IMAGE EVALUATION TEST TARGET (MT-3) // 1.0 I.I 1^ us 1.8 1.25 1.4 1.6 < 6" ■ ► ,d V] '5 ■ iV•-. Vs •:■.,■">, '■■■a v/:A' ."■: By F. G. FINLEY, M.D., :'*;y^'.*V OI«' ■' ;r •*■ '^ P/tysician to the Montreal Qe^ieral Hospital ; ' -ft ■■' ?••.■;" ^> " -^ "■ ■■■ -• t-v" . i • • '--,•■ ■AND.s.}'.- ■•!■/■ V'., ., , ■ ';|;:Pr'KT' W. I. BRADLEY, M.D., ^''f;^V>\7v'^'i''':V^fc^^^ ,_._-,, f^v^s,''^*^'.' ' • ■ ■■.'''■ ' 'pf/? /-iVi-y,; \ ^ ,;.•'•';*■', •^•■^f ,■ v^" - Assistant Pathologist to the Montreal Gensral Hospital. '- % ^i-t'.i'M;Y'i'''v'' . iV 'l.v'':"'^.:-^-V '' :'','^^*-»v l--,'. --^■;;vf'■ f-A' "•.■.iU> ..'.^'U^^- C:.^' • ,.?f ^■V",.'^"!';'''^^:^"'' > vt.' ^ '.:'•■ vit.i'>/'':vfr •' .•.•<^''r"0' -.i. ::; v ';?■ -'x-^'iy- ;^^/.■-/:fy^;;■>;>C'- ■>.>■':<' rVi,'.;-^.;. -v'-.' .■^■. ,.• -i'iv,0' ftv'? ; ■ '' " ■ • ■<■ <,■>■■ .B^A..?:^^ ■Vr:; N. ^^iVjBtE*** ^•^' ■M >V^''''^'.' From "Thk PRAcrriTiONKR "Av Aii//i(sf, 18i)7. A CASE OF PRIMARY SARCOMA OF THE PLEURA. By F. a. FIXLEY, .A[.I)., Phynivian, to the Montreal (rencral Hoqiltal : AND W. I. lUiADLEY, M.I)., Assidant Patholoyixt to the Muntnul (icaeral IIo.y)iln.l. A CASK OF PHIMAHV SARCOMA OF THF PLKrUA. By F. a. FINT-EY, M.D. rhyxicinii to the Moiifwtil (Inicral Ifospitnl ; AND W. I. HRADLKY, M.D.. yiMxistnii/ I'lit/io/of/iK/ to the Montrml (it»crnl Ifnspitnf. J. M., aged sixty-seven, male, was admitted to the Montreal General Hospital on the 1st of May, 1897, complaining of pain in the left side of the chest, restlessness, and shortness of breath. His previous health had always been good and his habits temperate. The family history was one of longevity. The father died of cancer of the jaw, aged seventy-eight. For three or four weeks before admission the patient began to suffer slightly from pain in the side, which was never severe ; he became weak, felt unstead}' in walking, suffered from severe cough without expectoration, and within the past two or three days noticed his breathing to be very short on slight exertion. On ex^' niination he was a well-nourished elderly man, the muscles were rather flabby, the subcutaneous fat was well marked, and Hcberden's nodules were present on the terminal linger joints. The respirations were twenty-eight and slightly laboured ; there was restlessness and inability to sleep. The left side of the thorax was a little full, and expansion A CASE OF PRIMARY SARCOMA almost nil ; there was a flat note from apex to base, front and back, extending over to tlie right sternal border, and almost to the costal border in the anterior axillary line ; the breath sounds were much enfeebled and ( )mpletely absent behind; the vocal resonance and fremitus were also greatly diminished. The cardiac impulse was not felt, but dulness extended two Hngers' breadth to the right of the sternum : the cardiac sounds were also best heard in this locality. The temperature 07-8° F. The pulse was 104 and of fair volume. Owing to the dyspno'a, restlessness, and evidence of large (juantity of fluid, it was decided to aspirate ; the needle was introduced in the sixth space in the axilla and ninety- two ounces of blood-stained serum were withdrawn. On the following day the note over the front of the chest was high pitched but not flat, but posteriorly the flat note extended up to the fifth spine. The subsequent history was one of rapid collection of fluid and repeated aspirations to relieve dyspnoja. Between the 6th and 27th of May he was aspirated six tiines, the total quantity of fluid drawn ofl* during this period being 854 ounces. The temperature was afebrile throughout, the two-hour chart ranging from 9G'4 to 98-4' ; it reached 9})' only on three occasions, and 100 and 100^ '^ only on two occasions for a few hours. The pulse during the greater part of his illness Avas re- markably suiall and feeble, and at times irregular, averaging about 100. On two occasions he had alarming syncopal attacks. The general nutrition remained fairly good, the subcutaneous fat abundant, but the nmsclcs became extremely flabby and soft. Glandular enlargements were never present. Death from cardiac failure took place on June 1st. On opening the chest the heart was found displaced to the right of the sternum, and the left pleura was greatly enlarged. On opening it 105 ounces of sero-sanguineous fluid escaped. The thoracic viscera were then removed en masse, the left pleura being readily stripped from the chest wall, and the impressions of the ribs being seen on its outer surface. Both layers of the pleura were universally thickened, the inner OF THE PLEURA. sni'fiicc bcinf( studdod with nodules of a white or reddisli <;oloiir, wliich on section wore seen to he unifonnly white and Juicy, fn size they varied from 5 to .SO mm. in thi(;kness hy (iit. incd. Wiich., ISW. Sr\. M. 47 M '>y — inuinonaii, "I'limiireis Siir- koni (1. Pleura."' D V II. t . m c d . Worli., l8i)U. 23 M. 4.