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ovoTn ' 't;j:rjsKEo by the Massachusetts 'rs.v.oi. society
>U.:M 263
OCTOBER 12, 1961
NUMBER Ij
'
OrijjinaJ Articles
rvrntivc EiTcets of Tsoniudd in the Treatment of Primary Tuberculosis in Children . . .
Prank W`. 'Mount and Skirley tf. Ferebf
*13
:pericncc with Portacaval Shunt (or Portal Hypertension......................................................... "21
('torge . Want: and Mary .-inn Pa.nt
icration of Blood on Storage: Measurement- of Adhesiveness r.( "\Rins" Platelets and Leuko cytes and Their Removal by filtration . -
Roy L. Sxank
"23
<tontie>n of Kidney Fimcrion by Splenorenal Arters.il Anastomosis: Report ot a Case . . 734
'-`*i\y M Seikley
' M&ikai Pn>gr*<s
:utr Glomerulonephritis vConclu:! d) . . Jerome P. rCuxtrer and Wlliient &. Schicart:
736
Medicai Intelligence
Salvage of the
N'car-Tran'metacarpal Amputation
Stephen W. Meagher
Isolation of Vaccinia Virus and Type 1 Adenovirus from Urine................................................................
ion Crasser ana Sidney Kibnek
Current Concepts fa l.empy: The Treatment of Hyperthyroidism....................................................
E. M. Chapman
743 744
Ci>e Records of the Massachusetts
Ethical Drugs
r riitorials
Generic -Names, Trademark* and
"Physicians for the Futurr*
-- /Joys of OYrtrn . .
/j< 757
*svrhu-Mtt*
Society
asaches#tts Department nt Pehite JTewlth
Notice* .
733 733
3C<orerkt-- ti*woenv<lvirendr*
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i The usual dosage for infants and children under twenty-five pounds is 5 mg. per
pound every six hours; for children twenty-five to fifty pounds, 125 mg. every six hours.
For adults and children over fifty pounds, :he usuai dosage is 250 mg. every six hours. gg In mure severe or deep-seated infections, these dosages may be doubled.
t\i Aeailoiu- ax: Puivuies*--12S and 250 mg. t; Oral Suspension--125 mg. t per S-ce,
3 teaspoonx.il; ans Drops--5 mg. t per drop.
Product brochure available; write Eli Lilly and Company, Indianapolis 5, Indiana.
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;n ci'-ncii' on the :ror.i;:i'"".
<. w.:n :..c u .. ..:gero*n! f . crtliy.-oid: .. " ::ildr .
- t*sc at any age having irenr.-T.t di.-cus*- uurir.:* .regnant...
rrrrun factor' -.u b*
;nus operation often insist on radioncth ' ceptru cs an :nd:c...:on for ;unrotal :i:y.- :dcc:-mv.
S-'inc at an;. *cc from fear of radiation ind.-i Toxic re.-n -o drug therapy, rciap*- after re-
:c?c treatment. IVw rufients scem-anxiouv --nv--*-- . -iged drug therapy, progressive en-
loionged or repeated courses of drug therapy, iarttement .f the goiter under rruuirni treatment and
aatients in this group are often restive and psychic factors in the patient or family that rcr.u. r
operative in a successful therapeutic program. medical :hcrnp\ Inr herd .:rr each indications for
>:ch the fetal uptake of radioactive iodine
operation. T;:.'
and safer- operative treatment
'gin until the fourth m..-nth of pvecnancy. [ after proper preparation wim .uv.hhyroid mea< -><
; advise this treatment during pr<`ur:;mry at;d has decreased the incidence of f-. -.rspiicntiott* nebbed agnimt its use in those boiow a pre- very low level and ! '-'red the time required ..
v.r.e : *-*n Hi'crmse of possible genetic damn-ce. hospital :r< an average of on:- week. Tine sk.d u; me
...... : llmii* h.ive varied since some age tv- individua. surgeon remains the decisive factor in
u rri* introduced in 1944. At first, it was up reduction of complications, and so it is that '.by.
years: more recently, it has been reduced roidectomv is no longer the province of the "generar*
forty to twenty-five yean. However, the num* surgeon but should be performed by one espcci.dlv
f citiidrcn treated
individual physicians is trained in thyroid surgery.
inir .1 'itrnincant group, for observation on the " iTccts of radiation. The late efTcets of this
(Tn 'rmtinued)
.=n will hi* wealed in time, but so far. '.he oc-
R; rrttEXCZS
ii occurrence of nodules of regenerative hyper<t adenomas has been most significant. .;h\nri drugs have the most important role in
!. White. W. H. On
t '(eenear* n-mptutm n{ rvi;lnii.iimic
otrer. 3rti. M. ]. 2;13MI3. UUUt.
2. Gunman. E.
and Mi: *.f. I Ci*rrr <-r:mam!---->. n(
rirrrrtijrrotqst^ \'rt* Kit J. M.d. ZS4:i.*, i:*36.
b CASE RECORDS OF THE
SACHUSETTS GENERAL HOSPITAL
Weekly Cinicopathologicsi Exercises
"ou.voeo ;y vsha*o
iasot
S"v;.\:.un Castlemax, M.3.. Editor
Betty U. Kieses. Assistant Editor
CASE 73-1963
Presentation of Case
trimissinn. A fifty-one-year-old man entered jitai because, of -leiV-ided picur.tic .-nest pain
' twelve hours' duration. . reviousiv he was admitted to the r.os.tu.h* ..f pneumonia of the upper lobe of the ng. At the time of discharge the x-ray films 't were nonnal except for a small rcsiau.-..
picuraJ effusion on the right side frig. ! '. . dr was well until the onset of the pw -;;t \c j.ad .ac: :..anv occupations, including work liioistercr anc in a siauehterr.r : .. P-'vrinninff
nineteen yc^*s befoiv entry he worked for five years
in confined spaces in the holds of ships, where he was
exposed to dust and asbestos.
