Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 76

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 76

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).

On physical examination, the sclera were white. The heart and lungs showed nothing abnormal. A hard, irregular mass was felt in the epigastrium, being especially prominent to the right of the middle line. What was thought to be the spleen, could be palpated two inches below the costal border in the left anterior axillary line. The abdomen contained much free fluid, which, together with the extreme weakness of the patient, and marked abdominal tenderness, rendered thorough physical examination impossible. The urine contained a trace of albumin, but otherwise showed nothing abnormal. Blood ex- amination revealed a leucocytosis of 34,000 of which 90 per cent were polymorphonuclears, 3,500,000 red cells, and 56 per cent hemoglobin.

The case was diagnosed carcinoma of the stomach.

Patient died on the eighth day after entering the hospital.

'The post mortem examination was made about three hours after death.

Anatomical diagnosis: Retroperitoneal sarcoma; tuber- culosis of the peritoneum and retroperitoneal lymph glands; chronic aortic endocarditis; atheroma of the aorta; chronic interstitial nephritis; miliary tubercules in the kidneys; atrophy of the spleen.

The body is that of a very old negro woman. Emaciation is extreme. Over the coccyx is a bed sore 1 cm. in diameter. The inguinal glands and one left supraclavicular gland are palpable.

The peritoneal cavity contains 2500 cc. of yellowish, slightly turbid fluid. The great omentum is short, rolled up and ad- herent throughout most of its length to the descending colon. The diaphragm is partially adherent to the anterior surface of the right lobe of the liver. Adhesions are present between the tip of the left lobe of the liver and spleen. Similar adhesions between subdiaphragmatic peritoneum and spleen enclose a multilocular cavity containing fluid similar to that in the gen- eral peritoneal cavity.

The visceral and parietal peritoneum are thickly studded with semi-translucent nodules (tubercles) miliary in size and larger, many of which are confluent. They are most numerous poste- riorly between the lower border of the ribs and the crest of the ilium, and in the pelvis. Here the peritoneum is deeply con- gested. Thin velamentous adhesions stretch from the uterus to the adjoining structures, forming a complete roof over the cul-de-sac of Douglas. These nodules are fewest in number on the posterior surface of the stomach.

Three large tumor masses are visible on opening the perito- neal cavity. The first projects beyond the anterior border of the liver immediately to the right of the gall bladder; the second has grown between the stomach and the transverse colon ; and the third projects from under the left costal border in the mammillary line. These masses are parts of a large irregular growth from the posterior abdominal wall between the liver and the root of the mesentery. Superiorly, it is attached to the gall bladder, and to the posterior part of the inferior surface of the liver to the left of the gall bladder. Posteriorly, the tumor lies in direct relation with the right kidney, vena cava, aorta, renal vessels, adrenals and left kid- ney, being adherent to the latter over the medial half of its anterior surface. On the left, it is adherent to the spleen, diaphragm and splenic flexure of the colon. Immediately in- ferior to it are the transverse colon, root of the mesentery, and duodeno-jejunal flexure. The transverse colon has been pushed downward in the middle line, but passes upward to the left of the mass in direct contact with, and adherent to, the descending colon to form the splenic flexure which is thus made a very sharp angle. The duodenum passes around the right border of the mass and, in its lower part, by turning backward and downward comes to lie somewhat between the growth and the right kidney. Anteriorly the central portion of the tumor is covered by the stomach, a small part of the duodenum, the gastro-colic omentum and the pancreas.

The pancreas has been pushed forward and upward so that it is no longer in direct relation with either the duodenum. portal vein or spleen. The head lies over the right margin of the growth and measures 2 cm. in its thickest part. The body and tail are stretched upward and to the left over the most prominent part of the growth. The pancreas is definitely separated from the tumor by a capsule.

On cut surface the appearance varies in different parts of the mass. That nearer the spinal column is firmer in con- sistency than the more superficial part. The color varies from pale yellowish-white to red and purple. Hemorrhages into the tumor are numerous especially in the left half of the mass immediately beneath the peritoneum. The tumor tissue is everywhere soft and friable; in the superficial hemorrhagic areas it is semi-fluid.

Several important structures lie well within the mass. The branches of the celiac axis are surrounded by tumor tissue. especially the splenic and hepatic arteries. These vessels stand open on section. The course of the portal vein is tortuous. and it is separated from the head of the pancreas by tumor tissue 1 cm. in thickness. The common bile duct is completely surrounded but is patent and bile is easily pressed from the gall bladder into the duodenum.

