COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX640661 50 RD667 Ad5 Primary malignant gr RECAP i i ! i 1 I i :^ ;ii !i 1 1 , ! i 1 1=1 Ml! i 1 ! 1 1 lUiuliiluinluiluiUini IBBlHiB lil!i'>n!!i!il!!!liil!!lll 1^-bGGl Ad^ Columbia SBmtier^ttp mtljeCitpotBrwgork CoUege of S^fiv^itims anb ^urgcong Hibrarp . J. C- . 'A,^^ ^^/cML^U^ ^/' // / PRIMARY MALIGNANT GROWTHS OF THE LUNGS AND BRONCHI Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/primarymalignantOOadle PRIMAEY MALIGNANT GROWTHS OF THE LUNGS AND BRONCHI A PATHOLOGICAL AND CLINICAL STUDY BY I. ABLER, A.M., M.D., Professor Emeritus at the New York Polyclinic, Consulting Physician to the German, Beth-Israel, Har Moriah, and Peoples Hospitals, and Montefiore Home and Hospital 'Oportet omnia signa contemplari' LONGMANS, GREEN, AND CO. FOURTH AVENUE & 30TH STREET, NEW YORK LONDON, BOMBAY, AND CALCUTTA 1912 COPYRIGHT, 1912, BY I. ABLER, A.M., M.D. All Bights Reserved THE'PLIMPTON'PRESS [ W • D • o] NORWOOD. MASS'U'S -A TO MY OLD-TIME TEACHER AND FRIEND HIS EXCELLENCY GEH. RAT. PROF. DR. JULIUS ARNOLD IN HEIDELBERG IN GRATITUDE AND AFFECTION PEEFACE T HAD intended that this little monograph on lung ■^ tumors should be handed to Professor Arnold on the occasion of the festival held August 19, 1905, to celebrate the seventieth birthday of the master. The plan as originally conceived could not be carried out, but it is hoped that the delay in bringing out the work may not have been alto- gether valueless in that it made possible a considerable increase in the volume of the material. Great thanks are due to my friends and assistants. Dr. O. Hensel and Dr. O. F. Krehbiel, for their indispensable aid in collecting and sifting the material. I am greatly indebted, as well, to Miss Laura E. Smith, of the Library of the New York Acad- emy of Medicine. I wish also to express my sincere thanks to Dr. H. S. Tienken for her untiring interest, un- selfish devotion, and technical skill in the proper recording and tabulating of the material, and to Dr. A. L. Garbat and to Miss F. H. Fiske for the strenuous work of seeing it through the press. Finally, I would acknowledge my debt to Dr. F. S. Mandlebaum of New York and to Professor S. B. Wolbach of Boston for the very beautiful photographs used here as illustrations. The author dares to hope for kindly criticism and some renewed interest in the subject. I. ADLER New York, Christmas, 1911 vii CONTENTS CHAPTER PAGE I. Introductory 3 Mostly statistical, II. Introductory {Continued) 13 Remarks on Plan oj Monograph. III. A Few Historical Notes 16 The Precancerous Influences. IV. Precancerous Influences (Continued) .... 26 Etiology of Malignant Tumors — Relation of Tuberculosis to Lung Tumors. V. Pathology 39 Gross Appearance of Lung Tumors — A Minute Study of Sarcoma and Carcinoma. VI. Pathology (Continued) 55 Histogenesis of Carcinoma — Endothelioma. VII. Pathology (Continued) 62 Metaplctsia. VIII. Clinical 68 IX. Clinical (Continued) , . 86 Appendices ■ - . 110 TABLES I. Carcinoma , . 114 II. Sarcoma , . 240 III. Doubtful 278 IV. Miscellaneous 314 LIST OF ILLUSTRATIONS [The Plates Numbered I to XVI are at the End op the Volume] Frontispiece. — Section of lung, showing a large tumor originating from the root and destroying the greater part of lung. Communicating cavities and tumor nodules of varying sizes. That portion of lung not infiltrated with tumor, compressed and pushed backward towards the spine. (From a drawing by H. Becker.) Plate I. — Transverse section across an infiltrating tumor and adjoining lung. Tumor area sharply defined against lung tissue. Infiltration so dense and complete that only a few vessels and slightly dilated bronchi are visible as remnants of normal structure. (From a drawing by H. Becker.) Plate II. — Shows destruction of almost entire lung. Pulmonary tissue almost completely replaced by tumor. (From a drawing by H. Becker.) Plate III. — Section of medullary carcinoma illustrating the occasional impossi- bihty of differentiating between carcinoma and sarcoma. Plate IV. — Same section as preceding, photographed with high power, ex- hibiting the same indeterminate character. Plate V. — Section from another portion of the same tumor as shown in Plate IV. In structure and in character of cells plainly suggesting carcinoma. Plate VI. — Shows section through kidney from same case. An incipient metastatic deposit, consisting of a few genuine epithelial cells just entering Bowman's Capsule, is shown. Plate VII. — Typical picture of ordinary form of carcinoma. A large alveole is seen, directly injecting a lymph- vessel with cancerous cells. Plate VIII. — Rapidly proUferating carcinoma, suggesting glandular type. Very little stroma between the alveoles, which latter contain mostly flat and cuboidal epithelial cells. Plate IX. — Same form of carcinoma. Smaller and more plexiform alveolar structure, more voluminous stroma, injection of lymph-spaces and lymph- vessels from alveoles. Plate X. — Cancroid with characteristic homy epithelial nests. xi xii LIST OF ILLUSTRATIONS Plate XI. — Cylindrical-celled carcinoma, the epithelium not ciliated. Alveolar structm-e, alveoles varying largely in size. Much mucoid degeneration. Origin from bronchial mucous glands. Plate XII. — Same type of tumor. To the right, dilated bronchus. In middle bronchial mucous glands, transition to carcinomatous alveoles plainly seen. Plate XIII. — Similar type of timior. Shows partial destruction of bronchial cartilage and various transitions from normal bronchial mucous glands to cancerous alveoles. Plate XIV. — Cylindrical-celled carcinoma. Suggestions of alveolar structure. Striking papillary arrangement. Plate XV. — Besides alveolar structure, shows marked participation of lymph- vessels and spaces in the cancerous proliferation. Plate XVI. — Shows practically only affection of lymphatic apparatus. Both this plate and the one preceding represent sections taken from tumors which in other localizations show typical carcinomatous structure. PEIMAEY MALIGNANT GEOWTHS OF THE LUNG PEIMAEY MALIGNANT GEOWTHS OF THE LUNG CHAPTER I INTRODUCTORY IS it worth while to write a monograph on the subject of primary mahgnant tmnors of the Imig? In the com'se of the last two centuries an ever-increasing hteratiu-e has accu- mulated around this subject. But this Hterature is without correlation, much of it buried in dissertations and other out- of-the-way places, and, with but a few notable exceptions, no attempt has been made to study the subject as a whole, either the pathological or the cUnical aspect having been emphasized at the expense of the other, according to the special predilec- tion of the author. On one point, however, there is nearly complete consensus of opinion, and that is that primary mahg- nant neoplasms of the lungs are among the rarest forms of disease. This latter opinion of the extreme rarity of primary timaors has persisted for centuries. Within the last few decades attempts have been made to combat this dogma, but even now the overwhelming majority of medical practitioners rarely, if ever, think of a diagnosis of tumor of the lungs, and the ubiquitous tuberculosis, with its multiform clinical appear- ances and its plastic adaptation to all ages and all conditions of mankind, is ever ready to fxmiish, to all but a very few, a comfortable and satisfactory diagnosis. Most textbooks hardly notice lung tumors, and if they give the subject any consideration it is, for the most part, insuf- ficient. Thus the well-known and still authoritative textbook on Diseases of the Lungs and Pleurae, including Tuberculosis and Mediastinal Growths, by Sk R. Douglas Powell and 3 4 PRIMARY MALIGNANT GROWTHS OF THE LUNG P. Horton-Smith Hartley (5th Edition, 1911), while treating at length of thoracic tumors and of mediastinal tumors, etc., has scarcely more than one page to cover the entire subject of carcinoma and sarcoma of the lungs. The excellent book of A. Frankel ^ and the admirable chapters on carcinoma of the lungs in the latest edition of Wolff, ^ as well as a few other publications,^ attempt a more comprehensive presentation of this type of tumor, but they seldom get into the hands of the medical public at large, and so it happens that the general practitioner is not in a position to diagnosticate a primary lung tumor as often as might be, and the belief in the extreme rarity of these cases is still maintained. To add to these difficulties, even the diagnoses made on the autopsy table are not always reliable. There are still careless or insuf- ficiently trained persons called upon to do this rather dehcate work. It may happen also that the most careful and search- ing autopsy will not furnish the true diagnosis until a thorough microscopical examination has been made. Take for example the case of Walter Kretschmar; * also of Morelli,^ This latter case is remarkable for a number of unusual features: the youth of the patient, — a female aged twenty-eight, — the sudden onset after cold, with fever and cough, the clinical symptoms of a pneumonic consoUdation in right base with pleural effusion and endocarditis. The sputum showed diplo- cocci. On autopsy both lungs showed white nodules, corre- sponding to blood vessels, and connective tissue strands not infrequently seen after pneumonic processes. No tumor could be recognized, and only upon microscopic examination were nests of epithelial cells discovered in the lymph spaces 1 Spezielle Pathologie u. Therapie der Lungenkrankheiten, 1904. 2 Die Lehre von der Krebskrankheit, Vol. II, pp. 803 ff., Jena, 1911. ' Credit must be given here to Alfred v. Sokolowski, Klinik der Brustkrank- heiten, Vol. I, Berlin, 1906, and his study of primary malignant and non-malig- nant neoplasms of the bronchi and lungs. He seems to consider bronchial carcinoma extremely rare, — much more rare than primary tumors of the lung. He has a chapter of about fifteen pages devoted to lung tumors, citing several cases of his own experience. He goes rather quickly over the pathology and diagnosis of carcinoma and in the same way hurries over sarcoma without bringing in anything notably new. ^ tjber das primare Bronchial- imd Lungencarcinom, Diss. Leipzig, 1904. B Table I, No. 201. INTRODUCTORY 5 of the fibrous tissue, and epithelial clusters in the alveoles and in the alveolar septa. Furthermore, v. Hansemann ^ relates that in his experi- ence at the Friedrichshain Hospital there were 711 carcino- mata out of 7790 autopsies, of which 156, or 21.94%, were not diagnosticated during life, not even as tumors. Among these 156 cases there were sixteen bronchial and pul- monary tumors. Is it not somewhat humiliating to realize that the difficulties of diagnosis are still so great as to pre- vent the best and most experienced medical men, with all the advantages of a large hospital, from discovering almost one-fifth of all the carcinomata that come before them? If these figures hold good generally, about one-fifth more car- cinoma cases should be added to our ordinary statistics. Another important addition to the difficulties to be contended with lies in the fact that in many countries, as for example our own, justly claiming an advanced stage of civilization, the overwhelmingly great majority of the dead are not sub- jected to any post-mortem examination, and the death certificates on which burial permits are officially given are often ludicrously insufficient. For this reason the United States Census is entirely useless for our purposes. As an example of the misleading diagnoses and insufficient observa- tion which hamper one in getting up the literature of this subject, look up the following: Two Cases of Melanotic Tumors in the Lungs.^ Reliable autopsies, in the majority of cases, there are not, and many autopsy notes that have been recorded are so insufficient in their data and descriptions that a conclusive opinion on the case cannot be formed. The same applies to the clinical notes. It is therefore impossible to say, from the figures given by the United States Census concerning causes of death, how many persons mentioned as having died from tuberculosis, pneumonia, or kindred diseases, may not really have died from lung tumors. Considering all this, it seems primarily necessary to ^ Riechelmann, Eine Krebsstatistik vom pathologisch-anatomischen Stand- punkt, Berl. Klin. Woch., 1902, N. 31 and 32, pp. 728 ff. 2 Journal A. M. A., 1888, p. 53. 6 PRIMARY MALIGNANT GROWTHS OF THE LUNG procure enlightenment on the question : Are malignant tumors of the lung as rare as has been supposed? And if they are not so rare, is their more frequent occurrence due to a supposed general increase in the incidence of malignant growths? WilUams/ an enthusiastic exponent of the increase of car- cinoma as a whole and the corresponding decrease of tuberculosis, supports his view with a great mass of statis- tical figures, of which some few are quoted here. 1840 Incidence in England and Wales 1905 2786, a proportion to total number of deaths of 1:129, or 177 per million living. 30221, a proportion to total number of deaths of 1:17, or 885 per million living. As to Newsholme's contention ^ that the registered increase is only apparent, being actually due to improved methods of diagnosis and death certification, WiUiams's answer is that (1) the uniformity in increase is too marked to be due to im- proved diagnosis, and (2) the very improvements cited have also caused subtractions from the cancer total, since many diseases formerly erroneously called cancer are now given their true names. Nencki is quoted in this connection * as giving the increase in cancer death-rate in Switzerland from 114 in 1889 to 132 in 1898 (per 100,000 living). WilHams gives the following figures for other countries: Deaths fbom Cancer Paris, France 1865 84 1900 120 Germany 1872 59 1900 71 Berlin 1870-1882 57 1899 109 Italy 1880 21 1905 58 United States (per 100,000 Uving) 1850.... .... 9 1900 . . . ...43 New York 1864 . . . ...32 1900 . . . ...63 Boston 1863 . . . ...28 1903 . . . ...85 New Orleans 1864 . . . ...15 1903 . . . ...82 San Francisco 1856 . . . ...16 1900 . . . ...112 * Natural History of Cancer, New York, 1908. » Proceedings of the Royal Society, 1893, Vol. LFV, p. 209. ' Die Frequenz und Verteilung des Krebses in der Schweiz, etc., Zeitschr. f. schw. Statistik, 1900, Vol. II, p. 332. INTRODUCTORY 7 Other important statistical work to be consulted is that of Robert Behla/ the great standard work, in four volumes, of Juliusburger,2 and the work of Newsholme.