On admission the \uicnt was acutely ill. with a
temperature of 104'" v'. and bens of pneumonia in
the upper lobe of :: left lung. X-ray films of the
chest -'Fig. 21 dc-uousirareb complete opacification
of the ieu-upper-lung iteid; the trachea was devi
ated to the left- Penicillin, streptomycin and chlor
amphenicol were given, and he began :o respond by
the fourth hospital u.'.v. Sputum cultures grew out
coiiiorro and protetj*. - mnisms, and a subsequent
cuirure dcmon>tratet. rnedlllncierb organisms. A tu
berculin skin t"'t was negative. On die eighth hospital
day the fever rrcurred, and Staphylococcus aureus
was recovered from a sputum 'uiturc. With sodium
methiriliin {Stani'vhhn merany the pat:^*nt im
proved. Serial x-r:t\ :d:ns of the ci---1 rc.-r-h-rj ,t
progressive but inccmp.ecc reduction :n '-uumc of
density in the left-uppcr-iung fluid. A film taken on
the twor.ry.finc hospita: day frig. 3; demonstrated
a cen;:.i.. rarefied area within the left apicai density
that had a sharply defined inferif-r :::ar?in and pe
ripheral air pockets. He w.is discharw^d unproved on*
the thirtieth iiospita: day.
Second n-itniisioti -two weeks later). In the in-
crim tlu patient experienced persistent weakness,
unsteadiness ana anorexia, although he c..inrd .)
pounds in weigh:. No productive
ch::!> <
fever occurrec. X-ray dims of the <du**.t five o.;.-
before admission again demonstrated .. .urze density
orrr.rr.nn^ the
'V'"'*-
---- `
746 THE NEW ENOE.^Wj* jV.1
* -
'
14 ,:~Z*
ft*'
w, .
.?. *w*. -
iiT-1 -T"~nr
Fsoure I. Film of the Cl.*-: Taken Six Years before Ad
mission. Showing a L*-euiuted Ptenral Effusion at the
Jlipht-Lung Base,, .1 -til an Area of Pneumonitis m the
Upper Lobe.
",,A.- "' . -
FiiSUiit j. Detail f:on: v .
Film >( '.u Ck<
fining an Area of C ntrui : imtufenev in :he !./
V% ~
Suggest/?e of Loculared J-y-......or P'.emui 1 along the J.aii-'ui Chest Wall.
> JS - Vf.v
Ficvr.t J. ri'i'm <>/ /< > asst V ...* en : :'! Att::..
.s/iourm- Ova
,:-n of f/* L+fl (. : /<<.' /.,,>.
thoras. with marked deviation of the trachea to i.;v left: .-nsidernbie io>> .! win-:v.-i me left upix*:' lobe. . ovation of ti:<- .oft hiius. d;iai-::on of bioncni and ;.:A Sbrotic changes were ooserwd
' .'.;cul examination . .-.dod a wo:! :.yu;- S'w.ciu.' ' - .. ,.:h sound: :hrot:y-.eu.
the c: . .. .\ Urac<* .
the aj.i' * no at-...
- .. ......
The temperature, pui.se and /esphatium ' m;*l. The biood pressure wu*. !3j systolic. oj dl
*1 urine was normal. Examination of tia
revealed a hemoeiooin of 13.6 gm. per 1U0
hematocrit of 37 per cent and a whiuwei! c
7400. The pro'hrombin conn-rtf was ;'w` >*
The fasting glucose was
the htiuooin
and the urea nitrogen 12 me. per iOu ml. T.
line phosphatase was 3.2 Wodanskv units. .
cepnaiin rioccuiation was negative in foiry-cigr
The amylase was 9 Russell units. A 5ipoi s:
raw a nt-viutw cruaiac test. A brop.eho'Couii
u;..".(u: ivum .. :na:I.od inii.mmtatton and e-.
. \ Mihceoi tnc d-p...;;:;rt*r-:ob' :i*ociius. A I
v'.uu dc'.tionsua.. - hiiiue oi
<<iisur\ i
< :::r ieii upj^er lobe. . r. n.i> r .-.ue !
lion: tite wttuhera; braneues did i
An .tcraiii :i was pertormed on i!.r id:
dav.
Du - r.;. i-vnAi DlACNOstsv
Hsu:n S. Pit-
wim -merrd *.
: We haw the pi
'dial ait-.- '
z
>`ui
CAST
' THJv M ' SAC7IW.77S J-ACKAw HOS?r \l.
' ::-s. ;
i: :por*ant poir.t* are br'Migh.
: p-.tNt iu'- -v. ' ; years prcvv* :;v n?.*v ,ir.
".i'ijijs1 :sii?! i.-.c: a rrsts...tu * v;ur..
>n the right >idc whr. discharged. There _>
*n of the rnditio:. -*f tJie left lung at that
know that lie was then weii lor six years,
i rotation ot interest is the occupational
.iiich included five years of work in the
ups. as well as employ-mem as an U;'n*;'terrr
ianghterhousc at unknown tunes.
nokir.M ,-)t the x-ray alms I ^nutlri iike to
v ahotit rite first admission. The physical
strd pneumonia with an open bronchus, and
vonhy that the trachea was described as
oward the lesion instead at away from it.
rhnt the pneutnonia was superimposed on
in a redueed volume from a pre-existing
he <ame urea. The acute process responded
;n tiu* three antibiotics that were given
iv pending the .epons ot the cultures.
Hinder organisms were probably the im-
and t suspect that t!v*y were present
i.s<*u although not cultured until the second
* t ilAt cite consolidation was apparently
'-tent with FriecHinder's pneumonia.
x perimposed upon an underlying proc-
i^xr significant finding was the culture
u>h. (tuii'us, perhaps secondary ro the anti-
py. Either ti.r Fricdliinder or the staphy-
ranisrns could have produced the rarefied
no air pockets that were visible on the
day. Now, may we see the x-ray films?
u:d L. Weber: The films of the chest
ars before admission f'Fig. 1) demonstrate
a in rile upper and middle ficids of die
`.nuMsicnt wi pneumonia and a pieural
icn cieared with the exception of a small
ight cotopi.renic angie. On an cxaniiaa-
1*2rs iatcr tlicre is no evidence of pncti-
:nc obliteration of die right cosrophrenic
present.
:\n: Are die lungs entirely dear ru'ar the
V<-<. On the first examination during iihio? -rig. 2' one can see a homo;irv ailing the upper chest cavity on the iterating the mediastinal border and ex.ie laierai chest wail. The inferior border d dinrply defined. The Ur/-. ;ulus is not
there is no evidence of a mass in that r-lung firid and die right-lung fieid
u opinion, the trachea is only slightly ie left. The visualized rih structures are ' hm t;uten right days later <now mul .i translucent areas within the previtrated homogeneous density, which bar red. A faiiiv homogeneous density is dong the ieft lateral chest wall.