There is some thickening of the mitral valve. The attached borders of the aortic cusps are calcified and the cusps them- selves thickened. In the coronary arteries are numerous atheromatous plaques. The thoracic and abdominal aorta and the common iliac arteries contain numerous atheromatous plaques.

In the apex of the lower lobe of the left lung is a -pin-head-

Digitized by Google

80 porwally calcimed nodule. The anterior borders are physematous. Otherwise the lungs show nothing note- rthy.

The palpable, left supraclavicular gland contains several liary yellowish-white nodules. The tracheo-bronchial glands e anthracotic and very slightly enlarged. Lying posterior to e œesophagus 2 cm. above the diaphragm, is a gland the size a small almond, which, on cut surface, shows a soft, white tinctly limited area 3 mm. in diameter. The spleen is rophied and its capsule covered with tags of adhesions.

The gastric mucosa is covered with thick blood-stained ucus. In the middle third, especially on the posterior wall, e a dozen or so pin-head-sized ulcers, each containing a small pod clot and extending 1 to 2 mm. into the mucosa. The ntents of the intestines are blood tinged in the upper part d black and tarry in the region of the ileocccal valve and low. Sixty-five centimeters below the duodeno-jejunal flex- e, in the attached border of the intestine and extending into e mesentery is a mass 6.5 x 2.5 x 4 cm. It is firmly attached the wall of the intestine and cannot be peeled off from it. ne mass is soft, yellowish-white on cut surface, is very able and contains two small irregular cavities containing crotic material.

In the liver are a number of metastases from 0.5 to 1 cm. diameter. The gall bladder contains dark green bile and merous soft, small, black stones.

On cut surface both kidneys are red in color, the cortex asures 3 to 5 mm. in thickness and the cortical markings e indistinct. The capsule strips easily, leaving a finely anular surface. On the posterior surface of the left kidney ere is one, of the right kidney two pin-head-sized, yellowish- ite, opaque nodules. The interior of the urinary bladder is rmal in appearance.

In the right ovary there is a small cyst 1.5 cm. in diameter, staining clear fluid. The left ovary is atrophied. The llopian tubes are normal except for the tubercles on their itoneal surface. The uterus is small and its walls contain nerous small interstitial fibroids. The peritoneal surface is kly covered with confluent tubercles. The cervix shows results of a lateral tear. No evidence of primary tuber- sis of the genitalia can be discovered.

The organs of the neck and the brain were not removed.) ficroscopical examination shows the large retroperitoneal or to be a typical spindle-celled sarcoma. The tumor mass he insertion of the mesentery to the small intestine is lar in every respect to the larger growth. Sections cut to tmine the relation of the smaller tumor to the wall of the Itine show that in the peripheral part both muscular layers jate the sarcoma from the submucosa. Toward the center bngitudinal muscle fibers, and still further on the circular 3, completely disappear and the tumor is separated from mbmucous layer only by a thin capsule. The muscular is not involved in the neoplasm. It has the appearance ving been bevelled off from without inward toward the ucosa and is always separated from the tumor by a thin le.

The small nodules in the peritoneum are characteristic tubercules. Many of the sections from the peripheral part of the large retroperitoneal tumor show a narrow rim of lymphatic tissue. In this zone numerous tuberculous foci are found with areas of necrosis and giant cells. The tuberculosis seems to be limited to the remaining retroperitoneal lymphatic struct- ures. In no section has the sarcoma tissue itself been found infected. In the postœesophageal gland, in addition to the metastatic sarcoma, there are two or three very small foci of tuberculosis, but the two processes are always separated. The supraclavicular gland contains tubercules.

Tubercle bacilli were found in a number of sections cut so as to include the zone of lymphatic tissue on the surface of the large retroperitoneal growth.

The chief interest of this case lies in the association of a very rapidly growing retroperitoneal sarcoma with a very viru- lent tuberculous infection of the peritoneum. It was not pos- sible to determine which condition appeared earliest. The fresh appearance of the tubercules and the exceedingly rapid growth of the sarcoma make it probable that both processes began about the same time. No source of origin of the tuber- culous peritonitis could be found although searched for dili- gently. There were no tuberculous ulcers in the intestine, and the only tuberculosis of the genital organs was on their perito- neal surfaces. The fact that tubercles were more numerous and more often confluent in the pelvic peritoneum may have been due to the effect of gravity in causing the infected peritoneal fluid to collect there.