^ Looking carefully over these statistics, it is the writer's opinion that the statistics of Williams, as well as all statistical material thus far collected, with a great deal of care and labor, have not succeeded in proving conclusively that there is a real increase in the incidence of cancer and a corresponding decrease in the incidence of tuberculosis. The fact may turn out to be so, but at this writing can by no means be considered as proven. The only figiu-es which in the course of time will give us the means of definitely solving problems such as this will be those obtained from hospitals, where the material is more uniform, where the best modem methods of observation and diagnosis are applied, and where finally the autopsies and microscopical examinations are done with the utmost care. Reports of life insurance officers, statis- tics taken from books of registrars and recorders, where only the causes of death are mentioned, cannot be effectively utilized. It has been shown, especially by the researches of Behla just quoted, that some sort of influence of occupation or trade may possibly be considered a factor in the incidence of carcinoma. If so, this factor is of very slight significance and may, at least for the study of lung tumors, be entirely disregarded. It is the conviction of the writer, and he shares this belief with many others, — the mention of whose names and criti- cism of whose work need not be entered upon here, — that there is no absolute increase in the incidence of carcinoma. Nevertheless, the incidence of malignant neoplasms of the lungs seems to show a decided increase. It has been stated that statistical research in this direction is beset with many difficulties. It may be hoped that in the course of a few ^ Krebs und Tuberkulose in beruflicher Beziehung vom Standpunkte der vergleichenden internationalen Statistik, Berlin, 1910. ^ Die Krankheits- und Sterblichkeitsverhaltnisse in der Ortskrankenkasse fiir Leipzig und Umgegend. ' The Statistics of Cancer, The Practitioner, April, 1899. 8 PRIMARY MALIGNANT GROWTHS OF THE LUNG years accurate and reliable figures will be available. In the meantime, however, the following table, founded on figures collected by Karrenstein ^ and considerably amended and enlarged, will at least serve to show, not the causes, but the fact of the apparent increase. It is very significant that in Primart Carcinoma of the Lungs and Bronchi I II in IV V VI VII Time Place % of all Total % of aU Total Author Carci- No. Autop- No. of noma Carci- noma Cases sies Autop- sies 1. 1852-67 Stadtkrankenhaus, Dresden 0.91 8716 Reinhardt^ 2. 1852-1908 Patholog. Institut, Wurzburg 15 or 0.93 1607 Fockler ' 3. 1854-85 Stadtkrankenhaus, Mtinchen 8 cases 0.065 12307 Fuchs* 4. 1870-88 Patholog. Institut der Universit . Kolozsvar 145 Buday ^ 5. 1872-89 Patholog. Institut, Bern 2 0.42 474 0.059 3363 C. Miillers 6. 1872-98 Reichsgesundheits- amt, Hamburg 84 0.70 11930 0.02 336486 Reiche' 7. 1873-87 Patholog. Institut, Kiel Danielsen ^ 8. 1877-84 Stadtkrankenhaus, Dresden 9 cases 0.22 4712 Wolfs 9. 1881-94 Patholog. Institut, Breslau 1.83 870 9246 Passler^" 10. 1885-94 Stadtkrankenhaus, Dresden 31 cases 0.43 7728 Wolf 11 1 Charit^-Annalen, Berlin, 1908. 2 Reinhardt, Der primare Lungenkrebs, Arch. f. Heilkunde, XIX, 1878.-2. ^ Fockler, Krebsstatistik nach den Befunden des patholog. Instituts zu Wurzburg, Diss. Wiirzburg, 1909. ^ Fiichs, Beitr. zur Kenntnis der Geschwiilstbildungen in der Lunge, Diss. Miinchen, 1886. ^ Buday, Statistik der im patholog. -anatom. Institut der Universitat Koloz- svar usw. Zeitschr. f. Krebsforschung, Vol. VI, S. 7. ' Miiller, C, Beitrag zur Statistik der malignen Tumoren, Diss. Bern, 1890. ^ Reiche, Beitrage zur Statistik des Carcinoms, Deut. Med. Woch., 1900, N. 7, p. 120 ff. 8 Danielsen, Quoted from Schlereth, 2 FaUe von primarem Lungenkrebs, Diss. Kiel, 1888. 9 Wolf, Fortschritte der Medizin, 1895. 10 Passler, s. S. 315, No. 5. " Wolf, loc. cit. INTRODLXTORY 9 Primary Carcinoma of the Lungs and Bronchi — Continued I II III IV V VI VII Time Place %■ of all Total %of aU Total Author Carci- No. Autop- No. of noma Carci- noma Cases sies Autop- sies 11. 1886-96 Krankenhaus, Munchen 9 1.2 706 0.10 8727 Periitzi 12. 1887-1906 Patholog. Institut, Wien 68 0.17 40000 Haberfeld2 13. 1888-97 Patholog. Institut, Greifswald 1.78 Kaminski^ 14. 1888-1905 Patholog. Institut, Universit. Kolozsvar 10 4.5 221 Buday * 15. 1895-1901 Friedrichshain, Berlin 711 7790 Riechelmann ^ 16. 1899-1903 Patholog. Lab. Lubarsch, Posen 3 1.2 159 0.17 1741 Sehrte 17. Vor 1900 Patholog. Institut am Urban-BerUn 4 100 0.4 Feilchenfeldt^ 18. 1899-1904 Patholog. Institut am Urban-Berlin 0.6 Benda^ 19. Zeitraum Patholog. Institut, 20 Rieck 9 V. 10 Jahr. Univ. Miinchen 1.92 20. 6 1.3 447 Lebertio 21. 1900 Patholog. Institut, Charit^Berlin 2.91 3 cases 103 0.23 1300 Karrenstein i^ 22. 1900-05 Urban-Berlin 31 0.61 496 0.6 5002 Redlichi2 23. 1901 Patholog. Institut, Charity-Berlin 8.86 7 cases 79 0.53 1310 Karrenstein" ^ Perutz, Zur Histogenesis des primaren Lungenkarzinoms, Diss. Miinchen, 1897. ^Haberfeld, Carcinom des Magens, der Gallenblase und Bronchien. Z'tschrift f. Krebsforsch., Vol. VII, I. Fasc, p. 204. 3 Kaminski, s. S. 315, No. 6. * Buday, loc. cit. ^ Riechelmann, Eine Krebsstatistik von path.-anatom. Standpunkt, Berl. klin. Woch., 1902, N. 31 and 32, pp. 728 ff. ^ Sehrt, Beitrage zur Kenntnis des primaren Lungenkarzinoms, Diss. Leip- zig, 1904. 7 Feilchenfeldt, Quoted from Benda, Deut. Med. Woch., 1904, S. 1454. Beitrage zur Statistik und Kasuistik des Karzinoms, Diss. Leipzig, 1901 (after Redlich). 8 Benda, loc. cit., S. 1453. 5 Rieck, Krebsstathstik nach den Befunden des patholog. Instituts zu Miinchen, Diss. Munchen, 1904. 1" Lebert, Traits pratique des Maladies cancereuses. " Karrenstein, Charite-Annalen, XXXII Jahrg., Berlin, 1908. 12 Redlich, Die Sektions-Statistik des Carcinoms, etc., am Stadt-Kranken- haus am Urban, 1900-1905, Diss. Berlin, 1907. 10 PRIMARY MALIGNANT GROWTHS OF THE LUNG Primary Carcinoma of the Lungs and Bronchi — Continued I II III IV V VI VII Time Place % of all Total % of aU Total Author Carci- No. Autop- No. of noma Carci- noma Cases sies Autop- sies 24. 1902 Patholog. Institut, Charity-Berlin 3.23 3 cases 93 0.31 999 Karrenstein^ 25. 1903 Patholog. Institut, Charite-BerUn 3.19 3 cases 94 0.24 1272 Karrenstein ^ 26. 1904 Patholog. Institut, Charite-Berlin 2.67 4 cases 150 0.28 1399 Karrenstein ^ 27. 1905 Patholog. Institut, Charite-Berlin 0.71 1 case 140 0.08 1313 Karrenstein^ 28. 1906 Patholog. Institut, Charite-Berlin 4.84 6 cases 124 0.46 1319 Karrenstein^ 29. 1906-08 Krankenhaus, r. d. I., Manchen 174 0.18 945 Forstner^ 30. 1907 Patholog. Institut, Charite-Berlin 3.31 5 cases 151 0.37 1360 Karrenstein 1 31. 1908 Stadtkrankanstalten, Hamburg 11 1.2 920 Korber' 32. 1908-09 Patholog. Institut Krankenhaus, Miinchen 1.8 212 0.29 1371 Nobiling^ 33. Basel 1.76 Kauf mann ^ 34. 1910-11 Charity- Annalen, Berlin 0.76 141 0.05 185 Orth6 1900 the Pathological Institute of the Charite in Berlin recorded only three cases of lung tumor, while in 1906 and 1907 five and six cases respectively, were recorded. It is more significant still when the reports of the Pathological Institute of Kolozsvar from 1870 to 1880 and from 1888 to 1905 respectively, are compared. It is to be remembered that this table is made up mainly from records of pathological laboratories of fairly high standing. There seems hardly room for doubt that the increase in the percentage of lung tumors is to be attributed mainly to ^ Karrenstein, Charitl-Annalen, XXXII Jahrg., Berlin, 1908. 2 Forstner, tjber maligne Tumoren, Diss. Miinchen, 1908. ' Korber, Die Ergebnisse der Hamburgischen Krebsforschung im Jahre 1908. Mitt. Hamburgischen Staatskrankenanstalten, Vol. IX, Supp., 1908. * Nobihng, Z'tschrift f . Krebsforsch. patholog. Institut Krankenhaus, Miinchen, r. d. I., 1908-1909. ' Kaufmann, Lehrbuch der Spec. Path. Anatomie, Basel, 1909. 6 Orth, Charit6-Annalen, Berlin, XXXV Jahrg., 1911. INTRODUCTORY 11 the increased attention paid to these types of tumor and the greater care and more extensive microscopic investigation with which autopsies are carried out at present. As early as 1837, Stokes ^ had aheady remarked that in his experience lung tumors are by no means as rare, either in England or in Ireland, as was generally assumed, and Boyd ^ even goes so far as to assert that primary cancer is more frequent in lungs than secondary cancer, an assertion which he explains as follows : ''A case of maUgnant deposit in the bronchial glands, infiltrating the lung, ending in ulceration and the formation of cavities, is frequently set down as one of hopeless phthisis, a post-mortem on which would be of no interest, and all record of the frequency of the disease is in consequence entirely lost." This utterance of Boyd's is probably some- what of an exaggeration, for while it has just been shown that the behef in the extreme rarity of lung tumors, a lusus naturae, as it were, can no longer be maintained, it must be conceded that these tumors belong to the class of rarer neoplasms and their incidence is out of all proportion to the frequency of occurrence of other malignant neoplasms, as for example of the female breast or the stomach. Seeing, thus, that lung tumors are to be reckoned with more often than was formerly believed, it is to be expected that nimierous problems, both pathological and clinical, will present themselves. Besides these problems of purely theo- retical interest to the pathologist and the clinician, there is the great importance to the patient of a correct diagnosis. It cannot be a matter of indifference to the unfortunate sufferer whether his case be diagnosticated as tuberculosis or as tumor. If tuberculosis, he will be sent from one climate and one sanitarium to another, he and his family possibly deluded with false hopes, until finally secondary symptoms have cleared up the case and death has brought relief. The grave prognosis which is an integral part of the diagnosis of tumor may be of paramount importance to the patient as well as to his relatives. At all events, so much is certain, that if 1 Diseases of the Chest, London, 1837. 2 Table I, No. 46. 12 PRIMARY MALIGNANT GROWTHS OF THE LUNG the diagnosis of lung tumors is to be developed so as to render it more precise, and if any reasonable attempt is to be made to convert the present desperate prognosis into one less hopeless, this great result can only be achieved if the internist shall work hand in hand and shoulder to shoulder with the surgeon. The internist must be able to furnish as early and as accurate a diagnosis as possible, so that the surgeon under favorable conditions may develop his technique as early as possible. With these few introductory words, the initial question, it is dared to hope, is answered affirmatively. CHAPTER II IN TROD UCTOR Y {Continued) IN undertaking to write this monograph, it is proposed to present the subject and the problems connected therewith in as comprehensive and at the same time as concise a manner as possible. Not only carcinoma, but the other malignant tumors of the lung are to be presented, both from a broad pathological, as well as from a clinical point of view. As the first step toward the accomplishment of this end, it was found necessary to collect a very large material from the literature. Thus far, but comparatively few cases had been picked up. Passler,^ after much sifting, managed to collect about seventy-four cases of undoubted primary car- cinoma of the lungs. This was in 1896, just fifteen years ago. The latest publication ^ casually remarks that about one hundred cases may now be found in literature. The difficulties of collecting cases in point have already been hinted at. It is extremely trying to delve into all sorts of doctor-dissertations, obscure and forgotten publications of all kinds and in all languages, to be frequently rewarded by finding that, after all, the case is secondary, or is not a case in point at all, or that no autopsy was made, or that no micro- scopic examination was reported. Again, no clinical history is given, and the pathological diagnosis, though modern and very good, is not sufficiently supported by clinical observa- tions. The collection of cases from modern times has been simplified by the introduction of the microscope into pathol- ogy and the nomenclature of tumors based on microscopic lyirch. Arch., Vol. 145, 1896, p. 191. 2 Edward Boecker, Zur Kenntnis der primaren Lungenkarzinome, Dies. Gottingen, Berlin, 1910. 