;hTT*.\.v: T< that
`isistcn; with
Dr. 'A'l.ai-.R: I. eompa::*
'* lncu!ated fluid
in the upper du.-. cavity. Tk. amination per-
..formed -Ajew davs !a_a. how\ an increase the
translucent area* in i:;e upper-lung field am! again
the presumed fin id ai^ng the left up -or ch">t wail,
with streaky dcnri.k" in the lower-.;.ig field that
might be atelectruu .rvn.*.
Dr. Pittman *. There aofinitdv is t-*m a pronounced
deviation of the trachea toward the icsion. as I as
sumed from the mx-.-iption. Dr. W>.r.F.jt: The patient had a slight scoliosis :>f
the upper dorsal spine, w-.iii a comexity i.i the left
contributing to deviatio?* f the trachea. Also, if one
examines, the films in *-..vnee one nntires a slight
deviadon that deveioprt. during the course ef the illness.
Dr. Pittman: However, it doesn't imply the pre
existing reduction in volume of the upper-lung field
pulling the trachea over fiui: 1 had anticipated.
Dr. Weser; The final examination (Fig. 3} dem
onstrates more clearing or more transiucency in the
homogeneous density in the upper umg. with persist
ence of the nomogeneous density along the left up
per chest wall, which is compatible with pleural fluid
or perhaps pleural thickening.
In iidbuior. to the conventional ex.-whnatiom 1am-
inagraphic and bronciv-irapnic studios were per
formed. Alrhougi: :hc u.v.chngram is inadequate,
the trsr!ua.
left-main--mu bronchus and the
pri-uan* bronchi are well -down, and an intrinsic le
sion is not evident. Titer*' is slight rievatinn ot tnc
left-main--.etn brotu'aus. consistent with reduction in
the volume of the left upper lobe.
Dr. Pittman: Therefore, on the firv of the tw
recent arimi'riou.s I assume that this nan had pneu
monia. prooaoiy due to Friediancictb organisms with
a superimposed stapnyAcoccni infection. When he
left the hospital lie was not well, hut improved, and
nine days after discharge v-my films mowed a large
density peripherally, with io* of volume and eleva
tion of the hilus. that wa- probable a p.; ;ral rather
man an mtrnuuimonar- process. 'V> now have to
consider ute syrurxoms .;;u 'igns in addition to the
ennnees demonstrated radtologically that i>*d to the
second admission. They were predominantly weak
ness, unsteadiness, anorexia and -i heart murmur. The
absence of a productive cough megests that thr proc
ess that was present at that time did not communicate
with die bronchuv and now that l have scon the.
x-rav films I a: * u\inccd that it "as in the pleural
cavity, anvwav. i uvre were no signs of nb*trt:rrion un
bronchoscopic exanunation. svhich diowei; :m*:viy in
flammatory changes. Tfive only abnormal laboratory
finding was a minimally elevated bilirubin of l.' mg.
ver 100 mi. The choice oj tests performed >uggest*
that i;:: attending puysiciari.s had in mind a lesion
in <!
--- - ---
US
THE NEW ENGLAND JOURNAL OF MEDICINE
Oct. 12.
What processes must I consider In this case? Since
the available data are sparse, I am trying not to
neglect even the smallest hint In the information
given to us. I shall rur. quickly through the pos
sibilities that I considered before seeing the x-ray
films because they no longer seem relevant. I thought
of an ah uolar-celL. carcinoma, which__can produce
fibrosis, but I was overemphasizing the tracheal de
viation. Profuse sputum is usually a manifestation of
that type of cancer, and tin* involvement frequently
is bilateral. This man had a process six yean before
admission and a recent process that was comparable
in many respects, but the fust one cleared completely,
and it seems unnecessary to look for an underlying,
tong standing neoplasm. The lesion was not suggestive
of adenocarcinoma, which is a peripheral process,
and it bore no resemblance to a metastatic carcinoma,
die suspicion of which, was apparently the motive for
tiie tests of liver function and the amylase determina
tion. Certainly, tuberculous could produce this pic
ture, and the negative tuberculin test doesn't exclude
it. but it does make it less likely. There wu< nothing
to suggest sarcoidosis.
Having di.-wmded thoxc entities, I
turn to a
consideration of the patient's varied occupational
history, beginnhig with the hazards that he may.
have encountered from industiial dusts. He was ex
posed u? asbestos a number ot years before entry.
Asbestosis is a form of silicosis, and whether or not
asbestos gets into the ah. -on depends upon the par-
tide size. I: is my undemanding that the particles
that arc encountered during handling of the manu
factured product arc too large to reach the alveoli.
It is when one works in the asbestos industry itself
that die dust exposure is dangerous ;:nd I'm going
to rule out the holds of ships as resra/ds a diagno
sis of asbestosis. ' Another perdnem pneumoconiosis
is byssinosis. which is produced by cotton dust. That
seems the most likely hurni'ul agent that he might
nave bean exposed tc> durintr his care--- as an up
holsterer, but ausin the particle sice wcuid have been
too larse. and that condition !>n't sucsested bv -.his
V*
*
picture. The question of infection rcl-ted to his
cu nation ari^-* next. Admittedly, his occupation
may have had nothing to do iih this illness, but I
have to me the few tUL'.s g:ve:t in search oi a clue.
Fungous infection?. :..uy he associated with many types
of dust, and one uut l mink o: particularly is histo
plasmosis. I don't be" * e time poultry is killed in
Slaughterhouses. ana d . .. merely touch on tiiat diag
nosis and discard it. ` -topiuj-?nosis can be respon
sible I-.;: bbrodc peripr...-: ai nta^.es and tan induce
cavitation, but otherwise ir.-v Tv-dings in this case
.-mblance m it. Thor- .i;<: other fungi- hut
:-'<r to take the tiir-i even to name them.
An. . ...... v.jrhous* drier.*- thr.` ` shall n.-f.--.n
in 'u.-.'i.:.. ri
Hll rabbits
i' .