— Bernard, f5. 0. — L e u 1) e , Hirscli J. 1)., ]KH!». 14 o 'A Syiii|iloMis. I'uiii, froiiuuiit voinitiiij}, weak |iiiIh(! iitid niiHt!)! surface teuipt-ra- ture of left arm. Dysimo'a, iit tirst 0)1 exertion, and later at rest. Se- vere cough, puru- lent exi)ectora- tion. liater.severe pain, weak radial pulse on left side. Repeated aspira- tions for removal of fluid. Kmania tion, marasmus. Death with symp- tomsof cardiac pa- ralysis; duration about six months. .Sense of j)re8sure on left side, in- creasing to i)ain, radiating down leftleg.Cachexia, cough and expec- toration sliglit. Later, parai)legia, l)aralysis of blad- der and rectum, decubitus, sliglit elevation of tem- perature. Cougli, dyspnoea, imui left side, night sweats. Death from cardiac and re- spiratory failure. Pain in left side. Intensepain little and ring finger. G^dema of arm. No details. I'liysical si^jns. Kuiging, dulncHH. distant blowing breathing, absent vocal fremitus at left ajtex, front and back. I'uiic- ture gave blood, slid wing ccIIh larger than lenco- (! y t e H, a few spindle and large sized cells. .Signs of fluid on leftside. Slightly enlarged glands lielow clavicli' and in axiUa on same side. Bulging of thorax at left liase be- hind, with ab- sence of resjiira- tory movement. Feeble breath sounds over this area. Puncture negative. Dulness from base to middle of in f ra-spinous fossa. Heart dis- placed and, later, veins enlarged on chest wall. Blood - stained fluid, two quarts removed. Glands size of walnuts in supra - clavi- cular and axil- lary regions. Bulging of affect- ed side. Absolute dulness dimin- ished V.F., slight blowing breath- ing. Displace- m e n t of the heart. Puncture negntive. riisi.iiii.iii'iii ii|) |H'nraiii-eH. Angio - sarconiat- ous mass in upiier part of right pleura, involving intercostal hu- meral nerve. Pleura univers- ally thickened with n o d u 1 ar growths. Metas- tac'.'s in !iings and bronchial glands enlorged. Large tumour of pleura weighi.ig 7 Kg. Erosion of vertebi'ieand pres- sure on spinal cord. Growth size of a sheep's head of left pleura, which is partially adher- ent and contains yellow fluid me- tastases in right pleura and lungs. Enlarged medias- tinal glantls. No autopsy. No autop.sy. OF THE VLKURA. Krom un oxiuiiinutioii oC those ciiscs it would upiu'iu- (luit l)riiiuu'y sarcoinatous j^Towths of iho pleiini inay appoiir as a sinjrio largo j^rowth, or as a ditl'iiscid iiodidar thickoniii..' of the ploiira with ottiisiou of fluid, usually tingod witli blood. Kxaniplos of the former class an; oases l,.S, 4, (i: whiL«t the second is exouii)lified by ceases 2, 5, and our own. The physical signs ditibr uiatorially in the two classes. In the case of single largo tumours there is often bulging of the chest wall, dulnoss, abst^noe of rosj)iratory movomonts, feeble, somotimos blowing rosj)iration, and occasionally (tardiac displacement. In the difVuso cases the signs are essentially those of unilateral pleural effusion. In our own case and in Derus- ohinsky's the recurrence of fluid after as[»iration was extremely rapid, rf being often obtained for two or three days only. Of the other symptoms, pain is usually prominent, dyspnea is present on exertion, and sometimes at rest; thereisconunonly a dry cough, and in two of the cases there was enlargement of the glands in the axilla and clavicular region, to the size of a bean or walnut. The temperature is atebrile.and there is a marked tendency to cardiac weakness. In two cases (1, 5) ])ressure symptoms in the arm, on the nerves and vessels, were ])rominent, and afforded material aid in the diagnosis. It is somewhat remarkable that in all the cases quoted, with the exception of Lcube's, in which no statement is made on the point, the disease Wi)« on the left side. T