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1947 'I, Vol. 236 No. 11 CASF. RF.CORDS OF T1IK MASSACIUSFTTS CK.VKRA I. IIOSPITAI. 407 ; tnizes l*erialvted as Sudded ; $e of v; fact scar Stito a | rands \ 3 the s the gree, : the iilure i astic ;. In $e of t tion, : hich l. the ", the iout "it of e of J be itics , :rial - sses are their , ex- . be a hey Hies : jse. ure :ast 'ty, in f a ure . of rind i:en > ft ifus ds ite :nc : td Adequate experimental trial should precede the clinical use of any untested plastic material in surgery. References Simondt, H. R., and Ellis, C. Handbook oj Plastics. 1083 pp. New York: D. Van Notirand Company, Incorporated, 1945. Bailey, R. L. Polythene Used in Britain as /nsulation in British Airera/t tp4t. it. 1. du Poni de Nemours and Company, Incorporaied. Meyers, L. Intravenous othcicrizaiion. Am. J. Hurting 45:9j0. 1945. Poppc, J. R., and de Oliveira. H. R. Treatment of syphilitic aneu* ryams by cellophane wrapping. J. Thoracie Sure. IS: 186-195, 1944. Ingraham, F, D., Alexander, K., Jr.t and Matson, D. D. Unpublished data. Huelaebusch, J. B., Foter, M. J., and Gibby, I/W. Effect of rubber tubing upon stability of penicillin and streptomycin solutions. Scienee 104:479, 1946. ' Wheeldon, T. Use of cellophane as permanent tendon sheath. J. Bone W Joint Surg. 21:393-396, 1939: McKeever, D. C. Use of cellophane as interposition membrane in synovectomy. J. Bone tif Joint Surg. 41:576-580, 1943. . Harley, G. H., and Breck, L. W. Cellophane in bone and joint sur gery., Am. J. Surg. 68:229-231, 1945. Donati, D. Ricerche stflrimentali sull'uso del cellophane in plaitiche durali di varia nrandezza. Bull. d. sc. mtd., Bologna 1G9.42S-432, 1937. Christyakov, N. L. Use of cellophane in treatment of wounds. Am. Rtv. Soviet Mtd. 3:490-493, 1946. Page, I. H. Method for producing persistent hypertension by cello phane. Science 89:273, 1939. 6*>. Utm. Producii-ii of persistent arterial hypertension by cellophane perinephritis. J .1. M, A. 113:1046-2048. 1939. V 0 Ctracf. I . anj Pape. I H. Pathological anatomy of cellophane peri nephritis. Am. /. Path. 16:21 1-22., 1940. 71. Diiiiiliuc. f. W. I*.fleet nf cellophane perinephritis on granular cell. of tualayloincriilar apparatua. Arch. Polk. 33:211.216, 1914. 72. Pcarse, H. I*.. F.xpecimcntal studies on gradual occlusion of large arteries. An., Surg. 112:923-937, 1940. 73. Idtm. F.xpcriiucmal studies on gradual occlusion ol large arteries. 7r. Am. S. A. 68:443-457. 1940. r4. Gross, R. I*.. Complete surgical division of patent ductus arterioaua: report of fourteen successful cases. Surg., Gynec fj Obit 78:36-43, -5. Harper, F. R., and Robinson, M. E. Occlusion of infected pacent ductus arteriosus ivith cellophane. Am. ]. Surg. 64:294-296, 1944. 76. Harrison, F. W.. and Cbandy, J. Subclavian aneuryim cured by cellophane fibrosis. Ann. Surg. 118:478-481. 1943. 77. Grant, F. C., and Norcross, N. C. Repair of cranial defects by cranio plasty. Ann. Surg. 110:488-512, 1939. . 78. Ncv, K.3V. Repair of cranial defecta with celluloid. Am. J. Surg. 44: 394-399, 1939. 79. Smith-Peiersen, M. N. Arthroplasty of hip: new method. I. Bonr iS Joint Surg. 21:269-288, 1939. ' 80. Baker, D. R. New type of plastic hip cup for arthroplasty or for use as artificial femoral head. Culhrir Clin. Butt. 11:133, 1942. 81. BejUs^ J. E. Suture studies: new suture. Arch. Surg. 41:1414-1425, 82. Blaine. G. Experimental observations on use of absorbable and non-absorbabie plastic# in bone surgery. Brit. J. Surg. 33:245-250, 1946. 83. Hueper, W. C Martin, G.J., and Thompson, M. R. .Methyl cellulose solution as plama substitute. Am. J. Surg. 56:629-635, 1942. CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL Weekly Clinicopathological Exercises FOUNDED BY RICHARD ,C. CABOT Tracy B. Mallory, M.D., Editor Benjamin Castleman, M.D., Associate Editor Edith E. Parris, Assistant Editor CASE 33111 Presentation of Case A thirty-seven-year-old Swedish asbestos worker entered the hospital because of cough and chest pain. Two and a half years before admission the patient had developed a cough, nasal, congestion, nasal dis charge, fever and shortness of breath that had per sisted one week and had been followed by a dull, aching pleuritic pain along the left costal margin. He was hospitalized for a'week and then rested at home for four months. In the hospital about 1000 cc. of fluid was removed from the left side of the chest. Subsequently, he returned to work and felt well except for a morning cough productive of small amounts of odorless white sputum. Occa sional chest pain and exertional dyspnea were also noted. A year and a half later there was an in sidious onset of weakness and fatigability and a gradual loss of 25 pounds in weight. Three months before entry the