:.d
.
roduce abscess
cavi'b-s that persist for months and can can
pleural effusion.'*'
I have come down the list to one other, more
mon and to my mind much more logical disease
a slaughterhouse worker might have. He .nay h:
infected large animals, including swine, and :
thinking now of brucellosis, which can cause ch
pulmonary lesions and effusions; It is manifest,
many systemic symptoms, and in working with
meager history I cannot neglect the weakness
unsteadiness that this man experienced and the
diac murmur because brucellosis can produce t
carditis and can cause murmurs without recog
endocarditis.5 I find this the least unlikely cxplan
of tiie patient's illness, both past and present. T
fore, I shall say that he had on the firs; recent a;
sion an acute lel't-uopcr-lobc pneumonia, pro
due to Fricdiiincer's organisms with a superim:
Stapit. aureus infection, and that that conduioi
cured. In addition, I am going to accuse hi
having chronic brucellosis, probably acquired
infected swine while working in a slaughterhouse
haps first manifested six years ago by die proc
the right lung and currently pi-.-during elT
fibrosis and possibiy some granulomas in the >e:t
with a systemic reaction.
! ku Lawis W. Kane: Was dtis man m aicoi
Dr. John H. Kxcwlss: No, lie ua< not.
Dr. Benjamin Caetleman: Why du you av
Dr. Kax::: This story is perfectly cur-i.stent
multiple aspirations of saliva producing infeed
die riffht lung originally and subsequently inn
and ,, iung abscess on the left side. The n:i
types oi organism in the cultures v;ppor: that
nosis. I tiiink that the patient riuli-,1 up v.!
empyema as well as a lung aiiv.-i-s> <>m the ha
aspiiation o: contaminated material.
Dh. Samvel Thier: I might add that bewa.
epigastric pain and vomiting an upper eustroinu
scries was cone during the first recent admissin
was '-ormai. The question o' aspiration pnem
was .-juddered. Aio observed at dun ti::v.* w:
treme iettkopenia, which was tiie reason :' u-i-e
with so many antibiotics while we u- -rv:
decipher the cultures. The wime-erii co-.m \
the range of 2000. and this was ..::e of ae-. <-.ai
ineumon.T oroc<- .wcomtAwned bv leu.v*vc:::
r* had seen wit. .a tiie last few months.
Dr. Warren Point: Dr. Pittman, do I unde
you to iinpri that the pneumonia was basiea.
dttced by SuecD-sis. or do y'u: think dun tin* l
!o$is was s:-* h another inf-
concur* cut w!
e;ear-cut
die pneumonia.-1
L'R. Pittv * I am <;.g*resung iti uiv fantast:
he .. '
"... . edaSLS.
.. ' \\do vou have :* brine thu.
xniam eov.r..:ve -:*n.
he v.. - . ^.uugiuc
\% orker '
anti.
r\$z Rr.CGivi> .)F -`-nc
r-s gkattm ?u-v
*O
:'TMaN i i don't --* - ust Citi.
. (Vi.: If t];i. was F.-k'dlKru!-: A pneumonia.
,::'i .- expcr- ...*
;obc to be iargcr
aoiu- . with
bulging downward.
:r than ti:e mnikcci reduction in voiuni'.':*
x, Pittman: I wouid. and that is whv. .i< i load
.! record. I thought that th.- lung was rhc site
.rvinu* change because of the r.catcd ir-mrion
riatior. of the trachea. A chr.inimiiy seanvc: iooe
reduced volume seemed th': only way m account
: superimposed pneumonia and deviation of the
.a unvard the involved area. I explained the
mrour that was shown on the x-riv. aim
:r nasis of hn increase in sire of a portion of lung
conic: still expand.
Kant.: What operation do you think was per*
rri?
x. Pittman: Previously, I believed that it was a
'.cotomv because from the description of the x-r.w
I c::tir:`.` expect an effusion and had in mind
;on of an area of residual pneumonitis or possibly
muiomatous lesion. I now suspect 'hat the snr-
opened the chest to drain an -:;npyc:na.
\rlp. M. Chatman: Or.c occupational dis-
'* you didn't mention i< so-called metal-fume
. v .h is bclievevi co be allied to zinc and other
i products. Such fumes arc chai.utteristicaily
i in confined spaces in the holds of ships, and the
>e prooahiy results from fine mrtai fragments that
-gc the invg difTuseiy. That condition might
formed a background in this case for the suosc*
: bacicri.il infection, whatever it was.
. Pittman: This patient last worked in the
of 'hips fourteen years before these admissions.
.. Chapman : I am speculating that the back-
id was scairing of the it.:-; from fine metal par*
:: -i he inhaled in those confined areas.
. CASTLr.MA.v: What was the thinking on the
>
Ttnr.R: C"r initiai impression was that rhc tntgr.t ho . pneumonia. with the formation of a :b<rr*5. perhaps seconder/ to obstruction behind >piasm. and he was treated on that premise. 'urpoK' of the operation was to find out whether s a tumor and, if not. perhaps to resort the ved lung tissue.
PVTHOLOCILAJ. 0:
Dr. Ca-ti.f.m.,:.-: When . *.;r_ - ' : :
u.
patient's cites: .he found no fluid. The ' uppr? lobe
.svas bound d-wr. '_i;e chest wail, and it was r.---;*
sary to cmpl."
to dissect the adherent vi* . d
from :i a p;.r:e:..i pieur. which was extraord:;-.. :.
thick. T'tfC j;'i? uper Ive had shrunk into an o* - .o
mass, about 12 by 0 by cm., reminding the surgne.
of the -i/c and .shape of a tangerine. T:.r dl-oa :cl
no* in* - ivr the lingula of the upper lobe, !**? > wrciy
die ups.rr segment. ..r.c! he was able to divret i; free
from ti.r iinguii. which was expanded at tint rime of
operation. Since the n-scctcd segment was hard and
hbrotic, hr hciievrd that Iv* was dealing with a chronic
pneuroeruis rathor than a tumor.
On section the pleura was extremely thick, hyalin-
ized and acclhd.tr. and it was obvious why :ite surgeon
had difficulty in dissecting it. This is not the usual
finding in chronic pneumonitis, even with extensive
pleuritis. I think the area on the x-ray films that
suggested iocnii/*-.! nv.pycma or fluid was the thick
ened pieum. w-.ich in places measured almost 3 cm.
Micros^opicaiiv. there was marked fibrosis obliterat
ing portions of cite ring parenchyma. Section of
another area showed vory severe, rhronic purumo-
nitis. with cxtjdi.-.te in .-ome of the air spaces and
marked chronic inflammation, including the phago
cytes filled with lipid that one expert.' with any long
standing, chronic nr.p-imr.mtis (Fig. 4'-.
Cunical Diagnosis oneumonia. ? carcincm..'.. left upper lobe.