13 14 PRIMARY MALIGNANT GROWTHS OF THE LUNG study, which latter, though not fulfilling all demands, is most helpful. But even within the last two years, reports have been pubhshed where there is no autopsy at all, or one that is very insufficient, and the microscopic examination is either absent or summarized in such general terms as "simple carcinoma," etc. Nevertheless, though it has taken several years in the compiling, 374 cases of carcinoma have been collected. It was thought best to make full abstracts wherever possible, so that the principal data of each case, both clinical and pathological, may be at the disposal of the reader, enabling him to use his own judgment and form his own deductions. The same has been done for sarcoma, though the latter is infinitely more difi&cult to get at than carcinoma, — not only because sarcoma is so much rarer, as will be seen, but because very many cases are published without sufficient autopsy, and even if autopsied the almost intolerable confusion in the nomenclature makes the diagnosis from the printed case wellnigh impossible. A third collection has been made which contains cases desig- nated as doubtful, though many of them may be authentic and valuable. They have been classed as doubtful for various reasons, sometimes because the autopsy was lacking, though the clinical observations pointed almost with certainty to a tumor diagnosis, or it was impossible to decide whether the case was one of carcinoma or sarcoma, etc. A few other cases have been assembled which, properly speaking, do not belong to the subject in hand, but which may in their symptoms during life so closely resemble primary growths of the lung that it was thought wise to place them here for warning and for comparison. The reader should well understand that no claim is made for absolute completeness. Many cases were not taken into our collection either because they were not obtainable, or were written in a language that could not be readily trans- lated, or for other reasons. Besides this, too, it was imprac- ticable to continue collecting material indefinitely, and since the collection of material has been discontinued numerous cases have been published, which could not appear in the present collection. It may be stated also that, with the INTRODUCTORY (Continued) 15 exception of but comparatively few, the references were read and excerpted personally. This rather bulky collection is printed in the form of tables, the first and largest being of carcinoma cases; the second, sarcoma; the third, doubtful; and the fourth, a few miscellaneous cases. CHAPTER III A FEW HISTORICAL NOTES Precancerous Influences OUR knowledge of lung tinnors dates from comparatively recent times, and the history of its development can be sketched in a very few words. It may aptly be divided into several periods. In the first and longest period, lung tumors were absolutely unknown. This period includes all of ancient and mediaeval medicine until Morgagni ^ (1682-1772) laid the foundations of pathological anatomy. It is most interesting and significant that Morgagni himself was prob- ably the first to publish the results of several autopsies on lungs that might be diagnosticated as cancerous, and were so interpreted by him. It is probable that the first of the cases which he published as cancer of the lungs was really a case of primary lung tumor. In this case he describes the disease of a man sixty years old, which was accompanied by cough and copious expectoration of a yellowish, rather crude material, rarely, but then distinctly, stained by streaks of blood. At autopsy the lung was foimd extremely hard, adhesions to pleura and mediastina, and nothing else but an "ulcus cancrosiun" in the right lung.^ The oft-quoted observations of Lieutaud ^ deal probably with tuberculosis or diseased pleura, and not with tumor. The cases mentioned by Van Swieten * must also be considered extremely doubtful. 1 De Sedibus et Causis Morborum per Anatomen indigatis. 2 Loc. cit. ' Historia anatomico-medica, etc., Paris, 1767, Lib. II. * Comment, ad Boerhaavi Aphorism, Vol. II, 1747. 16 A FEW HISTORICAL NOTES 17 There are a number of French authors about this time ^ who pubhshed cases as cancerous that cannot be distinguished with certainty from tuberculosis. G. L. Bayle^ pubhshed thi'ee cases which he had carefully studied clinically and equally carefully after death, and he is the author of the phrase "phthisie cancereuse" which caused so much discus- sion. The first case he reports may possibly be a primary- tumor, although this is doubtful. The second case is cer- tainly secondary after amputation of the arm. The third case was that of a man seventy-two years old, in which there were found at autopsy, at the root of the lung, shining white encephaloid cancerous masses, which were associated with masses of tuberculosis. It is unnecessary to go into all the clinical and pathological details and theories on which Bayle bases his conclusions. There is some merit in his insistence that cancer and tuberculosis may exist together, although the tubercles, according to him, are the effect of an acid, and cancer the effect of an alkali. No clear idea, however, can be obtained of what he means by cancer and what by tubercu- losis, and it consequently happened altogether too frequently that his followers accepted true tubercular cavities as can- cerous, and vice versa, so that finally great confusion arose as between tubercular phthisis and cancerous phthisis. His contention that cancer of the lungs may exist for a very long time without any symptoms has been corroborated by modem medicine. On the other hand, he makes no distinction between primary and secondary tumor. Besides the French, a number of German authors have worked on fines similar to those of Bayle, and though the name "phthisie cancereuse" could not maintain itself for a very long period, the name "fungus hsematodes," or simply "fungus of the lung," — especially among German writers, — was used for all pulmonary neoplasms that bore a suspicion of mafignancy. Those seeking further information of these 1 Le Dran, Mem. de I'Acad. royale de Chir., Vol. Ill, p. 28, Obs. 22. Also J. F. Senaux, fils. 2 Journal de Medicine, Tome 73, 1787. Also Recherches sur la Phthisie pulmonaire, Paris, 1810, p. 299. Also Diet, de Science m6d., Paris, 1810. 3 18 PRIMARY MALIGNANT GROWTHS OF THE LUNG historical questions are referred to the EngUsh classics, espe- cially Stokes/ Graves,^ and Walshe;^ and also to the, for that period, very complete and thorough works of Reinhold Kohler,^ and among modern authors, J. Wolff. ^ With Bayle and his followers ends the second period, and we enter upon the third, characterized by the study of lung tumors by purely clinical methods, reenforced by gross pathological anatomy. This period is introduced by Laennec, the author of TAuscultation Mediate, who, with his great authority and keen mind, took up the combat against Bayle and his after all not very progressive theories of the "phthisie cancereuse" and successfully differentiated the carcinoma of the lungs, whether primary or secondary, from any form of phthisical process, even though cavities should be found coimected with the tumor. He described tumor of the lung in the clearest terms, under the designation ''encephaloid." The use of this term, appUed promiscuously to all sorts of tumors, caused considerable confusion imtil Virchow worked out a rational classification. Since the time of Laennec, his lifework, the practice and perfection of the methods of auscultation and percussion, has been assiduously continued and by these means a compara- tively large number of lung tumors has been diagnosticated and reported. For a long time the necessary distinction between primary and secondary tumors was not upheld, and a number of cases were insufficiently observed and carelessly reported, but still progress in the diagnosis of primary tumor of the lungs was certainly made. J. Bell ^ is said to have been the first to diagnosticate with certainty a primary tumor, which was undoubtedly sarcoma of the lung. The real founder of this school is Stokes, who, together with Graves, Walshe, Hughes, and others, laid the foundations of our present clinical and pathological knowledge of primary lung ' Loc. cit. 2 Clinical Lectures on the Practice of Medicine, London, New Sydenham Soc, 2d Ed., Dublin, 1848, by J. Moore Neligan. ^ A Practical Treatise on Diseases of the Lung, etc., 4th Ed., London, 1871. * tJber den Lungenkrebs, Diss. Tubingen, 1847, and Die Krebs- und Schein- krebskrankheit des Menschen, Stuttgart, 1853. 6 Loc. cit. 6 Table II, No. 3. A FEW HISTORICAL NOTES 19 tumors. Following upon this period of purely clinical and gross pathological observation, there comes the time when, after the fundamental discovery of Schwann, histology be- comes the main factor in pathological research. After the great work of Rokitansky,^ in gathering together a very large material which led to a general cleaning-up and reclassifying of pathological anatomy, it is above all the name and work of Virchow that dominate this entire epoch. He was the first to demand that medicine be lifted out of a maze of hypotheses and more or less plausible theories to become one of the natural sciences, based on critical observation and experiment. The "cellular pathology," with its battle-cry of "Omnis cellula e cellula," exercised great influence on the study of tumors. The entire onkology was taken up again and rearranged in the light of the fact that every cell origi- nated, not from blastema, not from plastic lymph, not from diatheses or other exogenic processes, but from cells alone. 2 The present time is still a part of this period, and the study of lung tumors must be continued along these lines. Notwithstanding the great amount of work that, as has just been shown, has been done and is still going on, Williams^ is probably correct when he makes the somewhat brusque statement that "it is necessary at the outset to refer thus pointedly to the crudeness and immaturity of medical knowl- edge, because nowhere do these qualities find more striking exemplification than in the terrible welter of disjointed facts and contradictory hypotheses that constitute such a large part of modern Humor science.'" There cannot be any intention to discuss here the multitude of questions and prob- lems concerning the etiology and the true natm^e of malignant growths in general. The many questions of fundamental import, the attempts into the field of etiology, the innumerable ^ Lehrbuch der pathol. Anatomie, 1844. 2 Thiersch, Der Epithelialkrebs namentlich der Haut, Leipzig, 1865; Wal- deyer, Uber den Krebs, Volkmanns Samml., 1873, No. 33; Bard, La Specificity cellulaire et I'Histologie chez I'embryo, Arch, de Phys. normal, et path., 3 Ser., 7, p. 406, the author of the aphorism: "Omnis cellula e cellula ejuedem generis." ' Loc. cit. 20 PRIMARY MALIGNANT GROWTHS OF THE LUNG theories, and above all, the enormous experimental work that has been done within recent years, — all this is obviously beyond the scope of this little monograph, which is to be devoted solely to the study of lung tumors. Nearly all the types of malignant neoplasms that occur in other parts of the body are also to be found among the primary growths of the lung, but before taking up the direct study of these tumors, some attention should be given to the conditions which have long been called "predisposing causes," but which latterly and more significantly are termed '^ precancerous conditions and affections."^ First, the influence of race on carcinoma. According to the latest statistics, race and geographical distribution seem to have a decided influence on the incidence of malignant growths.2 In the very thorough work of Dr. Levin,^ sufficient proof appears to be found that there is less cancer among the American Indians and American negroes than among the whites. Tuberculosis decimates the American Indians, while they are almost immune to cancer. This seems to contradict the statistical conclusions arrived at by Behla.^ Levin notes, too, that it is usually sarcoma or epithelioma of the different external parts of the body, which are neces- sarily more exposed to mechanical irritations, that affect the primitive races. In civilized nations there is a prevalence of carcinoma of the internal, parenchymatous organs. The following sentence, quoted from Levin, is important: "Thus the conclusion is forced on one's mind that, while every human being may carry within himself the X which may develop into cancer, it is the modern civilization and the conditions created by it that give rise to the mediate causes which produce the disease." The facts, indeed, at present available, support the conclusion that the white races, 1 All these data and figures have evidently been worked out principally for carcinoma, sarcoma being brought in now and then incidentally only, probably because of its rarity, possibly because no difference was made between the two. 2 Carl Lewin, Die Bosartigen Geschwiilste, Leipzig, 1909. Also Williams, loc. cit. ' I. Levin, Cancer among the American Indians, Zeitschr. f. Krebsforsch., Vol. X, Heft II, 1911. ^ Loc. cit. A FEW HISTORICAL NOTES 21 especially in Europe and the United States, can claim the greatest mortality from malignant growths, and there is only China, perhaps, that can compete with them in this respect. It is reasonable to suppose that this applies also to lung tumors, though there are no special statistics. Next, the question of heredity. This has always been considered a very potent factor in the etiology of malignant neoplasms in general. Josefson and Pfannenstill ^ have already noticed, however, that this does not apply to lung tumors. They have found only one case of accredited hered- ity among their seventy cases. According to Table I, in 290 cases of carcinoma heredity is not mentioned. As many of these cases are very superficially reported, and as in many others no clinical history is given, but the cases are simply introduced as pathological specimens, it is likely that among these 290 cases there may be many where the factor of hered- ity was simply overlooked. In twelve cases only it was posi- tively stated that there was a hereditary strain of cancer in the family, and in sixty-eight instances it was asserted that no hereditary strain could be discovered. According to the German Sammelforschung, in 9% of the males and 10.3% of the females hereditary predisposition for cancer was found.^ The experimental study of tumors has thus far not furnished any decided proof of the value of heredity as a causal factor, and Bashford is inclined to deny its influence altogether. It follows, — though the figures are very uncertain, — that the incidence of malignant growths of the lungs does not appear to be seriously affected by hereditary strain. The influence of sex. M. Askanazy* maintains that there is a distinct connection between premature sexual develop- ment and the development of malignant growths. Among tumors of other kinds he quotes also Linser,* who reported the case of a boy thirteen years of age with a complete 1 Primary Cancer of Lungs, Nov. Med. Arch., Stockholm, 1897, N. F. VIII, Festband, Axel Key; and Lubarsch and Ostertag, Ergebnisse, Wiesbaden, 1904, Vol. VIII, 1902. 2 Quoted from Lewin, loc. cit. 3 t)ber Sexuelle Friihreife, Zeitschr. f. Krebsforsch., Vol. X, Heft. Ill, 1910. 4 Virch. Archiv., 1899, Vol. 157, S. 281. 