pleuritic-pains became persistent, and. the weakness and dyspnea severe, and the patient slept propped on two pillows. Repeated sputum smears were negative for tubercle bacilli. The patient's work consisted in cutting asbestos insulating board; lie denied exposure to undue amounts of dust. There was no history of exposure to tuberculosis. ' Physical examination revealed the patient to be orthopneic and breathing rapidly at a rate of 30 per minute, with a dry, hacking cough and clubbed ' fingers. There was a slight, shotty, generalized lymphadenopathy. Respiratory expansion on the left was diminished, as were tactile and vocal fremitus and breath sounds. On the right there were increased bronchovcsicular breath sounds and scattered dry rales. The heart and mediastinum were shifted to the right, and the apical beat was maximal in the right midclavicular line. There was a ticktack rhythm with a rate of 110, and a pulsus paradoxicus. The abdomen was normal. . The temperature was 100F. The blood pressure was 128 systolic, 70 diastolic. . Examination of the blood disclosed a red-cell count of 4,900,000 and a white-cell count of 12,200, with 77 per cent neutrophils, 16 per cent lympho cytes and 7 per cent monocytes. The urine and stools were normal. X-ray examination showed numerous discrete areas of increased density scat tered over the right lung; pressing on the lower trachea and left main bronchus and deviating them to the right was a large mass measuring 11 cm. in diameter (Fig. 1). A small amount of aerated lung was seen at the periphery of the mass. There was either fluid or, more probably, dense pleural thick ening and collapsed lung between the mass and the lateral costal margin. The left lower-lung field was almost completely opaque. In the hospital the patient's condition became steadily worse. Further x-ray studies showed dis placement of the esophagus to the right (Fig. 2), extensive periosteal new bone formation of the left upper ribs, slight displacement of the stomach to SCF-FA-3200 -108 THE NEW ENGLAND JOURNAL OF MEDICINE Mar. 13, 1947 the left, enlargement of the spleen and the sugges tion of a retroperitoneal mass rotating the left kidney. Three attempted thoracenteses failed to encounter fluid, although the needle was inserted to a depth of S cm. No acid-fast organisms were found in the sputum. Tuberculin tests were nega tive in a 1:1000 dilution. The patient became ex- the final hospital admission, with fever for a week. About 1000 cc. of fluid was removed, following which the patient was discharged from the hospital. He then rested at home for four months, returned to work and remained in good condition for a year. This could have been pleurisy with effusion, perhaps tuberculous. Many sputum examinations, however. Fioure- 1. Roentgenogram of the Chert, .Shooing Opacity on the Left ana Multiple- Nodules in the. Right Lung.. ' ' tremely weak and dyspneic and perspired'.'con stantly. He died on the thirty-seventh hospital day. Differential Diagnosis Dr. Donald S.. Kinc: This seems to be the old problem of a tumor in the |ung with a decision to be made regarding the kind of tumor. As In most cases, .the decision will be based largely on the X-ray appearance. One should comment first on the occupation. This man worked with asbestos, cutting insulating board. Exposure to asbestos causes lung changes but never,'in my experience, to the extent that was present in this case. I believe that asbestosis was not a factor in the illness and that, if present, it was of secondary importance. The next question concerns tuberculosis. The onset of the disease was two and a half years before showed no tubercle'bacilli, and shortly before death a tuberculin skin test'was negative in a 1:1000 dilution. In any event, the evidence for tuberculosis does not seem sufficient to justify that diagnosis,in addition to what I believe was a tumor. My diag nosis is tumor, with-fluid that was secondary to the tumor and not due to tuberculosis or other infection. The x-ray'films present a different picture on each side of the chest. On the right side there are many nodules,, which are better shown in some films than others. In my experience, rounded nodular shadows of this sort have always been caused by metastatic tumor, either from some spot elsewhere in the lung or from some place outside the chest. If the tumor was metastatic from outside the lung, it could have been from above .the clavicles or below the diaphragm, or there could have been metastases from a primary bronchiogenic cancer in 236 No. 11 life CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL 409 the left lung or from a mediastinal tumor. I should air left in the left, lung is the small amount seen in like to ask Dr. Schatzki whether he has