` wr. Helen o. Pittman's Ducnoses
ohic .. .iccilosh with norosis. left ring,
oral effusion. :o:b..
mnonia. acute, left upper iohe. prri-a'oly dto
Fricdiander'* organisms, with sureri:npr<-d
s//r *iA
i.... ~..--J _
rto.uxe r. Chrtjnie PneumwiU'.
The aivtolar xax/* ere tr.:ck/ied: the an rccs an `-..led
}
II (i II
fi , *
j
l
;| ii
l: i
.i
j ! t
750
THE NEW ENGLAND JOURNAL OF MEDICINE
Oct. 12.
Dk. Pittman: Can these changes occur during a $ix*wck course of illness?
Dk. Cas*j !.M.\.\: I think they could, but in this case the background was probably much older than six weeks. Of course, we don't have a him taken during the* tluve y^ars bcfoie admission. but 1 ana sure dun something had been e* -.eg on for a matter of months, periupi even a vent.
Careful examination of die air spaces under the microscope showed a r.ttmber of brown, irregular bodies with a knob at each end. characteristic of the clubbing and the irreeul.nhv of asbestos bodies (Fig. 5;. The fiber is in the center and !.* covered with protein, which then degenerates slightly to cause the irreguiarm. Aabcsto* bodies stain brown because oi the impregnation with iron that occurs in their forma* tion. Therefore, tite underlying disease in tliis case was almost certainly asbestosis. Some authorities' be lieve that symptoms and >i^ns and j pneumonitis arise only when a secondary' infection is superimposed on the pre-existing asbestos libers -- that the asbestos fibers are fairiv inert, but when a secondary infection intervenes pneumonitis nut develop. Thickening of u.e pleura (Fig. b is typical of asbestosis, and, in fact, a anthologist with ^ experience with the dis ease immediately thinks asbestosis when he sees that change. There were no metnplastic changes of the bronchi suegr-ting that a tumor war. ffeinu formed in this case, and we made a careful search because asbestosis :s one of ti.*- predisposing .wctor* for carci noma of the lung.
Dr. Pittman: The findings interest me very u because from nay reading and from what l hate h Dr. Harriet L. Hardy say repeatedly, asbestosis d ops only after exposure to minute particles of a>l less than :J and no more than 10 micra in six didn't think that it was possible to contract the di: merely from applying asbestos in preparation anc dealing with die dust of the mining of asbestos.
Da. Castleman:- Of course, the disease de\eK
several years ago, when the hazards e%en in the
of a ship were probably far greater than the\ are :
when more precautions are taken.
.
Dk. Kane; The patient did have a lung aba didn't he?
Dr. Cattleman : There was no evidence of a abscras at die time of open tion. He must have an infection in the lung tiiat shrank, but .ill our : ings can be explained by secondary infection o underlying asbestosis.
Dr. Knowles : Dr. Castlemau, I don't n understand how you can relate the cxjoosurt asbestos to this man's recent illness. How can associate a localized disease in one little part of !un with the coin-, identa! fmdins of asbestos fin
Dk. Ca> i undoubted.'-/.
: He :..d die asbestos fibers
Dr. Knowlee : But he had had those for nine years.
Dk. Ha.stleman: Tliat's rii:i. and then a vcc ary infection developed in die left upper lobe.
* 1 * . A* :Sat.v -
Ficcsi. ;. mir'ioui Aibti
Area.
Ficuur 5. A.
riu and Tkickenin.' X28)
u., ?!t
V U\4t RF.'.ORDS >F TIL VtA.'-ACHUS'.
'/:tai.
-m-LK- So tin .
< . necessarily and slow. si,.-
resp::': ' >r.. - . in..;:u .\a ru^D
. out a ' ovonir orgnu:-*
pi (he
hospi-.;. vm- r.g or c.inrrher. -id occur:-.-
i<%: ,t t *
?.* >
on arrival rescaled a wcii
< S-.-sTimposed on the a*i'estosi.s. ci' doped. u^:i non.-*1 d infant to appeared hvpr-
te'tion is whethnr liic infection would haye_ ...thermic .;m. vus -y.m `tic and withrvr, respiration.
;ed without the asbestosis.
`!:o fyi*N .*.:.d fontan'-- were sunken. The nose and
Kx*wi.r' The x-ray films show only one
wv;c normal. N- heart rounds were audible.
on of pi'-ural thickening, and I find it difficult T:.t* edge of t!:-.- b-.er was palpable 2 cm. below the
ain. even tiiough it was marked, the localized ' right costal margin.
thickening, particularly in ar. upper lobe, on of j.-he'stosis. which ordinarily produce?
.! lowm-lnint changes and !ower-!obe pieurn:
The h^art rate. was i"< .ifter artificial respiration was instituted. While oxy-.cm was administered w.A-t
pressure thro>;c.-. an endotracheal tube. iniro*
U:g.
.'A.stlfman : It isn't necessarily bilateral. Pittma.x:' How do-you explain the complete
cardiac epinephrine was given, and a r-i'down for iiuravcnous-rhtiri -.{-.crapy was performed. After a mw minutes the baby became pink, and rhe pulse st mi.
; of the comparable process on the right side iizrd at a rate of 100 to I2i per jumuie. Spontaneou*
before admission? Thi? man must also nave lcstosis in the right lung at that time, and yet it
without tiie development of thick plcuritis.
respiration began, he erica loudly, and good move ments of all extremiti'-' were seen. The lung* were clear. A cruticni macular erythematous *kiu eruption
' \srLKMA.x: It probably was a less sev-uc was observed. The imravirnous-fiuiri rhernuv initially
!i consisted of ia mi. of mi line solution followed by 1 gm.
of aibumin. Subsequently. a mr.Itipie electrolyte,
A.XATOMICAL DlACXOS&S
potassium-containing solution was im-i^ed. to winch
put uivnntd<! and marked plcuritis, left l>*r lobe.
(
chloramphenicol, rvyuiromycin ami ;.:cv digoxits me, 20 mg. ot cortisoj hctnisuccinatr were added. During the next four hours breathing stopped twice. Ti;* first time, tr-uscitativc measures were .successful lu
Rf.FEREXCES
1 .i.:. <ri*'ininwrt.
1'ilar^mi.i:
//. ZS ;
'2 rW9
I**..',
: r.iiarenne I'npumnnsa J.A.M.A. JOT: liT*110. I?36.
