenital tract including per- haps that of the uterus and vagina. Most classifications of tumors leave those arising from these organs in a sad state of disorder and it is especially in tumors of this type that Adami's classification seems superior.

In a recent article on pleural tumors Ribbert gives his opinion that the so-called endotheliomata of the pleura are not derived from the endothelium of the lymph vessels, but either from the surface epithelial cells or from misplaced epithelium, and that they should be termed carcinomata. However, he says that such an origin has not yet been proved beyond doubt in a single case, since sufficiently early stages have not been observed.

The tumor described in this report can hardly be regarded in any other way than having arisen from the epithelial lining of the pleura. Its histology in no way resembles that of the classical " endothelial cancer," and it has many points of de- parture from those described by Benda and Dreesen.

Clinical History .- Mrs. - , a white woman, was a private patient of Dr. Thomas R. Brown, to whom the author is indebted for the clinical notes.

She was admitted to the Church Home and Infirmary, March 22, 1910, about two and a half weeks after the onset of her terminal illness, with extreme pain in the left chest and abdomen, some nausea and vomiting, and persistent cough.

Of interest in the family history is the fact that her mother died of carcinoma of the uterus.

In the past the patient had been strong and well physically, but, married to a confirmed drunkard, she had been subject to great nervous strain and at times was the victim of physical violence. A few years before the onset of the present illness a laparotomy had been performed by Dr. H. A. Kelly and the appendix, right tube and ovary removed. Examination of the specimens showed a chronic inflammatory process, but no evi- dence of neoplasm.

When she entered the hospital the physical signs were typical

of a pleural effusion on the left side. The heart was paix over to the right parasternal line. The point of marimal z pulse was difficult to determine, but there was a distinct pulse half way between the parasternal and sidesternal ling el the left side. The whole of the left chest showed absolute tr ness and loss of vocal fremitus. The breath sounds were aler over this area except in the upper left front, where they were d tant, harsh and of broncho-vesicular type.

The spleen was palpable. The liver, also, was readily fek : perfectly smooth and not tender on pressure.

No tubercle bacilli could be found in the sputum. The ra stools and stomach contents were normal. Rectal examiare revealed nothing abnormal. The blood count showed ! leucocytes and 3,500,000 red blood cells.

The left thorax was tapped 14 times and an average of a over 2000 cc. of fluid aspirated each time. In all 28,270 cc. ve removed: the largest amount aspirated at any one time ma 3150 cc. The fluid was always gelatinous, varied in color frica pinkish-straw to cherry red, and occasionally contained bits of fibrin. There was between 1 per cent and 2 per cent red blood cells and many leucocytes with a great preponderer of neutrophiles. No cells nor fragments suggesting a ta growth were observed. Cultures from the fluid remained suz. and stained smears showed no organisms. Inoculation : guinea pig also proved negative.

The relief after each tapping was slight and lasted only as" while. On each occasion there was a remarkable shifting d .: heart's position from 4 to 6 cm. without any change in the pa rate.

During the first month in the hospital, the temperature pulse curves were about normal. The temperature during . last 3 weeks was intermittent, from 97º F. to 102º F. or 104FF c the pulse varied from 100 to 130. The pain in the chest dyspnea were often very distressing and there occurred . tervals marked abdominal symptoms, as nausea, vomiting pain. Cough was never a prominent feature and there was sputum. On one occasion shortly after tapping a small quart of bright red blood was expectorated.

The subjective symptoms increased in severity and less less relief was experienced after the tappings which occurred more frequent intervals. The patient died apparently te asthenia ten weeks after the appearance of the first symptoci

The physical signs of extreme pleural effusion, the is orrhagic character of the exudate, the lack of relief afte. . piration, the rapid reaccumulation of the fluid, the De. bacteriological tests and the progressive cacheria led to clinical diagnosis of malignant growth of the left pec Whether the growth was primary or secondary could Ex determined.

The autopsy (J. H. U. Path. Lab., 3386) was perfr. two hours after death.

Anatomical Diagnosis .- Primary carcinoma of left pk. extension to left lung and bronchial lymph nodes; seroft .- ous pleuritis (left) ; total atelectasis of left lung; hydrope .- dium; right hydrothorax; hypostatic œdema and conger: of right lung with some atelectasis of lower lobe; thror: " of uterine plexus; pulmonary emboli; chronic passive erz- tion of spleen; fatty degeneration of heart muscle and Lies anemia; cachexia; scar of old laparotomy (right salt .: oophorectomy and appendectomy) ; chronic pelvic perio- with adhesions to sigmoid and ileum; dilatation of st. and duodenum.