Of the above 130 cases," tuberculosis was active in 34. Of the 20 cases (including the one here reported) in which suffi- cient data were given to permit their use in an analysis, tubercle bacilli were actually demonstrated in only 9 and not mentioned in 11. This is an important desideratum `since Baty-Shaw " has reported a case of sarcoma of the mediastinum associated with pseudo-tuberculosis of the left lung. Grossly, the lesion in the lung closely resembled true tuberculosis, but the bacilli could not be found either in the contents of the cavities nor in sections of the lung.

That sarcoma and tuberculosis are rarely found in the same patient is an admitted fact, but that there is anything incom- patible in the two conditions does not appear probable. The case here reported of a very virulent form of both diseases in the same patient would seem to be sufficient to preclude their being incompatible. There is no apparent reason why a tuber- culous process should, by chronic irritation, cause the de- velopment of a sarcoma, although the cases of Bobbio and Tauffer rather remotely suggest such a possibility. Both of these cases had been operated upon two or more times previous to the appearance of the tumor. Taylor and Teacher " have reported cases in which a cancer appeared to cause the de-

2 If we exclude Bang's 34 cases of brain tumor, some of which were undoubtedly not sarcomatous, the total will be 96 instead of 130.

" Brit. Med. Jour., 1901, 1, 1331.

2 Jour. Path. and Bact., 1909, XIV, 205.

Digitized by

Google

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 238

velopment of a sarcoma in the adjacent connective tissue. On the other hand, the general debility and consequent loss of resisting power which accompanies the growth of a sarcoma would prepare the soil for an infection with tuberculosis.

The following are suggested as possible reasons why the two lesions are not more frequently found associated : (1) The

age incidence of the two diseases is not quite the same. Sar- coma and tuberculosis affect all ages, but the former is more frequent before 20 and the latter after that age. (2) The rapidly fatal course of a sarcoma may attract attention to itself so completely that the presence of a mild tuberculosis would not be recognized clinically.

CARCINOMA OF THE RIGHT FALLOPIAN TUBE READILY PALPABLE THROUGH THE ABDOMEN.

By THOMAS S. CULLEN, M. B., Associate Professor of Gynecology, Johns Hopkins University.

Cancer forms a very small percentage of the pathological conditions of the Fallopian tube. As pointed out by Hurdon,' carcinoma was noted only three times in the tube, as compared with some four hundred cases of cancer of the uterus that came under our observation in the Johns Hopkins Hospital. Among the more important American articles on this subject are those of LeCount' and Hurdon." In the Johns Hopkins Bulletin of 1905, Vol. XVI, p. 399, I reported a case of adeno- carcinoma of the tube in which as a result of extensive involve- ment of the pelvic peritoneum and of the surrounding tissues I found it necessary to remove not only the entire uterus with the adnexa but also several inches of the sigmoid flexure and about one-third of the pelvic peritoneum.

Alban Doran,' of London, has given a complete survey of the literature and collected in all sixty-two cases. A further admirable monograph on the same subject by the same author ". appeared a few months ago. In this the number of cases of carcinoma of the tube had been increased to one hundred.

After such thorough presentations of the subjects as have been furnished by these authorities a further survey of the literature would be simply a repetition and I shall merely report a case which came under my observation in the labor- atory. Its chief interest lies in the large size of the growth. When I first saw the hardened specimen before learning the clinical history, I considered it to be a very large hydrosalpinx or pyosalpinx. On section, however, its true character was readily discernible.

Adeno-carcinoma of the right Fallopian Tube, extension to left Fallopian Tube; very small uterus.

San. No. 2453 .- Mrs. M. H., aged 46. Admitted to Dr. Kelly's private sanitarium on May 14, 1907. The patient entered com- plaining of a mass and great pain in the lower part of the abdo- men. The family and past history were negative.

1 Elizabeth Hurdon, Kelly, H. A., and Noble, C. P. Gynecology and Abdominal Surgery, Phila., 1907-08, I, 175.

? LeCount. Johns Hopkins Hosp. Bull., 1901, Vol. XII, p. 55.

" Elizabeth Hurdon. Johns Hopkins Hosp. Bull., 1901, Vol. XII, p. 315.

Alban Doran. J. Obst. & Gynæc. Brit. Emp., Lond., 1904, VI, 285.

" Alban Doran.