\ U TU, y*tutr tt! ,'ii uerllniii. 4+* jjp. Minnranoii**
\lmnrij P-r"
! . '.in Kr^nic/J*"m*/"h. wAi.. OE.ditPt^athboyiotfv o]t. pnK*i*nym.oeaonndin*Cw.. MIn.
t~'x` :>t>. .'ion title, omwn. {&UJ. Cltatitrr 2. P. 32.
restoring spontaneous respiration. The second time, during an hour and a half of assisted breathing, the. heart rate gram.*!!> decreased. The child died four and a half hours after admission.
DlFTERE.NTIAL DtAONOMS
Dr. Nath : R. Talbot*: la tin- rase one ran
only -.mess the .hoiogicni diagnosis. Rather than trv
to catalogue ail the conditions tlsat might have caused
CASE 74-1961
tills child's exitus. I prefer to focus intention on the most common causes of this type of problem. In re
Prescxtatiox of Case
viewing v. hat little information we .have 1 notice that the mother had endometritis, and it would be inter
A-weck-oi': male infant was admitted :o the because of rapid deterioration, i'.iiti was the product of a normal third pregnci deiivfx-. except that the mother was said iiad endometritis with a temperature of a few days after delivery'. The birth weight ounds. 14 ounces. The nconacai --xaminarion : a husky, biond infant, with a vigorous cn' evident abnormalities. He fed well and
pounds. !0 ounces, when discharged on the turn uuv. He progressed normally umii
R^iore entn*. when his nurse noted that he 10 p.m. and 2 a.m. .`'edings pooriy. Although by his condition m 6 a.::;, on rhe fifteenth fe. she delayed coiling the mother until 7 a.m.
esting to know whether :i:~ placenta of this pregnancy was examined since the microscopical examination ef the placenta may reveal infection that can lie riiarrd by the baby.
Dr. Jojix S. Robey: A fro7cn-sec::on cxarrsir.a. tion wasn't done, hut the. placenta was grossly noii'.ia!.
Dr. Talbot: `Pnis baby wn> fairly iarge at oinh. Was the mother diabetic by my chance?
Dr. Robey: No. Dr. Talbot: If the chiid had a h.,od incom patibility we wouici have been informed of it. I must proceed on the assumption that he was annarrmiv ail right until fourteen day? of age. Tbi' the .ige when congenital malformations and inborn errors are often detected, and one also thinks of trauma and *?"
tiicr summoned.a p.oriinxrician. who found the >oriy responsive, with sunken eves, poor coior
Aetiiif chief. Ch''dren') Medical Service. M.i*aeii:-4*tu
>:
Hotmrai: utociate prei--^or ai pediames. Harvare Medw^. Srhnnl.
^ No. 14
CAii RCORDS Or THE MASSACHUSETTS r.NKRAL IIOSHTAL
747
CASH RECORDS
OF THE
'
ssachvsetts general hospital
Weekly CHnfcopathoIogicai Exercises
fOUNDtO BY JUCKAXD C. CAUOT
*
3e.vja.min CastlejiaJ1?, M.D., Editor
3etty U. XiBBEE, Assistant Editor
CASE 62-1963
Presentation of Case
:;ty-six-year-old plumber was admitted to the
a? because of pain in the chest.
tient had been in good health until twenty-
^ previously, when he began to experience
idea chest pain. Six months later he was told
i x-ray film of the chest* was abnormal. Twelve
1 * 1
.% ,
because of persistent chest pain accompanied ;pnea and a cough productive of white spuTh ere had been no chills, fever, weight loss igue. A tuberculin skin test (second-strength was reported as strongiy positive, but studies of turn.and gastric washings for tuberculosis were e. X-ray films of the chest demonstrated a ! density on the righr side, which was thought resent partially organized hydrothorax; bronpic and bronchogrnphic studies were negative. >ided exploratory thoracotomy was performed, ccortication of. the pleura; the pathological di-
was "dense fibrotic pieuritis." He was disd home on isoniazid, 100 mg. three times daily.
months after discharge the patient re-entered rsc hospital because of continuing chest pain, had not been improved by nerve block per-
in a surgeon's office. An x-ray film of the .veaied thickening of die apical pleura on the - ~od a nncar'densTtyoverlying the diaphragm
die left cardiac border; 'on the right side nogcncous shadow compressed the lung ard and medially and extended from the > die level ofi the second rib; another density d from the third costal interspace to the dtaThe fourth, fifth and sixth intercostal nerves < 'fieri in r.n attempt to relieve the pain, and v < \w....n.uii-o of a sprciimm of the pleura re
relieved by the operation, and he was referred to a
psychiatrist for further evaluation and treatment.
Two weeks before admission he entered a mental hos
pital for management of depression. Anisocoria was
observed on admission. An x-ray film of the chest
showed a decrease in volume of the right hemithorax,
with partial collapse of the right lung, pleural elu
sion, shift of the mediastinum to the right and an
extensive density in the right-middle-lung field.
Transfer to this hospital was arranged.
Bilateral nerve deafness had been present for sev
enteen years. The patient had worked as a plumber
for forty years, having spent about half of that period
Installing insulation on boilers and pipes. He had
smoked V/t packages of cigarettes daily for many
years. Five years previously x-ray films were inter
preted as showing a peptic ulcer. There had been a
loss of 30 pounds in weight during the three months
before entry.
*
Physical examination disclosed a pleasant man
who did. not appear depressed. A right-sided Hor
ner syndrome and drooping of the right shoulder
were observed. Dullness and diminished breath
sounds were heard over the lower third of the right
lung; the heart was normal, and there were no mur
murs.- The liver edge was felt 2 fingerbreadths below
the right costal margin.
^**4, ,
,
AM MMAf* ,
% A 1W. OiiW*
the respirations 22. The blood pressure was 120 sys
tolic, 70 diastolic.
,
The urine was normal except for a rare red cell
and 1 or 2 white cells per high-power field in the
sediment. The hematocrit was 33 per cent, and the
white-cell count was. 11.350. The fasting glucose
was 100 mg., the urea nitrogen 13 mg., the calcium
9.0 me., the phosphorus 3.0 mg., the bilirubin 0-5
mg., and the protein 6.8 gm. (the albumin 4.4 gm.,
i
. -269 ` No.* 14 * CASE`RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
749
rovidc several interesting findings. First of all,
a fairiy extensive reaction along the periphery
right lung (Fig. 1). Its outline is irregular,
i it seems to be a soft-tissue reaction extending
mod the entire lung. This change means a de-
asc in volume`of the lung, which is further indi-
cd by elevation of the right leaf of the diaphragm
d bv* retraction of the heart arid mediastinum to-
id the right side. Within* the lung field there is a
item of fine fibrosis and perhaps a nodular innl-
te. I am less certain about, the findings on the left
s, but there appears to be pleural thickening along
. left lateral chest wall, as well as a similar but
:ch ls marked pattern of .fibrosis and. nodular
ii trace. The abnormality is-confined almost fin
ely to the* perihilar and basal regions of the lungs.