ever seen the. left upper lung. The films do not show what is rounded shadows of this size and density that were going on lower down. i ty'fy. not due to tumor. Dr. Kinc: So you will not help regarding the Dr. Richard Schatzki: Yes. Dr. King.: I stand corrected on that point. position of the tumor -- that is, whether it is in the lung or outside the lung? Dr. Schatzki: That does not mean that this Dr. Schatzki: I think that I could help if I was was not a tumor. . allowed to. Dr. King: I have never seen rounded shadows of Dr. King: I think that it would be all right; how this size and distribution with silicosis, tuberculosis about it, Dr. Castleman? . Figure 2. Roentgenogram of the Chest and Abdomen following a Barium Swallow, Showing Displacement of the Esophagus and Stomach by a Mass in the Left Side of the Chest. or in fact anything, and I' therefore believe that the process in the right lung was definitely a meta static tumor. The x-ray film of the left side of the chest shows a large, round mass displacing the trachea and the left main bronchus to the right. Is the tumor in the lung itself or in the mediastinum? Dr. Schatzki: The same mass is visible on this film in the same position. I do not believe that one should try to delineate the exact outline of the tumor when so little air is present. Other criteria should be used to demonstrate the mass. The only Dr. Benjamin Castleman: By all means. Dr. King: I need a great deal of help. Dr. Schatzki: There is some definite evidence of a large mass outside the lung. The first indication is. the position of the esophagus, which is displaced far to the right side by a mass. This mass has a diameter much larger than the mass in the upperlung field, and therefore it cannot be a tumor in the lung. The second point is the position of the fundus of the stomach, which is pushed downward in cpn- trast to what one would expect with a lung tumor 410, THE NEW ENGLAND JOURNAL OF MEDICINE Mar. 13. 1947 that has produced collapse. Thirdly, the ribs, if tumor outside the chest, but the possibility of anything,, are spaced farther: apart than on the tumors in the pharynx and the thyroid gland normal side, which is again unusual for a lung that should be mentioned because findings similar to has collapsed. . those in this case follow rnetastases from malignant Dr. King: I should, have committed myself tumors in those areas. We are not justified, how before I asked that question, but I agree with your ever, in making such a diagnosis with the evidence conclusions. I cannot be sure that this was not a at hand. Below the diaphragm there is no indication bronchiogenic carcinoma of the left upper lobe, but of disease of the stomach, pancreas, liver or. kidney. my-.opinion is against that diagnosis. There was These films at first suggested that the testicle or also involvement in the left lower, lobe. I suppose the prostate was the primary source, or perhaps a that this also may have been a tumor. Do you so-called "hypernephroma." This is a fairly char want to commit yourself on that, Dr. Schatzki? acteristic picture for rnetastases from the testicle Dr. Schatzki: I think that I know the answer. or prostate, but we have no evidence to make that It is obvious, as Thave said, that there was some diagnosis. There does not seem to me to be any thing outside the lung; otherwise, the stomach justifiable source for the tumor outside the chest, would not have been displaced or the ribs separated. and we are back to the problem of what this tumor Dr. King: Do you think that it was a tumor or was. fluid? ' Was it bronchiogenic or mediastinal? We have Dr. Schatzki: I believe that it was a tumor. seen exactly this picture with teratomas of the Dr. King: That is what I believe. mediastinum that have -eventually broken loose. Let us go down to the abdomen. Was the spleen If it was a lung tumor I lean toward a bronchiogenic enlarged or was it displaced downward? I should carcinoma with rnetastases to the right lung and like to omit the spleen if I may. possibly the retroperitoneal area. The findings Dr. Schatzki: So far as I am concerned, it may were not quite consistent with those of bronchio be excluded. genic carcinoma because such tumors are usually Dr. King: Was the stomach involved? not large enough to push the mediastinum to the . Dr. Schatzki: There is no evidence of involve other side unless a great deal of fluid is present. ment of the stomach. It was displaced, but this Also, the rib changes were more like those with a was due to the low position of the left leaf of the large tumor mass that had been pressing on that diaphragm. area for some time. The process had been going on Dr. King: Was the liver enlarged? Arid was the for perhaps two and a half years. My diagnosis is