22 PRIMARY MALIGNANT GROWTHS OF THE LUNG development of hair such as is seen after development of puberty. He died of a tumor in the left pleural cavity and mediastinmn which, on examination, showed absence of elastic fibres, in stroma, no cihated epitheha, the epithehal cells in certain places still stratified. The natural history of these evidently congenital tumors is as yet entirely obscure. It has always been maintained that males are by far more frequently subject to lung tumors than females. Tables I and II corroborate this. Among the 374 cases of carcinoma of the limgs, there are 269 males, or 71.9%; ninety-three females, or 24.8%; twelve in which the sex is not stated. In the same way, among ninety-four sarcoma cases, sixty- three, or 67%, are males; twenty-eight, or 29.7%, females; three where sex is not stated.' The domestic life led by women, with their consequent retirement and immunity from the irritations and traumatisms which must be frequent in the more unprotected life of men (the abuse of tobacco and alcohol, the many trades and vocations which are accom- panied by irritations of the respiratory organs, etc.) has been adduced in explanation of this fact. The entire subject is not yet ready for final judgment. The age of the patient. It is indisputable that age has a certain influence upon the incidence of both carcinoma and sarcoma. Statistics seem to show that carcinoma, roughly speaking, is a disease of that period of life which follows puberty after its completion, while, on the other hand, sar- coma as a rule is a disease of the earher years of hfe. But there are exceptions, and no age is entirely exempt from either type of tumor. The following figures, gathered from Tables I and II, clearly illustrate this. It is evident from this that the majority of carcinoma cases hes beyond the age of forty and attains its maximum between the ages of fifty and sixty. Descending slowly there are still two cases remaining between eighty and ninety, while the majority of sarcoma cases lies below the age of forty, cUmbing up slowly from the decade between ten and twenty, reaching the maximum between thirty and forty, declining again, slowly, and there are still five cases between seventy and eighty. A FEW HISTORICAL NOTES 23 The first decade, from birth to ten years, seems to be kommie from carcinoma (without counting, of course, the few cases of congenital tumor). Carcinoma Sarcoma Age not stated 18 Age not stated 9 1-10 1-10 6 10-20 6 10-20 12 20-30 10 20-30 14 30-40 30 30-40 19 40-50 78 40-50 14 50-60 113 50-60 12 60-70 94 60-70 3 70-80 23 70-80 5 80-90 2 374 94 These figures tally satisfactorily with the age tables given by many authors, for instance Fuchs.^ The question of the influence of age upon the incidence of maUgnant neoplasms is one that is intimately connected with certain problems that have of late years been thor- oughly studied and widely discussed, — the problems of growth and of senility in their physiological and pathological bearings. The older theories, such as those of Thiersch ^ and others, that as the body grows older the interstitial tissue undergoes a change, the equilibrium between this and the epitheUum is impaired, in consequence of which the epithelial tissue proUferates and tends to form carcinoma, while, on the other hand, in youth the connective tissue group is apt to overstep the bounds set to it and thus sarcoma and similar tumors may be formed — these theories no longer hold good. It has just been shown that no age is absolutely immune from the formation of neoplasms and that even in intra-uterine life tumors of all kinds may be developed. These facts seem to lead to the unavoidable conclusion that deeper and more complex principles are involved. It is altogether foreign to the purpose of this study, and would require a book by itseK, to go into details concerning the modem theories of growth and senility. It will suffice to say ^ Beitrage zur Kasuistik des prim. Lungencarzinoms, Diss. Leipzig, 1890. * Log. cit. 24 PRIMARY MALIGNANT GROWTHS OF THE LUNG that developmental energy of a high degree becomes active as soon as the sperma enters the ovum. After that, until the organism is fully grown, there is a continuous balancing of energies as manifested in highly compHcated chemical and physical processes. Immediately with the completion of growth, the changes begin which lead to senescence and final destruction of the body. The study of the intricate chemistry and physics of growth, regeneration, and senes- cence is by no means concluded, but has in reaUty only just begun. The relation of these problems to the formation and development of neoplasms is as yet sufficiently obscure, but many a single ray of light shed here and there justifies the hope of further enlightenment in the near future. It is of special interest in this connection to study the work of Rossle,'^ from which only a few conclusions may be quoted. It appears to him as certain that hypersemia is able to produce a considerable increase in the number of those cells which are organically an integral part of the matrix, and for that reason are subject to the laws of nutrition specific to the latter. Hypersemia, however, cannot produce those biological alterations in the cells in consequence of which endless proliferation is caused. Rossle agrees, also, that hypersemia alone cannot account for the development of tumor, but must be associated with many other factors, among others, probably senescence. His aphorisms con- cerning senility are also most plausible and interesting. There may be senescence of the entire organism or of individual organs only. SeniHty does not attack different parts of the body simultaneously. While one part may long ago have become senescent, other organs may as yet be quite youthful. According to Rossle, the general law may probably be that the more intense the function, the sooner the cell grows old. It is doubtful if, with all their plausibihty, these theories will stand before more than a superficial investigation. Rossle further asserts that epithelium in general retains its juvenile status approximately during the entire life of the individual 1 Die RoUe der Hyperamie und des Alters in der Geschwulstentstehung, Munch. Med. Woch., 1904, p. 1330. A FEW HISTORICAL NOTES 25 and can be rejuvenated by karyokinesis and regeneration. The earlier in the course of the life of an organism a tissue becomes senile the earher it will be possible for tumors to be developed from this tissue, for according to Rossle it is not those cells and tissues which have become senile, but those which have remained youthful and capable of reproduction and regeneration, which form the origins of these tumors. CHAPTER IV PRECANCEROUS INFLUENCES {Continued) AS all these questions are most intimately connected with the question of the etiology of tumors, it will be best to say a few words in this place on the subject of etiology, at present the centre of so much discussion and labor. The despairing exclamation of Heyf elder, ^ — "Je passe sous silence Fetiologie et le traitement de cette maladie qui, jusqu'a present, est hors du domaine de Tart," — is for- tunately no longer true in its entirety. But still it must be confessed that, with all the colossal labor expended on the question of the etiology of tumors in the last half-century, the fundamental cause, the unknown X, that lies at the very bottom of all these manifold processes, is still entirely obscure and there is as yet not even a sufficient basis for an intelhgent statement of the question that would seem to promise any result. What we know to-day of the physiology, the chemis- try, and physics of growth and senihty seems to suggest that mahgnant neoplasms might in general be accounted for in either one of two ways, and the discussions as to etiology actually do gravitate about these two points. Firstly, one might suppose, seeing that the greatest energy and the foundations for its proper balance are put out in early foetal life, that neoplasms are based ultimately on some earUer or later intra-uterine disturbance. This is, indeed, the theory that was furnished and elaborated by Cohnheim and his followers. 2 Cohnheim, however, did not look upon all this ^ Du Cancer du Poumon, Arch. Gen. de Med., Vol. 14, 2d Series, 1837, p. 345. ^ Many years before Cohnheim, in the paper by Langstaff (Table II, No. 49) in 1818, that author says ^p. 345) that he has noticed "pulpy tumors in the lungs of adult persons who had not been affected during their lives with the least symptoms of pulmonic disorder and who died of active disease of a 26 PRECANCEROUS INFLUENCES (Continued) 27 from the mere standpoint of general physiology and of chem- istry, but assmned remnants of embryonal tissue in this or that organ which, left over, as it were, and endowed with proliferative energy, might under favorable conditions become active and produce tumors. This theory of Cohnheim, which, for reasons not necessary to state here, seemed untenable, was again revived, though in a much modified form, by Borst ^ and his followers. Borst assumed, as the necessary foundation for the formation of neo- plasms, early disturbances in the intra-uterine development, the nature of which is not as yet accurately known. Accord- ing to him, it is not necessary to assume the bodily presence of actual embryonal remnants. He remarks that, according to his view, it is highly probable that each organ has its own peculiar onkology. A true carcinoma is not developed out of any, no matter how irregular, form of inflammation, no trans- formation into carcinoma is effected when short, glandular, cuboid cells happen to be turned into high cylindrical cells of entirely different structure or when high cylindrical cells happen to be changed into others, again of different structure and of different function, or when single layers of pavement epithelium become stratified into numerous layers of epidermal cells. All these and many more deformations of epithelium might be mentioned which, according to Borst's view, would in no wise transform the particular growth in hand into a carcinoma. What Borst does require, and requires without exception, is just that transformation of an epithelial cell into one of cancerous character, on the details of which so many express differing opinions, and the character of which is so difficult to describe and yet is so readily accepted as a matter of belief. different description in other viscera." He is inclined to think that fungus haematodes and cancer and scrofula "have their origin perhaps with the formation and development of the natural parts of the foetus in utero and that they remain, after the birth of the individual, in some instances dormant or inactive for a series of years, and in all only require a peciiliar morbid excitement to occasion this increase and destructiveness." ^ Die Lehre von den Geschwlilsten, Wiesbaden, 1902. Uber atypische Epithelwucherung und Krebs, Verhand. Deutsch. Path. Ges., Vol. 6-7, 1903- 1904, p. 110. 28 PRIAIARY MALIGNANT GROWTHS OF THE LUNG It would be most interesting to continue in detail the history of the various theories and speculations which have led to the present state of our knowledge of mahgnant tumors. This is impossible, because the subject of this essay is tumors of the lung, and not mahgnant growths in general. The necessity of closely adhering to this special subject is still more imperative because of the enormous material on tumors in general pubhshed from year to year, a few examples of which have abeady been mentioned, as Willams,^ Borst,^ the various writings of Ribbert and espe- cially his latest.^ But even a simple catalogue of the more important writings on these subjects, with only carcinoma as a subject, would be enough to fill a small book. Does it not after all seem as if one theory were as good as another and might, by some clever reasoning, be selected according to the subjective taste of the author who elects to defend it? In the writer's opinion, the best evidence appears to be on the side of Borst and his followers. Be that as it may, one can only reiterate again and again that, with all the labor and time spent on these questions by workers in many separate fields of research, and especially the tremendous amount of experi- mental work that has of late years been done by Ehrlich and his school, by Bashf ord and many others, — while it has added much that is valuable to our general knowledge and has been of immense service to our better understanding of many medical and biological problems, especially of onkology, — in spite of all this, no light has been shed upon the ultimate etiology of tumors, and the words of Kraske ^ are in the main still true, — ''We know no more to-day of cancer than did our grandfathers." That cases of tuberculosis the world over, thanks to the preventive work done everywhere, are steadily diminishing in number seems indubitable. There is, as we have seen, a great deal of legitimate doubt as to the increase of carcino- sis. Behla ^ has pointed out that by adequate disinfection of ^ Loc. cit. ^ Loc. cit. ^ Das Karzinom des Menschen, etc., Hugo Ribbert, Bonn, 1911. « Naturforschen^ersammlung in Freiburg, Marz, 1902. ^ Loc. cit., p. 177. PRECANCEROUS INFLUENCES (Continued) 29 tubercular sputum, ulcers, and numerous other places where tubercle baciUi may be found or suspected, by proper isolation and proper sanitaria, etc., the progress of tuber- culosis can to some extent be arrested and that a much greater advance in the arresting of this scourge of mankind may be hoped for in the future. It is quite different with carcinoma. There is as yet no known primary cause for malignant growths. Among the multitude of contagions that we know at the present day, none has been found that seems to have any connection, causative or otherwise, with carcinoma or sarcoma. Carcinomatosis, therefore, does not show any similarity with the contagious character of tuber- culosis. It does not seem to spread infection from individual to individual. It is more than doubtful whether environment, as some authors maintain, plays any active part in the development of mahgnant growths. Behla has not suc- ceeded in proving that special forms of vocation, trade, occupation, etc., or calling of any kind, have any active part in the causation of lung tumors. It is true enough that certain kinds of work are apt to produce inflammatory conditions (bronchitis acute or chronic, anthracosis, siderosis, chronic indurative pneumonia, and others), and the locaU- zation of tuberculosis may possibly be determined by such factors. But it has never been proven that any increased tendency toward the development of mahgnant tumors is caused thereby.^ It may be convenient in this connection to refer briefly to the so-called cancer of the lungs as occurring in the mines of Schneeberg, Silesia, Germany.