*.e lateral film of the chest taken at the same time
ain demonstrates the elevation of the diaphragm
d the extensive alteration that is apparently a
;urai reaction. A fluoroscopic spot Him (Fig. 3)
<en shortly thereafter reveals a fine, linear, reticular
:;sm that is probably indicative of fibrosis, and
xed in with that change or superimposed upon it
. see a pattern composed of very small nodules,
rich in some areas, particularly in the lower tones,
ce into conglomerate shadows. Finally, a high
ly don film (Fig. 2), which was taken primarily
hi-, it um
c v* .jparc~ p.aura. renetzen,
;o demonstrates very nicely that in at least two
*, the right fourth and the right fifth, the an-
rior part of the cortex is missing. This picture is
rtainly consistent with erosion or destruction, and
ere is probably also slight erosion of the sixth and
venth ribs.
.
Dr. Knowles: The films demonstrate that this
an had bilateral pleural involvement, but pre-
jjninantly of the right side. Furthermore, he had
lateral parenchymal changes that were largely con-
jed to the lower lobes. He also had erosive dissolu-
an of at least two ribs on the right side. I'd like to
k a few questions pertaining to the radiologic
udies because the crux of the problem, as I see it,
whether the patient had either bronchogenic car-
noma or a pleural mesothelioma as a complication
' what I believe was diffuse pulmonary asoestosis.
r. Dreyfuss, will you tell me about the character
' rise carina, in view of the fact that there might
ive been metastatic malignant disease in the con-
guous lymph nodes, which would distort it?
Dr. Dreyfuss: The oudine of die carina is sharp,
hat fact Is against significant subcarinai ade-
j f.
Hr. Kxowt.es: Secondly, would you say that the
cural fibrosis on the right side definitely extends
to the mediastinal structures and even Into the
inracic inlet on :hat ride?
Dr. Dkkykusa:..T1ic change tliac appears to be
iiMiral fibrosis or thickening definitely, and probably
ernfirantlv. extends alone the medial surface o( the
the right lung along the cardiac and mediastinal
border.
Dr. Knowles: Do you see any evidence of a Fan-
coast tumor, or so-called superior-sulcus tumor, in
vading the soft tissues of the right thoracic inlet and
thereby giving rise to the Homer syndrome?
___Dr. Dreyfuss: Of course, a soft-tissue lesion above
the apex of the lung always raises the suspicion of
a superior-sulcus. tumor, but I interpret the altera
tion in this case as a continuous process actually
encasing the lung. Another clue that I should like
to see before making a diagnosis of a Pancoast tu
mor is evidence of erosion or destruction of the first,
second or third rib, which is not indicated on these
films.
Dr. Knowles: Can you state fairly definitely that
fluid was absent and that the major portion of the
change was due to fibrotic disease?
.
Dr. Dreyfuss: I am quite certain of the absence
of a significant amount of fluid. The left leaf of
the diaphragm is very sharp, and the usual tapered
sign of fluid extending up the posterior gutter is
lacking on the right side.
,
Dr. Knowles: One other point is that. even,
though the" right hemidiaphragm was elevated the
liver extended 2 fingerbreadths below the right
costal margin. So I assume that there was significant
K * *****Mn Iv
' *
. ^ '" *
Dr. Dreyfuss : It is certainly suggested.
.
Dr. Knowles: .As I see it, the argument in this
case rests on four key findings: the disease was bilat
eral and both pleural'ana parenchymal; the patient
had persistent chest pain; erosive dissolution of the
ribs had occurred; and a right-sided Homer syn
drome had .developed. The last three features sug
gest a malignant process and remove the disease
from the simple class of just a fibrotic reaction to as-
bestosis. The only conclusion that' I can reach is
that he had chronic pulmonary asbestosis, and that
a complication oFsome type had developed.
At this point perhaps a brief historical review of
asbestosis is in order.1 .\sbcstos is a Greek word
meaning unquenchable or unconsumable in the
sense of being indestructible. In 450 B. C. the Ro
mans discovered that clothing made of this flexible
fiber facilitated the collection of the asher, after cre
mation. Its contemporary use is as insulating ma
terial for pipes, linings for chemical containers and
brakes on automobiles, insulating slabs and shingles,
firefighter suits, theater curtains and tindercoating
for ships and automobiles.1* Two years ago pul
monary asbestosis was reported in Massachusetts in
a man whose occupation included spraying under
coating on cars5: the material used had an aphalt
base with about 50 per cent asbestos, and he had
true jjulmonarv
Asbestos is the name
given to a series of minerals composed of certain
fibrous silicates, magnesium and iron. It is mined as
crushed rock and is then carded, woven and spun
VoL- 269 No. 14
CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
751
Dr. Casti.f.ma*: The sputum was examined choice on the negative evidence -- that is, the nega
both tumor cells and asbestos fibers, and neither tive bronchnsroptc study, the nonspecific radiologic
found.
findings with no suggestion of a localized mass and
a.. Knowuss: My argument is becoming less the negative sputum examinations. I think that the
reusable by the moment. Were the so-called asbestos operation was another right-sided thoracotomy, with,
corns observed on physical examination? These arc I hope, pleural and pulmonary biopsies and per
small, nodular fibrous areas that may develop on haps even biopsy of a diseased rib. I doubt whether
uhe hands, arms and legs of people "wHdTvorX-with' 'curative surgery could be done. *
*
asbestos fibers.
Dr. Lamar Souther: Why-do you think the pa
Ea. :Ca-stlrman None were found.
* tient lost so much weight?