Digitized by Google

. Tne mucous membrances and finger nails are decidedly The muscles are flabby. There are no glandular enlarge- :s in the neck, axillæ or inguinal regions.' The breasts are netrical, are not pendulous, there is no great excess of fat, imps, or any demonstrable abnormality. There is a linear an scar in the lower part of the abdomen. The fat of the minal wall is about 1 cm. in thickness and has an orange :. The peritoneal surfaces are normal; there is no free

The stomach and duodenum are greatly dilated. The extends about 5 cm. below the costal margin in the right millary line and to a point about 4 cm. above the umbilicus le median line. The diaphragm on the left side has been ed down until its abdominal surface is convex instead of 'ing the usual dome-like concavity. On the right the dia- gm reaches the fifth rib. Its peritoneal surfaces are smooth oth sides. The mesenteric lymph nodes are not enlarged. it two feet above the ileocacal valve a loop of the ileum ends into the pelvis and is adherent to the posterior wall of iterus. A loop of the sigmoid flexure is also adherent to an mmatory mass around the left ovary.

orax: On removing the sternum there is a gush of turbid, v-colored fluid from the left pleural cavity which is filled this material. The right pleura contains about one litre of tly cloudy fluid. The pericardium also shows a considerable ss of fluid. Its surfaces are smooth, although the parietal seems somewhat thickened.

e heart, which was displaced to the right, weighs 250 grams. e is a slight excess of lemon-colored, subepicardial fat, and angential section the muscle is slightly mottled with yel- sh specks.

ngs: The right lung is entirely free from adhesions. Its ices are smooth and glistening. The upper and middle lobes ilightly moist and show a moderate grade of compensatory lysema. The tissues of the lower lobe are distinctly more t and more congested and show in addition partial atelec- The small arteries contain reddish, friable thrombi which ude from the lumen on the cut surface.

e left pleural cavity is filled with several litres of cloudy in which float strands and filmy sheets of a very friable rial. This substance lines the whole pleural cavity in veil- layers, is quite soft, of a pinkish-gray color and can be scraped off with the fingers. When this is removed from arietal wall a harder tissue is revealed which is roughened all, thickly set nodules about the size of a pea and smaller. appearance is especially striking on the parietal pleura ite the third, fourth, fifth and sixth ribs.

: lung is reduced to a fusiform swelling along the left side : mediastinal tissues and projecting only about 3 cm. into eural cavity. It is covered by the friable shreddy material y described. On incision of the lung there is found im- tely beneath the fibrinous exudate a thin, apparently fibrous Beneath this the lung substance is green in color, com- ' collapsed and airless with small black specks scattered [hout. Here and there appear elevated nodules of a bluish- tissue. These nodules are about 1 cm. in diameter, but ›ally fuse into larger areas measuring 21/2 cm. All of are superficial and near the pleural surface. They are . with numerous, yellow and black specks. The left side of phragm shows also the upper surface of fibrinous material, : of white tissue measuring about 2 or 3 cm. in thickness, h which is a very pale muscle layer 5 mm. thick and show- re and there white streaks. The costal pleura is easily d off in some places, but in others is quite firmly bound thoracic wall. Section through the nodular area already hed shows that some of these nodules are 1 cm. in thick-

viaque, yellow and yellowish-white Hecks. The bronchial and peritracheal lymph nodes are enlarged and black. The surface of a few of those nearest the diseased pleura is covered by a rather thick bluish-white layer which extends down into the lymphatic tissue. The trachea and bronchi are somewhat congested, but are otherwise normal.

The axillary lymph nodes on the left side are not enlarged nor of increased consistence. Incision through the breast tissue shows nothing abnormal.

The esophagus and aorta are normal.

The spleen is enlarged, weighing 250 grams. The surface is dark purplish-gray in color. The organ is very firm with a dark purple, smooth, cut surface.

The stomach and duodenum are considerably dilated and their mucosa digested, but otherwise the gastro-intestinal canal shows nothing remarkable.

The liver weighs 1400 grams, measuring 26 x 19 x 10 cm. Multiple sections show nothing unusual.

The pancreas, adrenals and kidneys are practically normal, although somewhat pale.

Pelvic Organs: The rectum is normal. The left uterine ap- pendages are bound together and to the posterior wall of Doug- lass' pouch by old fibrous adhesions. The right appendages and appendix had been removed at operation. All the radicles of the venous plexus on each side of the cervix uteri contain cylindrical, reddish, friable casts. The retroperitoneal lymph nodes are somewhat enlarged, pink in color and slightly increased in con- sistence.

The neck organs and brain were not examined.

Microscopical Notes .- Sections through the nodular portion of the costal pleura show the subpleural tissues thickened and in- filtrated with small round cells (Figs. 1-4). The nodules de- scribed in gross show the histological appearance typical of carcinoma. There are very rarely any tumor cells in the sub- pleural tissues, but toward the pleural cavity there extend up numerous finger-like projections having a stroma like that of the sub-pleural tissues and covered by a single layer of columnar epithelium. These processes anastomose quite freely, and in this way form spaces of various sizes and shapes which are lined by one or more layers of columnar cells. Between the nodules the pleural membrane is preserved in many places. The cells show various stages of proliferation. For the most part the cells are columnar in shape, and there are frequent small villi covering the pleural surface (Figs. 3-4). Occasionally the pleural lining is straight and regular consisting of cubical cells (Figs. 1-2), or even flat cells having much the appearance of the normal lining cell (Fig. 6). The transitions may be traced from this regular arrangement to the complicated papillomatous nodules already described. Not only is the pleural surface covered with many villous projections, but these occur regularly in the cyst-like spaces of the larger tumor nodules giving the picture of an in- tracystic papilloma (Figs. 1, 3, 4, 5).