^ It was thought that here at least was proof positive of the production of mahgnant growths solely by the injurious effects of purely exogenic influences as furnished by irritating occupations. In this small Silesian ^ Conf. the work of Williams, loc. cit.; Karl Kolb, Der Einfluss des Berufes auf die Haufigkeit des Krebses, Zeitschr. f. Krebsforsch., Vol. IX, Heft III, Berlin, 1910; Behla, loc. cit., and many others. 2 Hesse, Das Vorkommen von primarem Lungenkrebs, die Bergkrankheit in den Schneeberger Gruben. Vierteljahrschrift f. gerichtliche Medizin, 1879, pp. 296 ff. Also Ancke, Lungenkrebs der Schneeberger Erzarbeiter, Diss. Miinchen, 1884. Also Komer, Munch. Med. Woch,, 1888, No. 11. 30 PRIMARY MALIGNANT GROWTHS OF THE LUNG town there were eight mines extending to a depth of fifteen hundred yards, from which cobalt, nickel, and bismuth were obtained. There were from six to seven hundred men employed in the mines, and of these the yearly mortaUty, excluding accidents and the like, was about twenty-eight to thirty-two, of which twenty-one to twenty-four were from carcinoma of the lungs, so that a total of seventy-five per cent of all miners in this town died from this disease. The worker was never affected until after twenty years of mine work, usually later, while the worker who siurvived fifty years of mine work was generally immune. Heredity can be excluded, for only those who worked in the mines, and worked steadily, were afflicted. Those who did not work continu- ously in the mines, or who had other occupations besides mining, or who lived better on the whole, might live to be seventy years or over. The symptoms need not be described here. The autopsies showed that the disease always com- menced from the root of the lung where the lymph nodes were involved and enlarged, ranging from the size of a walnut to that of a fist. Sometimes secondary tumors in the subcutis of the thorax, visible from without, occurred. The timiors were examined frequently, especially by E. Wagner,^ who found the nodules to be true Ijmapho-sarcoma. Cohnheim ^ had already hinted at the likelihood of these tumors not being real tumors at all, but products of some infection. The ques- tion was studied in all directions. It was found that only those who did actual mining, and for a considerable number of years, were attacked by the malady; that there was no local irritation caused by the nickel or cobalt or bismuth particles, but that it was a form of poisoning due to the arsenic found in some quantity in those ores. In other mines of cobalt, nickel, etc., in Sweden, Hungary, and the Tyrol, where the ore contained no arsenic, the disease did not occur. Since the authorities have sufficiently ventilated the mines and have properly regulated the lives of the miners, nothing has been heard of the ^'Schneeberger Lungenkrebs." ^ Eulenberg's Vierteljahrschr. f. Gerichtl. Medizin. 2 Vorlesungen, Vol. I» p. 718. PRECANCEROUS INFLUENCES (Continued) 31 Trauma. Much stress has been laid on traumatism as an important factor in the development of malignant neoplasms. By "traumatism" is meant here the injuries of the grosser kind, like severe contusions by blows, falls, and similar occurrences. It is always claimed that these severer forms of traumatism have some intimate and direct relations with the development and growth of maUgnant tumors; in fact are the growth-determining element. Statistics, however, do not seem to bear this out. Among the material col- lected in Table I dealing with carcinoma, there are but six cases in which traumatism in the ordinary larger sense is recorded.^ The really effective action of traumatism has for a long time been considered, as displayed in the development of sarcoma. Among the ninety cases tabulated on Table II, there are only two cases (Nos. 15 and 51) in which trauma is recorded. This seems to eliminate once and for all the idea that traimiatism of the grosser kind, at least, has any part in the development either of sarcoma or of carcinoma. Granted that the figures are very uncertain and clinical history and careful observations lacking, the small percentage of cases in which trauma is associated with the formation of tumors can only be due to a coincidence. It might, of course, be claimed that the tumor, — carcinoma or sarcoma, — had been latent before trauma, and that the trauma merely hastened the growth of the tumor. This is capable neither of proof nor of disproof and must remain for the present a matter of beUef and not of knowledge. Experimentally, so far as can be seen, convincing testimony has not been brought forward in either direction, but, as we must constantly keep in mind, no experimentation of any kind has as yet been able to produce an experimental case of malignant growth. The question of traumatism is, of coiu-se, still much discussed and it is surprising to note the lengths to which some authors are prepared to go. Herzfeld,^ for instance, concludes his work with the sentence, ^'Ohne Trauma, kein Tumor" (No tumor 1 Nos. 81, 104, 115, 158, 161, and 177. ' Tumor and Trauma, Zeitschr. f . Krebsforsch., Vol. 3, 1905, p. 73. 32 PRIMARY MALIGNANT GROWTHS OF THE LUNG without trauma). One interesting case is reported by Schoppler/ in which a fall down stairs with severe contusion of the left mamma was supposed to have given rise to a carcinoma, that portion of the breast having been, supposedly, healthy before trauma. It was quickly operated and the diagnosis corroborated by the microscope. The author considers this a convincing proof of the development of a carcinoma from a single traumatism. The writer does not think that he has proved his case, since, in order to have absolute proof, it would be necessary to have demonstrated, microscopically and otherwise, before the fall, that the portion of the breast affected had been entirely healthy. One must coincide with Bostrom^ in so far as he, with other authors, claims that no malignant tumor can be de- veloped after a single traumatism, from tissue previously healthy. It is not possible, however, to accept uncondi- tionally his further statements, that these large traumatisms may act as coincidental irritants and causes of mahgnant growths. Besides these blows and contusions, falls and all the grosser forms of traimiatisms, those smaller irritations which lead to chronic infianmiations and indurations, to hyperplasia, and often to hj^ersecretion and hyposecretion of the tissues, must be considered under the general head of traumatism. On this subject there is also a very large literature which cannot be mentioned here. A part of it will be found in Schoppler.' Besides the usual standard works, there are also the publica- tions of Brosch,^ Schuchhardt,^ and Ropke.^ Chronic irritations affecting the respiratory organs are numerous and are supposed by many to play a very active iZeitschr. f. Krebsforsch., Vol. 10, No. 2, 1911, p. 219. Einmaliges Trauma und Carcinom. 2 Traumaticismus und Parasitismus als Ursachen der Geschwiilste, Giessen, 1902. » Loc. cit. * Theoretische und experimentelle Untersuchungen zur Pathogenese u. Histogenese der malignen Geschwiilste. Quoted after Wolff, loc. cit. * Beitrage z, Entstehung des Carcinoms aus chronischentzundlichen Zu- standen der Hautdecken und Schleimhaute, Volkmanns Samml. klin. Vortr., No. 257, 1885. 6 Arch, f . Klin. Chirurgie, Bd. 78, 1905, H. II. PRECANCEROUS INFLUENCES (Continued) 33 part in the causation of tumors of the lung. Such causes are supposed to account for the predominance of males over females in the occurrence of tumors.^ It is very generally stated that the right side is the favorite localization of car- cinoma of the lung, and this is supposed to be in consequence of the anatomical and physiological conditions. The right bronchus is shorter and wider than the left, its course is considerably straighter, and it seems natural enough that irritating substances, both chemical and mechanical, are aspirated more easily into the right than into the left bronchus. The following figures calculated from Tables I and II seem to show that for carcinoma there is a pre- dominance in favor of the right side amounting to thirty- one cases. For sarcoma, on the other hand, there seems to be a predominance in favor of the left side. The figures calculated from Table III show no predominance of either side. Carcinoma Sarcoma Right side 188 Right side 36 left 157 left 51 both 18 both 2 doubtful 3 not stated 5 not stated 8 94 374 Comparison of these figures shows results so inconstant and differences so slight that it would not be wise to build any theories thereon. A. FrankeP comes to a similar conclusion, though based on a much smaller material. Tuberculosis. The authority of Rokitansky for a long time sustained the dogma that carcinoma and tuberculosis are incompatible diseases; in other words, that where tubercu- losis is found a cancer cannot develop. Another view, at one time popular, is expressed by an aphorism of Crazet^ — "The cancerous easily become tuberculous, but the tuber- culous do not easily become subject to cancer." Actual 1 Conf. p. 22, Chap. III. " Loc. cit. 3 Coincidence et rapport du tuberculose avec le cancer, These de Paris, 1878. 4 34 PRIMARY MALIGNANT GROWTHS OF THE LUNG experience has since shown, not only that carcinoma, espe- cially of the cancroid variety, is sometimes found in a tuber- culous cavity, but that ordinary pulmonary tuberculosis, with breaking down of tissue and formation of cavities, as well as miUary tuberculosis and locahzed tuberculosis in other organs, may be associated with pulmonary neoplasms. In some cases the diagnosis of associated pulmonary neoplasm and tuberculosis has been made during life. A selection of cases taken from the collected material will serve to illustrate the association of mahgnant growths and tuberculosis. Tumor was present in every case, whether expressly men- tioned or not. Table I 54 Cohn Autopsy Tuberculous cicatrix in right apex and in Bau- hini's valve 87 Friedlander Autopsy Cancer in left bronchus and tuberculous cavity left lung 98 Gougerot Clinical Pulmonary tuberculosis of old standing 106 Harbitz Clinical Tuberculous family history 257 Perrone Sputum No tubercle bacilli Autopsy Tubercular cavity at left apex, wall of cavity penetrated by tumor 295 Sehrt Autopsy Carcinoma right bronchus, extensive ulcerative tuberculosis 343 Wolf Clinical Chronic phthisis Autopsy Tubercular cavity left lung and tumor 344 WoK Clinical Chronic phthisis Autopsy Tubercular cavity right lobe and tumor 346 WoK Clinical Signs of pulmonary phthisis Autopsy Tumor left apex, mihary tubercles over right pleura 348 Wolf Autopsy Tumor of right upper lobe surrounded by fresh miUary tubercles, both suprarenals tubercu- lous, tuberculous ulcer in ileum 349 Wolf Autopsy Nodules root of right lung, excrescences on membrane of larger bronchi, bifurcation sur- rounded by large tumor, fresh miUary tuber- culosis of both lungs 350 Wolf Autopsy Tuberculous lobe, tuberculous pleuritis 356 Wolf Autopsy Carcinoma of main bronchus, miliary tubercles in liver 359 Wolf Clinical Anorexia and emaciation followed by signs of right pulmonary phthisis 365 Wolf Clinical Pulmonary phthisis 373 Wolf Clinical Symptoms of tuberculosis with bacilli Autopsy Lesions of old and more recent phthisis 374 Wolf Clinical Diagnosis first as tuberculosis, then as ss^jhilis PRECANCEROUS INFLUENCES (Continued) 35 Table II 36 Hildebrand Tubercle bacilli in sputum 79 Schnick Tubercle bacilli in sputum The cases will probably be much more nmnerous m future, m proportion to the increasing attention given to this subject at autopsies and microscopic examinations. Some authors appear to take a somewhat extreme stand regarding the relation between tuberculosis and tumors generally, and of tumors of the limg especially. For in- stance, Aronson ^ cites twenty-two cases of his own practice in which tuberculous patients had one parent or both suffer- ing from carcinoma. He even goes so far as to suggest the possibility that the tubercle bacillus under favorable con- ditions might produce carcinoma, and refers to the lupus carcinoma as the connecting link between tuberculosis and carcinoma. It is sufficient to quote the following sentence: ''The phthisical diathesis is not only inherited from parents suffering from tubercular phthisis, but also from those suffer- ing from carcinoma. Etiologically considered, carcinoma, lupus, tuberculosis, all these belong most probably to a single family." As a counterpart to these exaggerated statements, Bayha^ describes the so-called lupus epithelioma and declares this form of epithelial proliferation in no wise cancerous or malignant. He shows that genuine carcinoma develops much oftener on active and fresh lupus than on lupus scars. The proclivity of carcinoma to develop from lupus, and especially from lupus scars, has been mentioned so often as a fact beyond dispute that it is important to note the results of Bayha's investigation. He says distinctly that there is no direct transition from lupus to carcinoma, but that the malignant epithelium prohferates into the interpapillary depressions. WilUams ^ reiterates his view that as tubercu- losis declines, carcinoma necessarily increases. It is also his belief that the systemic depreciation that follows as a conse- 1 Beziehungen zwischen Tuberculose und Krebs, Deut. Med. Woch., 1902, No. 37, p. 842. ^ Uber Lupus Carcinom, Bruns, Beitrage zur Klin. Chir., Vol. Ill, 1888, p. 1. » Loo. cit., pp. 337 ff. 36 PRIMARY MALIGNANT GROWTHS OF THE LUNG quence of fresh tuberculosis, and even of tuberculosis only recently healed, is an undoubted factor in the etiology of cancer. On the other hand, he readily agrees to the fact that while a considerable amount of old, healed, calcified tuber- culous products may be found associated with neoplasm in the lungs, this association has no further meaning than that, cicatrized tuberculosis being so extremely common, the ordi- nary percentage is also found in the cancerous. Furthermore, F. P. Weber and many others suggest that old, quiescent tuberculous foci, not yet completely cicatrized, may be again started into activity by the local as well as systemic effect of the cancer, which naturally tends in a great measure to lower the patient's vitality. This, however, is a speculation of which we know nothing. The subject of tuberculosis in its relations to carcinoma should not be closed without mentioning the theories of Kurt Wolf."