J. Obst. & Gynæc. Brit. Emp., Lond., 1910, XVII. 1.

The menses began at 14, were regular, moderate in amount, somewhat painful and usually lasted four days. For the last two or three months the periods have been irregular but profuse. She had one miscarriage when 18. Recently there has been a profuse leucorrhæal discharge which, for the past year, has been associated with some odor and with blood.

Present Illness .- Two years ago the patient first had what she called an attack of appendicitis. The pain was located in the right iliac fossa and was severe and cramp-like in character. It has persisted in this region and for the last year has also been present in the left side. The pain radiates into the leg and for the last four or five months both legs have been swollen.

Operation .- The uterus was removed by bi-section; a small piece of intestine was also removed on account of a little sub- peritoneal cyst which was supposed to be secondary to the tubal growth. There was no glandular involvement and no evidence of any peritoneal implantation.

Path. No. 11536. The specimen consists of a small uterus, of a greatly enlarged right Fallopian tube and of an enlarged left Fallopian tube.

The body of the uterus is 4 cm. long and about 4 cm. broad It is markedly atrophied. The right tube at the uterus is about 7 mm. in diameter, but after passing outward 1 cm. it curves on itself, becomes markedly convoluted and 5 cm. from the uterus is 5 cm. in diameter. It continues to increase in size until at its outer end it is 10 cm. in diameter. Roughly it forms & sausage-like tumor 14 cm. long, 12 cm. broad, and about 10 cm. in thickness. Anteriorly it is covered with adhesions. Posteriorly it is perfectly smooth and springing from its surface is a sub- peritoneal cyst 1.5 cm. in diameter. Large congeries of blood vessels are seen ramifying beneath the peritoneum.

On section it is seen that the great increase in size is due in a large measure to a new growth. This has extended into the lumen of the tube, but at no point does it appear to have reached the outer surface. Where the tube is 5 cm. in diameter the growth completely fills the lumen. It is composed of a granular-looking new growth which presents a somewhat arborescent appearance. The growth apparently springs from all parts of the wall of the tube. Near the fimbriated extremity, where the tube is 10 cm. in diameter, for over fully half of its extent the walls are covered with a new growth. This in places reaches 2 cm. in thickness. At other points the tube seems to be free from the growth. The entire central portion of the tube has been filled with fluid that has undergone coagulation in the hardening fluid. In the fluid next the growth here and there are large blood clots. The gross picture leaves little doubt that we are dealing with a malignant growth. If it be malignant the reason why it has not extended outside seems evident, because the point of least resistance would be toward the center of the tube.

Digitized by

Google

THE JOHNS HOP

Quy Horn Ute

1. Beginning of tube

- --- -

Google

Digitized by

-- ----

Digitized by

Google

[ tube, near the uterus, is 5 mm. in diameter, but on utward a short distance it is dilated to 4 or 5 cm. It on section is found to be the seat of a similar growth. is covered with adhesions.

rical Examination .- Sections from the growth of the : show in some areas little tree-like or teat-like projec- nding into the cavity. They remind one very much of folds noted where a hydrosalpinx exists. At other : epithelium has proliferated forming gland-like areas. dvanced portions over wide areas papillary outgrowths These present a distinct arborescent appearance and :tions are covered with one or several layers of very eaingly regular cylindrical epithelium. Over large areas lot the slightest evidence of breaking down. In still ions of the growth one sees nuclei two or three times size. These stain somewhat deeply. In other portions longitudinal sections of finger-like processes with large sels in their interior are seen. Here and there the

proliferated until solid masses of glands have been Masses of epithelium without evidence of gland forma- Iso noted. In only a few places is there evidence of lown.

wth is, without doubt, a carcinoma, but is characterized ed tendency toward gland formation and papillary out- nd by its stability instead of its tendency toward break-

One might, with some propriety, claim that it re- o a marked degree, a very cellular and branching

eresting to note that the other tube presents a similar :. One tube may have picked the carcinoma up from the e tube walls themselves are not over 1 mm. in thick-

ness. We did not receive the ovaries or the small nodule from the bowel for examination.

We find no record of any other carcinomatous tube that has reached such large proportions.

Post-Operative History .- Sept. 30, 1910. Dr. Curtis F. Burnam kindly made inquiry concerning the patient and finds that there is at present a marked recurrence of the growth, there being a large palpable abdominal mass. The patient, however, is able to do her work most of the time and her general health has been but little affected.

The growth has evidently been a rather slow one as it is nearly three years and a half since operation.

DESCRIPTION OF FIGURES.

