A Case of Malignant Pleurisy

Abstract

A. M., aged 56, born in Glasgow, Scotland, a line of the angle of the scapula. The nodule at the site of the punctures grew in the sixteen ,weeks preceding death to the size of a large walnut, but did not involve the skin.Cough, though fairly persistent through the illness, was never troublesome. During the last few weeks a peculiar sputum was noted, odourless, clear, viscid, amber-coloured, jelly-like, very slightly frothy if at all, and changed in a few minutes by the carbolic acid solution in the sputum bowl into a dead-white opaque nummular mass, evidently highly fibrinous, and probably largely from the tubes of the compressed right lung. The wasted cachectic look of malignant disease did not appear. The colour never resembled that usually seen, though emaciation was distinct.Throughout the whole five months the subjective condition of the patient varied very little. His temperature ran during the last five weeks almost entirely a subnormal course, and lit was never at any time anything over IO0°F., and seldom so high. His pulse, to the last, seldom exceeded ioo, and never fell below 8o.About one month before death mild icedema of the lower limbs and a slight ascites were noted, both cardiac in origin.Death was due to asthenia, heart failure coming, on as he sat in his chair, and not very suddenly.The points of interest foundpost mortem-are as follows:I.-THE ABDOMEN.(a) Kidneys.-Both cirrhotic and with adherent capsule. Atrophy of both cortex and medulla, with hardening. Stellate scarring and fibrosis specially marked at upper end of left kidney, beneath which scar was found a rough uric acid calculus one-half by one-third by one-quarter inch] in size, with two smaller ones as large as wheat grains.(b) Liver.-Much enlarged, left lobe touching left side, and appearing during life as smooth firm mass in epigastrium. Its exact nature had not been determined during life from the disturbance of conditions usually discoverable by percussion and palpation, from the fact that the colon lay in front of the anterior surface of the liver, and had formed a permanent groove across it with marked ante-mortem coloration. The dislocation of the liver had been concealed by this cause, though the gall bladder was found to lie an inch and a-half to left of median line. The downward dislocation of the liver was as much as 34 inches, the highest point of the dome of the diaphragm being at the level of the sixth rib. The organ was much enlarged, slightly pale, and friable.To the right of the broad ligament lay a string of about twenty small white flattish nodules, the size of a split pea, under Glisson's capsule. A similar condition was found in the apposed area of the diaphragm, though there was no adhesion between diaphragm andliver, an instance of what has been noted by other observers that cancer can spread by apposition of tissues without the formation of adhesions.The greater part of the right half of the dome of the diaphragm was thickened, fixed, and adherent to the growth in the thorax. The abdomen contained about a pi...