^ Wolf distinguishes closely between bronchial carcinoma and carcinoma of the lung proper. Of the latter he reports nine cases, of carcinoma of the bronchus twenty- two. ^ He points out that bronchial carcinomata are nearly always found in those places which are most subjected to slight, but chronic, irritations, especially on the right side and more particularly near the bifurcations. He does not so much refer to the tracheal bifurcation, but more to the bifur- cations of the second, third, fourth, and following orders. NatiKally, all the irritations of aspiration, of dust, tobacco, and so on, as well as coughs, are apt to centre about these points. It is there that Wolf most frequently finds very small melanotic lymph nodes which, even at a very early stage, are tuberculous. Sooner or later a minute perforation into the bronchus takes place, into which the melanotic contents of the Uttle node are discharged ("Pigmentdurchbruch"). The lymph nodes on the down track toward the hilus of the lung, and of the hilus itself, become enlarged in the course of the process. It is Wolf's contention that these little melanotic lymph nodes are apt to be tuberculous; that 1 Wolf, Der Primare Lungenkrebs, Fort. d. Med., 1893, Vol. 13, Nos. 18 and 19. 2 Conf . Table I. PRECANCEROUS INFLUENCES (Continued) 37 when penetrating into the bronchus or developing at the root of the lung they act as a chronic irritant at the locali- zations most exposed. This "Pigmentdurchbruch,"i Wolf claims, is sufficient, in persons hereditarily predisposed, to start the development of malignant growth. This malignant neoplasm then proliferates in the bronchus first affected, travels along the ramifications of the bronchial tree, pene- trates into the lungs, and forms more or less extensive timiors. This theory of Wolf has been the subject of some discussion, but has not been generally adopted. The presence of the tubercle bacillus or any active tuberculous process has never been definitely demonstrated in these minute lymph nodes or their further development. He finds, out of the thirty- one cases which he reports, eleven cases which exhibit, not cicatrized and inactive, but mostly fresh and active tuber- culous processes, by the side of indubitable primary malig- nant neoplasms in the lungs. This, however, does not suffice to prove his ingenious theory. That carcinoma does occur on various cicatrizations, especially of the skin or mucous membrane, is a fact. It is only necessary to refer to the carcinoma on lupus, previously mentioned in this connection, on ulcer of the stomach, on leukoplakia, gall bladder, etc. This form of precancerous affection evidently is not concerned in limg tumors, unless we except the theories of Wolf, just briefly outhned, or of some other authors, who find in tuberculous cicatrizations or tuberculous ulcers a formative irritant for the development of carcinoma. An attempt has been made to obtain some knowledge of the duration of carcinomatous disease from Table I. Reliable values are, however, not easily obtainable, and it is possible to give only an approximate and very defective notion of the duration of primary carcinoma of the lung. The reasons for this are obvious. Many authors neglect to give any data from which the duration might be deduced, and the patients themselves are often so little self-observant and so careless > This "Pigmentdurchbruch," so fax as the writer knows, has been demon- strated only a single time. 38 PRIMARY MALIGNANT GROWTHS OF THE LUNG of their physical condition that they seek medical aid long after the first appearance of symptoms, the date of which, therefore, can no longer be fixed. Finally, the first appear- ance of symptoms does not necessarily coincide with the beginning of the disease. Among the 374 cases tabulated in Table I, there are no means of calculating the duration in 230 cases. The longest duration given is five years, the shortest two weeks. ^ ^ For details, see Appendix A. CHAPTER V PATHOLOGY THERE is an old aphorism saying that those organs most disposed to secondary tmnors are least disposed to the formation of primary neoplasms. The limgs are undoubtedly a favorite locaUzation for secondary tumors, but primary neoplasms are by no means rare. All the types of tumors represented in the onkology of other organs may also be found in the limgs. The gross appearance is not uniform or characteristic. It differs according to the peculiarities in each individual case. For carcinoma of the lungs, the older writers distinguish only between encephaloid, or what they called medullary, cancer (" Markschwamm " and fungus hsematodes) and the infiltrated form, the names being given merely to indicate external differences. Jaccoud ^ mentions that primary cancer of the lung is nearly always of the encephaloid variety and is seen either "en masse" or in a more infiltrated form. He considers the "cancer en masse" as the more frequent. It is not easy to determine just what kind of tumor, — sarcoma or carcinoma, — Jaccoud had before him. A much greater variety in gross appearance of this class of tumors is now recognized. One form that occurs occasionally is that of a single nodule, usually quite small, surrounded perhaps by a few minute miliary nodules deeply buried in the lung tissue of one lobe, producing only very slight or possibly no symptoms during life, and as a rule discovered by mere accident at autopsy. These cases are rare. The writer has seen two. There is the so-called mihary form of carcinosis, which in ^ Jaccoud, Legons de Clinique m^dicale, 1871-72, p. 454, Cancer de pou- mon; Traits de pathologic interne, Vol. 2, p. 120. 39 40 PRIMARY MALIGNANT GROWTHS OF THE LUNG the gross resembles very nearly an eruption of miliary tuber- cles.^ There is perhaps this difference, that the little nodules are somewhat larger than the tubercles and have not the peculiar grayish translucent appearance, but are more whitish and generally distributed along the lymphatics.^ The reader is referred, for a history and description of the acute miliary carcinosis in general, to J. Wolff. ^ As for the lungs, there seems to be no doubt that a miUary carcinosis actually exists, as Rokitansky* and Elisberg^ hold, but it is probable that these cases are not always primary. It is very much more likely that they are secondary to some small tumor that — possibly owing to lack of symptoms, possibly because hidden away in the depths of some bulky organ — was not detected. The nodular form of primary carcinoma of the lung as a rule involves in its beginnings only a portion of one lung, while metastatic carcinomatous nodules in the lungs are apt to be distributed throughout both lungs. The nodules are found of varying sizes, from that of a cherry pit or walnut to that of an egg, small apple, or even a human fist. They are not usually confluent, but are separated from each other by lung tissue. The boundary between the tumor and the lung is sharply defined. As the process continues, the lung tissue intervening between nodules often becomes involved in secondary inflammatory and degenerative conditions, and the nodules, as they increase in size, may merge one into the other. Jaccoud,® and since his time others, have been of opinion that cavities and breaking down of tissue within these nodular carcinomata do not occur, or at all events are very rare. On the contrary, however, the material col- lected in Table I will show that the formation of irregular cavities, especially in the larger nodulated tumors, is a common occurrence. The gross appearance on section of these nodules varies according to the kind of tumor and the condition in which it happens to be, and it is therefore not ^This form was first described by Demme, Schweiz. Monatschrift f. prakt. Medizin, Jahrg. Ill, 1858, No. VI. 2 Conf. Wunderlichs Archiv., 1857. ' Table I, No. 80. » Loc. cit.. Vol. II, pp. 398 S. " Loc. cit. « Loc. cit., 1856, Vol. I, p. 255. PATHOLOGY 41 possible to present a uniform and generally applicable description. One may be sure, however, that besides the usual grayish-white or yellowish or pinkish-white tumor material there may be found pathologically altered bronchi and vessels, bronchiectatic dilatations, and, as has been said, occasional cavities. The cavities have ragged, irregular walls, consisting of tumor. Stumps of vessels and bronchi often protrude into them from the walls. The cavities usually contain detritus from tumor material, old or fresh blood, mucus, and so on. The infiltrating form. This form is very common. Sepa- rate nodules, large and small, are rare. The tumor, usually starting from a bronchus, penetrates the bronchial wall and infiltrates the lung along the bronchial as well as the venous, arterial, lymphatic, and even nerve ramifications.^ This type is subject to many variations, according as the infiltra- tion happens to proliferate mainly along the preformed track of the bronchial ramifications or extends down to the root of the lung, involving not only larger bronchi but also the bron- chial, tracheal, and mediastinal glands. It thus forms, besides extensive pulmonary infiltrations, considerable masses of tumor at the root which, in their effect upon larger bronchi, trachea, large vessels, and other mediastinal organs, cause bronchiectatic dilatations, atelectatic areas, even gangrene, in the lungs, and all those symptoms, to be discussed later, which pertain to intra- thoracic growths in general. ^ There is another type of infiltrating tumor affecting only a portion of a lobe. This starts as a rule from smaller bronchi or bronchioli; the infiltration is sharply defined against the normal lung tissue, and is so dense that within the region of the tumor scarcely any lung tissue can be found. The entire area is taken up by tumor in which only a few arteries and veins and some slight dilated bronchi are visible.' In Plate 2 the destruction of almost the entire lung, from top to bottom, is well shown. There is little healthy lung tissue, for nearly the entire lung is gone and the pulmo- nary tissue replaced by tumor, at first creeping along and » Stilling, Table I, No. 310. * Conf. Frontispiece. » Plate 1. 42 PRIMARY MALIGNANT GROWTHS OF THE LUNG infiltrating the lung tissue, then degenerating and breaking down iato cavities, etc., as described. The gross forms thus far described apply in general only to carcinoma of the lungs. The rare cases of sarcoma may assume similar macroscopic forms and it will then become difficult to distinguish sarcoma from carcinoma with- out the aid of the microscope. There is one gross form, however, that is, to all intents and purposes, pecuUar to sarcoma. This form appears as very large tumors with fairly homogeneous structure, sometimes containing cavities, but comparatively rarely, and never when the tumor is a lymphosarcoma. These growths may become so large as to occupy the entire half, or more, of the chest. That portion of the lung which is not destroyed and replaced by tumor remains as a mere shell around this growth. Heart, dia- phragm, mediastinal contents may be extensively displaced. This very brief and necessarily incomplete sketch of the mere gross appearances will suffice to show how varied and comphcated, how difficult of interpretation, are the post- mortem pictures presented by lung tumors. Sometimes the picture as seen by the naked eye cannot be recognized as tumor at all, and the lesions as shown at autopsy will be interpreted as inflammatory or degenerative processes, — for instance, as chronic, indurative, or pneumonic lesions. It follows from this that at every autopsy, even at those where there is no reason to suspect the presence of tumor, a microscopic examination according to modern methods is necessary for every portion of the lungs that does not appear absolutely sound and healthy. Passing from the macroscopic to the microscopic study of primary maUgnant neoplasms of the limg, manifold difficulties in determining the histological structure of the tumor, its interpretation and classification, are encountered. As the simpler group of these tumors, and presenting fewer of these difficulties, sarcoma will be first discussed. Hertz ^ goes so far as to deny the existence of primary sarcoma of the lung, claiming that every sarcoma found in that organ is * Neubildungen der Lungen in Ziemssens Handbuch, 1874, Vol. 5. PATHOLOGY 43 secondary. It must be admitted that primary sarcoma of the lung is a great rarity. The writer has not had the good fortune to observe a single case. Nevertheless, it has been attempted here to show that the relation of primary sarcoma of the limg to primary carcinoma of that organ does not differ from the relation which sarcoma bears to carcinoma in general.^ This conclusion is based on a collection of ninety- four cases from the hterature on the subject, ninety of which have been listed in Table II. It is quite possible that a num- ber of those set down as doubtful in Table III are genuine sarcoma. It is possible also, and very probable, that a great many cases have not been recognized and therefore not recorded. 2 As more attention is paid to this subject, reports of cases are pubhshed in greater number than would have been thought possible some years ago. It would have been easy to increase the number of cases on Table II to more than one hundred. All this shows that the beUef in the extreme rarity of sarcoma has been somewhat exaggerated. It has been shown above that the gross pictures presented by sarcoma may differ so slightly from those offered by carcinoma that microscopic examination alone would serve to differentiate between the two. It may, however, be said roughly that sarcoma has a greater tendency to spread toward the root of the lung, and involve from there the mediastinal lymph nodes and other organs, than has carci- noma. Melanotic sarcoma is extremely rare, — there is, in fact, some doubt in the writer's mind that it occurs at all. The dark anthracotic pigmentation of lungs and bronchial glands, pathologically more prominent perhaps, may erro- neously lead to the suspicion of melanosis. The very large and massive tumors occupying a great portion of the chest have just been referred to. They are occasionally subject 1 According to Williams (loc. cit., p. 377), 54.5% of all tumors are car- cinoma, 9.4% sarcoma, 24.7% non-malignant, and 11.4% cysts. These figures corroborate the above statement. 