'Dr. Knowuss: I should like to say a word about
Dr. K.vowtss: I attribute the weight loss to the
:he pathologic physiology of this disease, although debilitating effects of chronic pain and ultimate in-,
it requires extraordinary courage to stick with ro/ vasion of the liver, either by metastatic disease or by
original premise after ail these questions have been direct extension. Loss of appetite may be the key
answered in the negative. -Pulmonary asbestosis is symptom of hepatic involvement.
commonly associated with the alveolar-capillary-block
Dr. Kzxxsth T. Biro: Diffuse lung disease,
svndrome.* The full-blown syndrome is characterized whether or not of occupational origin, may result
by reduction in lung volume, unobstructed air fiow, in weight loss. This effect is probably a manifestation
increased respiratory rate and ordinarily cyanosis on of persistent hypoxia. For example, the presenting
exercise, but with a normal carbon dioxide level or complaint of the patient with pulmonary emphysema*
:ven mild respiratory alkalosis since there is no is often progressive weight loss.
-
obstruction to the diffusion of carbon dioxide.
It is important to note that the crystalline form
What else should be considered in the .differential and size of inhaled particles may determine the re
diagnosis? Tuberculosis and fungous disease such as sponse of the host in pulmonary disease associated
.ctinomvccsis are possibilities, since both cause pleu- with occupational exposure. CroridoHte, one of the
-1 fibrosis and bilateral chronic disease, but there several varieties of asbestos fibers, may give rise not
no* evidence of chronic infection in this patient. only to parenchymal and pleural disease but also
* uis disease, with the exception of actinomy- to peritoneal manifestations.4 Chrysotile, 3MzO *
****,
net erode ribc but
a uciluatcai 23iO-
is me mam asbestos of commercial use.
jroiiferative reaction. So I can dismiss those two
Dr. Castuzmax: Dr. Isselbacher, do you have a
diagnoses.
comment?
The presence of the Homer syndrome bothered
Dr. Kurt J. Isssibachsr: As Dr. Knowles men
te considerably, but there is no question that a neo- tioned, in 1953 we became interested in a possible
iastic mesothelioma, by Invading the lower cervical relation between asbestosis and the development of
angfions and sympathetic fibers or the upper thorac- bronchogenic carcinoma. It seemed important to
; fibers, could be responsible for this condition. The document such a relation, if it existed, because of
ict that it was noticed soon after the .operation the magnitude cf the asbestos industry in this coun
'.ade me worry about metastatic disease or even a try. We were impressed by the preponderance of in
ctle infarct in the medulla, but with no other volvement of the lower lung when the carcinoma
:.sociated neurologic findings of the so-called lateral occurred in association with asbestosis. Another fac
.edullary or Wallenberg syndrome one has to place tor pointing toward an association of the two en
;e cause of the Homer syndrome peripheral to tities was the high incidence of bronchogenic card-
:e spinal cord and to the medulla. A superior- noma -- namely, 13.3 per cent. A third feature,
:lcus rumor with invasion of the sympathetic stel- which Dr. Knowles has emphasized in this case, ;^as
te ganglion or compression of the stellate ganglion the bilateral nature of the disease. In view of 'tne
a cervical rib, perhaps due to manipulation dur- occupational history in the present case, I find Dr.
g the operation, seems unlikely on both clinical Knowles's diagnosis most attractive.
id radiologic grounds. A final point to be explained the elevated alkaline phosphatase level.' It is pos-
'
Cuxtcal Dlacnoses
`
aie that the high value reflected metastases to the
? Asbestosis.
.
or the fiver from a bronchogenic carcinoma,
? Carcinoma of lung,
mterpret the elevation of the right leaf of the .* .gm as a sign of significant hepatic cnlarge-
Dr. John H. Kxowi.es's Dtaoxoses
em and choose to say that a pleural mesothelioma
Pulmonary asbestosis.
varied die diaphragm and also die liver.
Pleural mesothelioma, with' invasion of medias
My conclusion is that this man suffered from pul-
tinum, chest wall, right. homtritnphrngm and
onary
..-Mi diffuse parenchymal inter-
liver.
tial and nodular filnosis as well as extensive pleural >rrwis. In addition, I believe that he had a pleural
Patuolocuoai. Dj<crssiox
v 01. -'tUS .'"'O. I t
CA.'iC i<.
t^wJ v/f ijji,
id or..\c.A.\i< uw^i'i lAl.
. "The -patient died ten days after this operation. At axitopiy the entire right side of die chest was ob-
crated by dense fibrous tissue that in many places s obviously neoplastic. In the region of die right
cr lobe the pleura had a thickness of as much as 5 cm. As Dr. Knowles surmised, the pleural tumor had extended, through the diaphragm and overlay the surface of the liver (Fig. 6\. However, the paren chyma of the liver was spared cxccprfora'fcwsmalhmetastatic nodules. The neoplastic tissue extended into the lower lobe of the right lung, producing the serrated or cobblestone margin, as it projected from die pleura Into the lung, that is characteristic of the mesothelioma. The left lung was also involved by this dense pleural tumor, and there were a few small metastatic nodules within its parenchyma
The tremendous mass of the mesothelioma in volved the entire mediastinum, and compression of the subclavian veins on the right side accounted for the Homer syndrome. The tumor extended down to involve the pericardium as well, and there were two small nodules on the epicardium, From the pleura it extended into the ribs, as was seen on the x-ray films, and two of the ribs were completely destroyed. The vertebras were also involved, not by direct extension but by actual metastasis. .As I mendoned, the huge tumor extended down from the chest
i overlay the right lobe of the liver, and when it peeled off nodules were seen on the surface of liver. The omentum was completely covered
with mesothelioma Implants, which were present throughout the abdomen, especially in the region of the right lower quadrant over the cecum, the ascend ing colon and the terminal ileum.
Microscopical examination of one of the metastases within the left lung (Fig. 7) revealed mesothclial cells with a tremendous fibrous-tissue counterpart, which is characteristic of the mesothelioma, as I indicated (Fig. 8). In fact, an occasional mesotheli oma is almost- entirely fibrous, and at times it is very difficult for the pathologist to differentiate it from merely dense collagen or a fibrosarcoma- We know from experimental evidence that the mesothelioma cell, when grown on tissue culture, may produce col lagen, and that Is what it was doing in this metas
tasis. On the other hand, other mesotheliomas are predominantly made up of large mcsotheiial cells.
TiGUftt 7. Metastatic Nodule in the Left Lung. (X1S)
r
[ l \
rn;i xc 6. Sagt/tui Section through the Lotver Loire of the Right Lung, Diufihrugtn and Liver,
he "esnikslU >na encircle* (he lung (above) anti *overf:et ' e -nsiteriuf surface of the liter (below). Note the pleural
C.'
.f, 1 \ -1 .9 ?*' .*>/
I'n.i *. !!. .!/
'f'rt
:h r
t.lt r,;nee <d