displacement of the stomach to the left due to a mediastinal tumor, probably a teratoma, with such enlargement? rnetastases to the right lung. I do not believe that ' Dr. Schatzki: The liver was not enlarged so far the tumor was a lymphoma, although again that as I can tell. must always be considered. I doubt whether it Dr. King: This is an intravenous pyelogram was a bronchiogenic carcinoma with rnetastases. showing a retroperitoneal mass rotating the left Dr. F. Dennette Adams: How do you exclude kidney. lymphoma? Dr. Schatzki; Both kidneys are low in position, Dr. King: I do not exclude it. I have not seen and I am wondering if what we see is not again due x-ray findings such as these with lymphoma, which to the low position of the diaphragm. usually causes more symptoms than this man had Dr. King: You do not see the retroperitoneal for two and a half years. The other conditions I mass? have named seem likel er. Dr. Schatzki: Not that I can be sure of. I do Dr. Alfred Kranes: Is it not unusual for fluid not see the outline of the kidneys so well as I should due to tumor to subside for so long a time? like to. The upper pole of the right kidney is clearly Dr. King: Yes; that is one of the things against seen, but the upper pole of the left kidney is not. trying to explain the whole picture as tumor. I Dr. King: I suppose that you have helped all agree that subsidence of all symptoms for a year you can. Do you want to say anything more? after the removal of 1000 cc. of fluid in a case of Dr. Schatzki: Yes; there are some rib changes. tumor is not usual. I wanted to make the diagnosis Dr. Kinc: You mean the periosteal changes in of tuberculosis, but I could not. the rib? I have seen such changes only with pus. Dr. Charles L. Short: I saw this patient on Have you seen periosteal changes with large tumor the ward, and I went through much the same line masses? of reasoning as Dr. King has. From the history Dr'. Schatzki: We have seen them in patients who my impression was tuberculosis, but from the x-ray did not have empyema but who had a chronic findings that certainly could not have been the nonspecific process in the lung. primary diagnosis. I do not believe that most of Dr.. King: The films show the periosteal changes us went so far as Dr. King in being willing to say clearly, and I am inclined to agree. that the tumor was primary in the chest. We Actually, we have no evidence of any source of thought of lymphoma and for that reason small i Vol. 23i doses on the shortlj left cla that tl Dr. diagne be lik lymph Can Mec Mes- Dr. encase- I 1 bf Figure Sh, shiny, small 1 thickei the pi There lung, 1 in sha: 947 of nd to int >wice ion e7*. or aa iaricle hat iny sst, nor VoL 236 No. 11 CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL 411 I 0 -y<' . doses of x-ray therapy were given, without effect on the lesion. We were able to get a needle biopsy shortly before death. A mass developed above the left clavicle about S cm. in diameter, and we thought that there was also a mass in the epigastrium. Dr. King: Such metastases would be against my diagnosis. A primary carcinoma of the lung would be likelier to metastasize to the neck, although lymphoma could do so. Clinical Diagnosis Carcinoma of lung, probably metastatic. . Dr. King's Diagnosis Mediastinal teratoma, with metastases to right lung. Anatomical Diagnosis Mesothelioma of pleura and pericardium, with metastases to right lung and retroperitoneal lymph nodes. Pathological Discussion Dr: Castleman: The left lung was completely from any parenchymatous tumor nodules. The heart and pericardium together weighed 1100 gm. The heart itself was perfectly normal, the increase in weight being due to the tremendous thickening of the visceral pericardium, which measured as 412 THE NEW ENGLAND JOURNAL OF MEDICINE Mar. 13, 1947 bronchus, near a bronchus or in the lung itself. plain film of the abdomen and a barium enema The nodules in the right lung were well circum showed an abrupt, shelf-like obstruction in the scribed in the parenchyma away from the bronchi lower sigmoid, with a markedly dilated large bowel, . and were definitely metastatic. We were quite particularly on the right, and beginning small- certain that we could rule out bronchiogenic or bowel dilatation. Routine urine examinations were primary carcinoma of the lung. The bronchial said to have been negative. There was a slight lymph nodes contained no tumor. We searched leukocytosis, and the blood sugar was 196 mg. per every organ for a primary source, but we were 100 cc. On the following day the patient appeared unable to find any. acutely ill. The abdomen was greatly distended, The histology of the tumor was typical of what and the patient complained of abdominal pain. No has been described