2 A quotation from Menetrier (Lubin, These de Paris, 1909, Contributions k I'Etude du Sarcome primitif du Poumon) seems apt enough in this connec- tion: "Le cancer n'est pas une forme morbide primitive; c'est un aboutissant d'etats pathologiques multiples, anterieurs et preparatoires." 44 PRIMARY MALIGNANT GROWTHS OF THE LUNG to osseous and especially to calcareous degeneration.^ A scrutiny of Table II shows that about half of the cases tabulated are of this massive type. Between these and the more infiltrating forms there are, of course, all manner of transitions. An especially interesting case came to hand after the Tables were finished. In this case the entire left half of the chest was filled by a voluminous mass, dislocating the heart, impinging on the right lung, and depressing the liver. The left lung was almost completely replaced by a huge tumor which pushed the remnants of the pulmonary tissue upward. The tumor contained a cavity in the midst of soft tumor material. The duration of the disease was almost three and a half years. ^ A most interesting case, also, is that reported^ of a male thirty-three years old, who entered the hospital in July, 1896. He had been sick since the previous December with cough, haemoptyses, pains in right chest, and in addition bronzed skin and bluish sclerse. In February, 1896, he was seized with a severe pain in the right leg, especially in the knee, which lasted until death. The entire right side was more painful than the left; no pig- mentation in the mouth; percussion absolutely flat over entire right anterior chest, and resistance much greater than normal; some cavernous breathing below the right clavicle, otherwise absolute silence over the whole right posterior lung; sputum contained nothing characteristic. The autopsy showed an enormous sarcoma of the right lung, many metastases of liver, pancreas, etc. Microscopically, a giant celled sarcoma of mixed type. A diagnosis of primary tumor of the lung had been made during life, but at autopsy the authors were inclined to consider the lung tumor secondary and the tumor in the femur as primary; in the first place on account of its microscopic structure, — the mixed giant celled sarcoma, — the giant cell being more common in 1 Chiari, Table III, No. 4. 2 Heilbron et Sezary, Sarcome primitif du poiimon, Bull, et Mem. de la Soc. Anatom. de Paris, Ann^e 85, No. 7, p. 758. 3 Packard and Steele, Case of Sarcoma of the Lungs, with symptoms of Addison's disease with involvement of suprarenal capsules. Med. News, 1897, No. 11. PATHOLOGY 45 bone; furthermore, the advanced condition of degeneration in the femur beyond that of the lung. For this reason the authors claim the tumor in the lung as secondary. This may be correct, but the true facts cannot be obtained with certainty. If it is secondary in the lungs, we have the very unusual, as far as the writer knows, the unique, occurrence of a secondary sarcomatous deposit involving only a single lung and assuming such huge proportions as almost to occupy the entire lung. It might be interesting to refer here also to a publication by Eckersdorff.^ According to his statistics 1.5 per mille of all autopsies are primary sarcoma of the lungs. Eckersdorff finds up to the year 1908 only four cases of primary sarcoma of the lungs. He publishes two cases, one of a man fifty years old living rather a wild life. In November, 1902, in joke, a friend gave him a blow between the shoulder-blades which led to a strong desire to urinate. Next day he felt still much affected, but on second day entirely well again. Soon thereafter he began to be hoarse, had pains in region of heart and intermittency of pulse. The most interesting part of the later history is the rapid change when, after considerable dyspnoea, irregular and rapid pulse, urine without albumen, enor- mous thirst, the patient would suddenly get better. It was not until late in the course of the disease that total dulness of left lung with abolished breathing sounds was discovered. This dulness disappeared quickly with the exception of one place. Later on there was a sudden dis- appearance of the pains. Death February 7th in collapse. The diagnosis during life was: probable neoplasm in the lung. The anatomical diagnosis, an annular carcinoma of the left main bronchus with obstruction of this and the formation of metastatic deposits in the lymph nodes and on the heart, oedoema of both lungs, pneumonia of the left lower lobe, and dilatation of both ventricles of the heart. Microscopical examination showed that it was not a car- cinoma, but a sarcoma of small round cell type. The ' Zwei Falle von primarem Sarkom der Lunge, Centralbl. f. allg. Path., Vol. 17, 1906, p. 355. 46 PRIT^IARY MALIGNANT GROWTHS OF THE LUNG histogenesis cannot with certainty be determined. The author thinks that the connective tissue of the bronchial mucosa is the place of origin. He does not express a positive opinion as to the causal effect of the blow. In a second case the origin is referred to the interalveolar septa. The author expresses the hope that in future the sputum may be studied more carefully in such cases. Another case which appeared after the Tables were finished may be mentioned here, though not a sarcoma, the interest- ing feature of it being the observation of the blood. Haemo- globin is not mentioned, but in the first blood count the red cells are reduced to 3,886,100 and the leucocytes are increased to 19,840, of which the polynuclears are seventy- nine per cent. A second blood count also does not give the haemoglobin. The red cells have dropped down to 2,926,400, the whites have increased to 24,800, and the poly- nuclears are now eighty-six per cent. A large tumor is found with cavities supposed to involve the larger bronchi and the hilus. The microscopical analysis shows a cancroid. Origin from the bronchus is nevertheless assumed. The frequent occurrence of primary sarcoma of the lungs in the form of huge and ponderous tumors is also corrob- orated by Duran.i Schech^ states that when in the right lung, the favorite seat of the tumor is the upper lobe, while in the left lung the favorite seat of tumor is the lower lobe, and that he has seen the tumor primary in both lungs only twice. Looking over Table II in regard to this point, one will find that there is no such difference, but that tumor in the right upper or left lower lobe, and the converse, occurs with equal frequency. There are five cases cited in the Table where both lungs are affected. The duration of sarcoma of the lungs does not seem to differ very materially from that of carcinoma. There are fifty-two cases out of the ninety in Table II from which some approximation as to their possible duration may be reached. Among these fifty- two^ the shortest period of duration is one month and the ^ Du sarcome primitif du poumon, Th^se de Paris, 1893. « Table II, No. 78. PATHOLOGY 47 longest six years, the average being about four and a half months, as compared to that of carcinoma, the average for which is two and a third months. It is evident that these averages have no real significance, and the only legitimate deduction from the figures is that primary carcinoma and sarcoma of the lungs are of indefinite duration, running at times a very rapid course and again assuming the character of chronic disease and lasting for many years. ^ The histology of primary sarcoma of the lungs offers in the main nothing peculiar or characteristic, but practically corresponds with the histology of sarcoma of other organs. It has been said^ that the spindle cells occur more frequently than any other type of cell. Examination of Table II in regard to this point shows only sixty-eight cases available, as in the remaining twenty-three there was no clear state- ment as to the character of the cells. Out of these sixty- eight cases just half were of the typical uncomplicated round celled variety, fourteen only were spindle celled, seven uncomplicated lympho-sarcoma, and there were also a few mixed tumors, such as lympho-sarcoma with small round cells, with spindle cells, etc. It seems, therefore, that round celled, and not spindle celled, sarcomata are by far the most frequent. Occasionally, giant cells are found.^ There are found, also, the usual combinations, such as myxo-sarcoma, fibro-sarcoma, and others; various degenera- tions, as mucoid, colloid, more frequently fatty, and also calcareous and osseous, attributable principally to the stroma; occasionally there are cystic forms. The histogenesis is still obscure. It seems certain that a great many of the pulmonary sarcomata take their origin from the root of the lung, probably in one or the other of the smaller or smallest of the peribronchial glands, growing from there, as mentioned before, along the track of the bron- chi, and at an early period penetrating a larger or smaller ^ For further details regarding duration of primary sarcoma of limgs, see Appendix B. * Schech, loc. cit. ' Packard and Steele, loc. cit. Also Colomiatti, Table II, No. 14. Also Klemm, Table IV, No. 10. 48 PMIvLmY MALIGNANT GROWTHS OF THE LUNG bronchus, obstructing it, and thus continuing in its course through the lungs, the tissue of which it destroys on its way. It may also, it is said, penetrate through the pores of the septa directly into the alveoles. The large massive tumors almost invariably start at the hilus. It is assmned by many, though not yet conceded by all, that sarcoma may develop from the interalveolar septa in the lung itself. The septa, at one or several spots becoming sarcomatous, may compress the pulmonary alveoles and fill with tumor material what is left of the air-vesicles, thus forming nodules of vary- ing size which, again merging into similar nodules, can form considerable tumors. The lung tissue in the immediate en- vironment of these nodular tumors is usually quite healthy, or evidences only minor changes. Microscopic examination may show remains of septa or the latter may have been de- stroyed altogether. As a rule there is no open communication with the bronchus, but bronchial remnants are seen within the tumor. In some instances the sarcomatous tissue does not completely destroy the septa, so that the alveolar struc- ture in some places at least remains distinctly visible. The air-vesicles are then filled with a mass of polymorphous cells which, according to the individual bias of the observer, may pass either for epitheUal cells or for deformed sarcoma (round) cells or for endothelial cells. The dispute concerning endothelium will be touched upon later. For the present it may be said that some authors consider the endothelium to play a considerable role in the histology of sarcoma, and Burkhardt,^ after extensive researches, thinks that sarcoma and endothelioma are not to be separated from each other, inasmuch as every sarcoma, besides the proliferating cells of the connective tissue, contains a greater or less proportion of endothelia of the lymph spaces as well as adventitia cells. All sarcoma are, therefore, according to him, more or less endothelioma, and only according as the connective tissue cells or the endothelia react stronger do the various types stand out. This is, of course, a very extreme point of view ^ Sarkome und Endotheliome nach ihrem path.-anatom. und klin. Ver- halten, Bnins Beitr. z. klin. Chir. 36, 1902. PATHOLOGY 49 and will have to be discussed later when endothelioma is touched upon. The microscopic picture often speaks for this theory, as it presents distinct alveolar structure with much enlarged septa consisting of spindle cells and alveoles filled with polymorphous cells. It is this type of tumor that probably comes under the head of what Virchow termed carcinoma sarcomatodes.^ The case of Weichselbaum ^ seems to be a true adeno-sarcoma. Is it not possible that this kind of tumor resembles those produced experimentally by Ehrlich and his school, in which the stroma of a carcinoma was ultimately converted into genuine spindle or round celled sarcoma? Carcinoma. The epithelium found in the lungs (lungs being taken in the broader sense and including the bronchi) consists of cylindrical epithelium, cihated as well as not cihated. The ciliated cells form the hning of the mucous membrane of the larger bronchial tubes. As with continued dichotomous division the branches of the bronchial tree be- come smaller, so the high ciliated cells become lower, the cilia gradually disappear, and the very smallest bronchioles are simply lined by a small, low, cuboid epithelium without cilia. The bronchial epithelium in the minutest bronchioles is by gradual transformation changed into the respiratory and alveolar epithelimn. In the adult this consists of fiat, squamous cells resembling endothelium. They line the septa and the pulmonary alveoli. The endothelium itself, those cells which form the inner coating of the lymph vessels and spaces, must be presently considered somewhat more in detail, as it is still a subject of dispute. Cyhndrical epithelium is also found in the bronchial mucous glands. This has no cilia and differs in no way from the ordinary cylindrical cell as found in glands. Considering only the very limited group of cells that contribute to the structure and formation of the carcinoma of the lung, it is often surprisingly difficult to distinguish the kind of epithelial cells that make up the tumor, and its ^ Bohme, M., Primares Sarco-Carcinom der Pleura, Virchows Archiv., Vol. 81, 1880, p. 181. 2 Table III, No. 94. 