FIG. 1 .- Primary Carcinoma of the Fallopian Tube. (Natural size.)

The small uterus has been bisected and one-half is seen in the lower part of the picture. The tube at the cornu is small, but after passing outward a short distance rapidly increases in size. Its outer end is so much distended that it might readily be mis- taken for an ovarian cyst. The surface of the tube is covered by numerous adhesions and its vessels are large and tortuous. The interior of the tube is shown in Fig. 2.

FIG. 2 .- Primary Carcinoma of the Fallopian Tube. (Natural size.)

For the general contour see Fig. 1. In the lower part of the picture is a cross section of half of a bisected uterus. The great increase in size of the tube is in a large measure due to a friable, stringy growth which almost completely fills the lumen. The great distension of the outer end of the tube has been caused by an accumulation of serous fluid which has coagulated in the hardening fluid. This coagulum is seen retracting from the tube wall and could readily be lifted out of the tube in one piece. It will be noted that where the tube is so much dilated its walls over a considerable area are totally devoid of new growth.

IN MEMORIAM. AUGUST HORN.

ust 19, 1910, our friend and associate, August Horn, only in Bad Nauheim, where he had gone in quest He had been ill for nearly a year with post-typhoid s and many of the distressing secondary affections

this disease. He was buried in Leipzig-Mockau, nvalid father and mother still live. He was an only de of humble parents.

rtistic ability asserted itself early, and in 1884 at 5 years, he entered the " Königliche Kunstakademie gewerbeschule " in Leipzig, where he devoted his study of the fine arts and, as it was customary in in Leipzig's academy, he also took up one of the , viz., lithography. This was done to assure himself od in case his talent should prove insufficient for k. This step I consider fortunate as will appear as always very conscientious and came to excel in ch required a combination of artistic feeling with a of technical skill. On the other hand, in the study y and science underlying art, Horn showed less But his instinct usually supplied what his mind › and so well did he observe and analyze that he l in his work the lack of theoretical study.

trative narrowness of artistic ideals in Leipzig to become a student in Munich, where he painted

for a number of years under several well-known masters. Through his colleagues he became known to wealthy art con- noisseurs, and since the life of a poor artist, in a center like Munich, is one of great deprivations, he turned aside, tem- porarily at least, to become a copyist. He was sent to Dresden, Venice, Milan, Rome and other places with orders to copy famous works of the old masters. These copies were exceed- ingly well done, faithful even to the technical peculiarities characteristic of each master.

Such was his work when I visited Leipzig in 1898. Having been requested to suggest an artist for Dr. Halsted and his department, if one such could be found, I at once thought of Horn and induced him to give up his work in Italy and become a medical illustrator. He began his work here as illustrator in the surgical service of the hospital in the fall of 1898, and soon demonstrated that his ability was equal to his task. His faith- ful water color paintings of tumors of the breast and similar drawings are unique and only paralleled by the best French pictures of pathological subjects. In 1901, Horn became a member of Dr. Kelly's staff of artists. His drawings for the " Vermiform Appendix " and " Medical Gynecology " are too well known to require any praise. Later he was engaged jointly by Drs. Kelly and Cullen, for whom he did most of the illus- trations of the books " Myomata of the Uterus " and " Adeno- myoma of the Uterus." His last work, just begun, was intended to illustrate a book on diseases of the ovary by Dr. Cullen. Many articles in medical journals by Drs. Halstead, Cullen, MacCallum, Hunner, Watts, Holden and others were

Digitized by

Google

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 238

illustrated by Mr. Horn, all with great zeal, fidelity and feeling for the artistic possibilities of a supposedly dry subject. To him all things in nature were capable of displaying beauty; he felt its presence, hunted for it, and brought it out in all his drawings with unerring instinct.

Horn's best work was done in the realistic style. There he was a master. In other respects, however, he may have had some deficiencies. He never liked to make diagrams or work out a problem ; he also could not draw a picture intended to represent the salient features of a case or of a group of cases. He could not visualize nor generalize, perhaps because his knowledge of medicine as a science was small. lle was not a student and his storehouse of anatomical infor- mation was limited. Therefore he rarely had a clear mental pic- ture before he began his diagram. He then began to experiment, alter, and usually ended up with a mediocre picture and his spirit downcast. But if given the op- portunity of sketching an opera- tion or of drawing a specimen at his leisure, he was in his element ; his eye and hand worked together with splendid precision. He knew how to find the inherent beauty of a line or contour, how to illu-

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 76

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

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