as a mesothelioma (Fig. 5). organs or masses could be felt. The pulse was The cells in some areas were cuboidal and arranged about 115. On the same day an emergency cecos- around fibrous stalks giving a pseudopapillary tomy was performed under a local anesthetic. There pattern. In other areas the cells were large, irregular was an increased amount of clear, straw-colored and closely packed. Some were multinucleated, and fluid in the peritoneal cavity. The colon and cecum others seemed to be forming mucinous material. were greatly distended, and a large amount of fluid A number of papers have been written to the and gas was removed by trocar suction. A glass effect that there is no such tumor as mesothelioma Mixter tube, was fixed in place by sutures. Follow of the pleura, that the cells lining the pleura do not ing the operation the patient was said to have im form tumors and that these tumors really arise proved for a while, but the abdominal symptoms from a small focus in the lung. We have held a subsequently reappeared. She was transferred to similar opinion for a long time. This is perhaps the this hospital on the afternoon of the second post first case in which we believed that there was operative day. ', actually such a tumor. It certainly fits in with The patient was known to have hypertension. most of the cases of mesothelioma of the pleura A sister had diabetes. that have been reported.* Physical examination revealed an obese, dis Dr. King: I do not consider that it is fair to have oriented woman. The left border of the heart given me a case with a diagnosis against which extended beyond the midclavicular line, but the you, as pathologists, have been talking for twenty heart sounds were normal. There were coarse years. I could never make Dr. Mallory accept a rhonchi, which cleared on coughing, in both lower diagnosis of mesothelioma of the pleura. lobe's. The abdomen was distended, tense and Dr. Castleman: He has been sold on this one. slightly tender. Peristalsis was limited to a few The lesion in the abdomen was retroperitoneal tinkles. The diaphragm was high on both sides but tumor, but there was no tumor elsewhere. moved to percussion. The. cecostomy appeared to Dr. Adams: What was the large lesion in the left be functioning well. lung? . The temperature was 100F., the pulse 120, and Dr. Castleman: It was merely nodularity due the respirations 30. The blood pressure was 110 to the pleural tumor. systolic, 70 diastolic. Klemperer, P.t and Rabin, C. B. Primary neoplaama of pleura. Arch. A Levine tube was passed immediately on entry, Path. 11:385*12, 1931. and 500 cc. of brownish fluid, as well as considerable gas, was aspirated from the stomach. The patient CASE 33112 also received 600 cc. of 5 per cent dextrose in water and oxygen. During the night she became extremely Presentation of Case A seventy-two-year-old Polish housewife entered the hospital in coma. Eleven days before entry the patient had re ceived a slight back injury in an automobile acci dent. A physician examined her at that time and found only slight spasm along the lumbar muscles. Three. days later the physician was called again because the patient complained of slight bleeding supposedly from the vagina; he could find no evi dence of bleeding. Six days before entry the patient began to have frequent episodes of abdominal cramps. These continued daily. Three days later disturbed, tore up the oxygen tent and pulled out the intravenous drip and. stomach tubes. The cecostomy drained 1680 cc. of fluid, and 646 cc. of urine was passed on the first hospital day. On the morning of the second hospital day the disten tion appeared to be slightly less, and peristaltic tinkles were somewhat more frequent. The tongue was dry. The temperature was 102F., the pulse 130, and the respirations 30. The blood pressure was 100 systolic, 60 diastolic. . Examination of the blbod showed a hemoglobin of 16.3 gm. per 100 cc., a hematocrit of 50 and a the abdomen was distended, with , marked tender white-cell count of 9700, with 85 per cent neutro ness and a mass in the right lower quadrant. The phils. The total protein was 8.5 gm. and the non patient was taken to another hospital, where a protein nitrogen 100 mg. per 100 cc.; the carbon Vol. 236 dioxide millieqi 18 secc The and ga' . tain su many 1 s 6 whit< the che high in atelecti - .. greatly tained slightly the rig materii ' ' Duri d rowsy ' ; ` trose ii 5 per c 100,00C : begun. : . 74 mill clammj was sof 1 7 pressun was str ' ' The uri amount On t , somewh and pei howeve -t. hemato nonprot 200 mg carbon patient saline s 7 The cec On tl i to ios: restless, 56. The equiv. ] i: calcium An eleci cardia i and mo showed & was giw effect o: 500 cc. solution 5 per saline sc into coi reached