Near the base of these nodules this cystic and papillomatous structure is most marked. The cells are of a high columnar type with large vesicular nuclei (Fig. 6) .. Usually there is a single layer, but at times they are piled up several cells thick. In the more superficial parts of the tumor, the papillomatous projections are less marked, and the spaces are being filled up by proliferation of the epithelial cells (Fig. 7), so that here and there they appear as solid strands of epithelial cells, separated by narrow bands of stroma giving the typical appearance of car- cinoma simplex (Fig. 8). The free surface of the tumor is covered by a thick layer of fibrin and leucocytes with many red blood cells. Below this there is a very cellular granulation tissue which forms the stroma for the more superficial parts of the tumor. Occasionally the tumor is seen beneath the former line

Digitized by Google

292

JOHNS HOPKINS HOSPITAL BULLETIN.

[No .:

of the pleura in the subpleural tissue. Here it takes the form of a small cyst-like structure with papillomatous projections into its cavity (Fig. 4). These are lined with quite regular high, columnar epithelium. Similar structures are found occasionally in the fibrous layer over the diaphragm. The muscle of the dia- phragm is infiltrated with the elements of the acute inflamma- tion, is quite œdematous, but shows no infiltration by the tumor.

Sections through the lung and visceral pleura show on its surface an acute inflammatory exudate and beneath this a thick layer of granulation tissue (Fig. 9). There is no sign of the original pleural lining. Along the superficial surface of the lung there are masses of the tumor quite similar to the areas already described, appearing as larger or smaller cystic structures with papillomatous lining (Fig. 11). Many of the larger ones show granular necrotic contents. The tumor cells like those on the costal pleura are cylindrical with vesicular nuclei and fairly regular appearance, although here and there several layers are seen and an occasional dark, irregular nucleus. Dipping. down into the atelectatic lung there are larger tumor nodules which have a somewhat different appearance. These have much the same general arrangement with thin, anastomosing strands of stroma lined by columnar cells of irregular shape and size, giving a much more malignant appearance (Figs. 9, 11, 12). There is no sharply defined line between these tumor masses and the lung tissue, but little tongues of the tumor extend in between the tissues of the collapsed lung in a definitely invasive manner (Fig. 12.) The bronchi within the lung seem quite regular and normal.

In other sections of the visceral pleura and lung, instead of the large areas along the former pleural line there are small spaces from 15 to 30 microns in diameter lined by similar cylindrical or cubical cells (Fig. 9, 10). In these sections the portion of the tumor invading the lung resembles those already described.

Left bronchial gland: The metastasis here is quite similar to those in the lungs-the cells, however, are not quite so irregular in appearance, and there is more of a tendency in proliferating to fill up the alveolar space, forming solid strands of epithelial cells. The basement membranes of the gland-like structures are very indefinite (Fig. 13).

Other lymph nodes, mesenteric, axillary, retroperitoneal and higher peritracheal nodes show no metastases.

Mitotic figures are rarely seen in the more typical papillo- matous areas at the base of the parietal nodules and on the surface of the lung. They are readily found in the more super- ficial portions of the nodules and are quite numerous in the ex- tensions into the lung tissue.

In summary we have a large number of nodules on the parietal pleura consisting of a papillomatous growth with cylindrical cells covering the connective tissue strands. At the edge of such nodules we find villi projecting from the pleural surface forming a transitional stage between the more con- spicuous growth and the flat pleural surface. Selective stains show the usual layer of elastic tissue beneath the pleura, although the fibers are much stretched and quite atrophic. This gives additional evidence, if any is needed, that the mem- brane in question is really the serous covering of the pleura. Just below the line of the pleura there occur occasionally small, cyst-like structures resembling the basal portion of the sur- face nodules. These are found in other parts of the parietal pleura, which do not show the lining membrane, and along the surface of the lung. In close association with these regular, adenomatous areas begin the extensions into the lung sub- star : which have a less typical histological appearance

(adeno-carcinoma) and show definitely invasive growth it . deeper portions.

The objection may be raised that such a picture mig .: afforded by the extension of a bronchial cancer to the pec. This view has been given careful attention. All the eric : is in favor of a primary pleural tumor extending into the .. There is none favoring a bronchial origin. In many sex". from different blocks the bronchi seem perfectly normal. i portions of the tumor within the lung are, as a rule, trian ;.. in shape with the base at the surface and aper in the it. All are in direct connection with the growth on the surface the lung and transitions from the adenomatous tumor oc . surface to the adeno-carcinoma within the lung are eride: most of the sections. The cells at the apices of the ... nodules lose their gland-like arrangement and infiltrate : atelectatic lung as solid, slender strands of epithelial ce :

Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.

Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 139

Author: Jacob Anthony Kimmell Publication date: 1910 Publisher: Number of Pages: 1189

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189