5 50 PRIMARY MALIGNANT GROWTHS OF THE LUNG structural peculiarities, and to understand the histogenesis. The enormous plasticity of the epithelium, the influence which territorial hmitations, intense proliferation, pressure upon each other, and various other intra- and extra-cellular changes bring to bear upon the cells, — all these features conspicuously increase the difficulties. It may really appear at times as if there were no specific kinds of epithe- lium, but that the epithelial cell, according to merely extrinsic conditions, might assume any form, cylindrical cells being transformed into pavement cells, pavement cells into horny pearls, etc. One is frequently at a loss to decide whether, in the section before him, the cells are of epithelial or connective tissue origin, whether it is a carci- noma or a sarcoma. Frankel, in the discussion of Simmond's paper, ^ states emphatically that great difiiculty is often experienced in distinguishing between carcinoma and sarcoma, owing, on the one hand, to the alveolar structure of the lung simulating carcinoma, and on the other hand to the almost limitless proliferation and change of form of the epithelia suggesting sarcoma. A good example of this is shown in Plate 3. Here the cells are so crowded, the prolif- eration is so rapid, that it would be impossible at the spot photographed to make any other diagnosis than that of a small round-celled sarcoma. No one would easily believe that these cells are mere transformations of epithelial cells and that the tumor is a true carcinoma. Plate 4 shows the same section with a higher power. One sees a great variety of polymorphous cells, some of which resemble epithelial, others sarcoma cells. In one spot a mitosis is plainly to be seen. Plate 5 is a section of the same tumor from another place, photographed with a moderate magnification, which plainly demonstrates the alveolar structure, the typical stroma, and in several places undoubted epithelial cells. There can be no hesitancy in calling this tumor a carci- noma. Plate 6 is a section from the kidney of the same patient, photographed with high power and showing most ^ liber die Histologie des prim. Lungenkrebses, Miin. Med. Woch,, 1896, p. 189. PATHOLOGY 51 beautifully a few undoubted epithelial cells just after their entrance into Bowman's Capsule. This picture may serve to remove all possible doubt as to the true natiire of the tumor. The various well-known types of carcinoma are all repre- sented. The carcinoma simplex. Plate 7 is a good illustra- tion of this. The alveolar structure is very plain, the alveoles varying in size, lined with cuboid or cylindrical cells and filled with polymorphous cells jumbled together, compressed out of shape and partly degenerated (horny, mucoid, colloid, fatty degeneration, etc., are frequently met with). The stroma is usually rich in cells and here and there a lymph space filled with epithelial cells is seen. It is very interest- ing to note in the picture a tolerably large alveole projecting its epithelial material directly into a lymph vessel. Plate 8 shows the typical glandular carcinoma without any distinc- tive features, and consisting mostly of flat and cuboidal epithelial cells with very little stroma. In this section there is nothing to suggest the origin of the tumor from the lung. Plate 9 shows the same form of carcinoma with smaller and more plexiform alveolar structure, more voluminous and firmer interstitial tissue, and a very plain demonstration of the infiltration of lymph vessels and spaces from the alveolar contents. In Plate 10 is shown a good example of a can- croid with the characteristic horny epithehal pearls. The basilar lining of cuboid cells is in this section not very plain. The cylindrical celled carcinoma. Plate 11. The cells are not ciliated. The alveolar structure is evident, the alveoles varying in size. The larger ones are about the size of a moderately large bronchus, and it is obvious that they are formed by the confluence of a number of smaller alveoles. The contents of these larger alveolar spaces, sometimes sug- gesting small cavities, consist of cellular and mucous detritus and scattered epithelial cells in various stages of degenera- tion. The stroma between the alveoles generally consists of rather soft connective tissue containing moderately abun- dant connective tissue cells. This form of carcinoma, occur- 52 PRIMARY MALIGNANT GROWTHS OF THE LUNG ring as it does quite frequently, is considered by many pathologists to be the typical, if not the only form, in which carcinoma occurs in the lungs. It is demonstrable that this type of tumor develops from the cells of the bronchial mucous glands. That this is so was first shown by Langhans,^ whose views were widely accepted. ^ In Plate 12 there is seen very clearly to the right of the pic- ture a dilated bronchus with mucoid detritus in its interior and a partially detached epithelial lining. In the middle of the picture are shown the bronchial epithelial glands, the majority of them unchanged, others just at the beginning of carcinomatous proliferation. Toward the left are some alveoles lined with cylindrical cells and the transition from proliferating bronchial mucous glands to carcinomatous alveoles is clearly perceptible. Plate 13 illustrates similar conditions. The bronchial cartilage is in parts destroyed and there are similar carcinomatous degenerations as in the preceding figure. Some of the alveoles, evidently originat- ing from degenerated bronchial mucous glands, contain carci- nomatous epithelium, not typically glandular, but exhibiting the usual character of pavement epithelium. Carcinoma may also develop from the surface epithelium of the bronchi. It is still a matter of some dispute what kind of cells are characteristic of this form of carcinoma. It is thought by competent authorities that the surface epithelium of the bronchi develops a carcinoma of alveolar structure with polymorphous and polyedric cells that are, in the great majority of cases flat, but sometimes varying numbers of cylindrical cells are mingled with them. Such forms of carcinoma are exemplified by Plates 8 and 9. It was contended by some^ that the carcinoma just described might develop from the bronchial mucous membrane, but might also take its origin from the flat epithelium of the pulmonary alveoles. This contention caused considerable 1 Virch. Arch., Vol. 53, 1871, p. 470. 2 Chiari, Table I, No. 51; Ebstein, Table I, No. 75; Stilling, Table I, No. 310, and others. 3 Ehrich, Table I, No. 77, and others. PATHOLOGY 53 discord among the few pathologists who studied the subject. A number of these without hesitation considered every pul- monary carcinoma, where they found fiat polyedral epithe- lium, as necessarily derived from the alveolar cells. A little closer study showed the untenable character of these theories. It is unnecessary to enter into all the details of the discussion. Some considered the flat epithelium in pulmonary carcinoma extremely rare, others considered it very frequent. Frohhch,^ for instance, found it twelve times among sixteen cases. According to the statistics of Watsuji,2 32.2% of all pulmonary carcinomata are of the pavement cell variety. There is, however, no evidence that these carcinomata develop from the pulmonary alveoles. On the contrary there is considerable evidence against the supposition. It is now held that carcinoma starting from the pulmonary alveoles is extremely rare, and some go so far as to deny its existence altogether. Marchand and his pupils ^ succeeded in demonstrating beyond doubt a tumor starting from the alveolar respiratory epitheUum. The tumor in question would hardly be recognized as tumor by the naked eye, but rather suggested the opaque and some- what translucent tissues as they occur in chronic broncho- pneumonia, and the structure as shown by the microscope was a great siuprise. It was found that the tumor was made up of cylindrical cells with more or less of a papillary arrangement. As the respiratory epithelium in the embryo is of the cylindrical type, the occiu-rence of cylindrical cells in these growths is not surprising. The tumor is probably congenital. Plate 14 shows a section of this sort of tumor, in which remnants of alveolar structure, with somewhat irregular but nevertheless recognizable high cylindrical cells, can still be traced. There are perfectly clear patches showing papillary arrangement. Neglecting in this place all further detail, it may be briefly stated that it is at present the common consensus of opinion, and probably justly so, that the great majority of 1 Table I, No. 88. * Zeitschr. f. Krebsforsch., Vol. I, p. 445. * Ejretschmer, loc. cit. 54 PRIMARY MALIGNANT GROWTHS OF THE LUNG primary carcinomata of the lungs develop from the bronchi, and that a cancer of the lung is, taken strictly, a bronchial carcinoma; that, on the other hand, a carcinoma starting from lung tissue itself occurs, but is extremely rare, and is built up, not of flat, but of cylindrical epithelium. CHAPTER VI PATHOLOGY (Continued) \ NY attempt to work out the histogenesis of lung tumors "^~*- leads at once to troublesome questions concerning epithelium, metaplasia, and other fundamental problems about which there exist great differences of opinion in the pathological world. It may be said at once that it is gen- erally impossible to determine the histogenesis of a fully developed lung tumor and it rarely or never happens that we meet with a tumor so small that its very beginnings can be clearly seen. Even the close study of the growing edges of the tumor will give no satisfaction, and any certainty with regard to the histogenetic origin of the majority of lung tumors must, for the present at least, be given up as hope- less. Turning to epithelium, it is at this moment practically impossible to say what "epitheUum" really means and what its relations are to other kinds of cells, especially to endo- thehum. The literature on the subject of endothelium and its relation to tumors, as well as to acute and chronic inflam- mations in adult tissue and its embryonal history, is really enormous, and no attempt at even a sketch can be made here. The work of Borst^ in his large treatise on tumors, and his several other separate publications, ^ and the critical compilations of Monckeberg,' go deeply into the question of endothelioma, while Volkmann,^ and before him Kolaczek,^ have done fundamental work in the study of these tumors. Leaving this mass of literature to those specially interested, it is important to arrive, at the very beginning, at some un- ^ Lehre von den Geschwiilsten, Wiesbaden, 1902. 2 Das Verhalten der Endothelien, Wurzburg, 1897, and others. ' Lubarsch, Ergebnisse, 10 Jahrg., Wiesbaden, 1906. * Deut. Z'tschrift f. Chir., Vol. XLI, 1895. 6 Deut. Z'tschrift f. Chir., Vols. IX and XIII, 1878 and 1880. 55 56 PRIMARY MALIGNANT GROWTHS OF THE LUNG derstanding of the nature of epithelial cells. It is generally accepted that epithelium assumes various forms differing in morphological structure and in physiological function. The forms recognized by all are: (1) cylindrical epithelium, which is differentiated into several species : (a) endowed with cilia upon which certain physiological motor functions depend, and (6) without cilia, dispersed in a single layer or in several strata, serving as an inner coating to numerous hollow organs, and lastly, (c) glandular cylindrical epithelium, to which are allotted duties of secretion and excretion; (2) fiat, squamous, or pavement epithelium, arranged either in single layers or; in numerous strata and modified in its morpho- logical structure according to the physiological function which it is called upon to perform. The lining of numerous internal organs consists of this type of epithelium. The epidermis which protects the surface of the entire common integument is in the main built up of such cells, specially differentiated as to their structure and chemical constitu- tion (kerato-hyalin, intra-cellular structure, and protoplas- matic bridges). No further detailed description of epithelial cells is necessary. Until very recently it was accepted as a fact that the three germinal layers were the dominant factors in the histogenesis of all the tissues and organs in intra- as well as extra-uterine life. All the epithelium that was needed for the viscera of the chest and abdomen was supposed to be furnished by the entoderm. The epithelium of the common integument and of several other organs closely connected with the outer surface is referred to the ectoderm. There is besides this a certain class of flat cells bearing nearly all the hallmarks of genuine flat epithelial cells, which are universally found in the body as a lining of the great lymphatic cavities (pleura, peritoneum, etc.). The inner coat of the arteries and veins and the perivas- cular lymph spaces, as well as all lymph spaces throughout the body, are lined with this peculiar epithelium. Its origin is said to be from the mesoderm, the mesoderm being the third germinal layer, from which the fibrous and connective tissue, the bones, cartilages, elastic fibres, etc., — aptly PATHOLOGY (Continued) 57 called by the Germans ''Stiitzgewebe," — are said to origi- nate. These cells just mentioned as coming from the meso- derm could not be classified as genuine epithelium and were therefore called by His endothelium. They showed, on the one hand, close connection with the connective tissue cells, with which, indeed, they have much in common, espe- cially the property of forming fibro-plastic cells. There are many tumors that are supposed to be developed from the endothelium and are therefore named endothelioma. These are usually non-malignant, but there are also malig- nant forms of endothelioma. Borst and his followers have also not infrequently found endothelioma as a primary malignant neoplasm in the lung. The writer himself^ was at one time convinced of the occurrence of primary malig- nant endothelioma in the lungs, but has since been forced to change his opinion. At the present writing opinions as to the embryonal development of the so-called endothelium are extremely perplexing. The doctrine that the endothelium, as well as the connective, osseous, and other specific elements, are derived from the mesoderm, is becoming more and more discredited. Hertwig^ derives the mesoderm from the primary entoderm, and according to him, at a very early stage independent mesenchym germinal cells emigrate and proliferate in the spaces between the ento- and ecto- derm, and thus form the basis for the development of the connective tissue substances and blood. Schultze,^ on the other hand, derives the mesoderm from the ectoderm, and according to him nearly all the cells of the mesoderm possess considerable mobiUty of their own, so that they wander through all the organs developed from either of the germinal layers. It will be seen by these two quotations how unsatis- factory as yet the embryonal history of endothelium is. It will also be seen that embryology is tending more and more ^ I. Adler, Remarks on Primaxy Endothelioma of the Lung, Pleura, etc., Journal of Medical Research, VI, 1901. * O. Hertwig, Lehrbuch d. Entwicklungsgeschichte, 1896. * O. Schultze, Grundriss der Entwicklungsgeschichte, Leipzig, 1896. 58 PRIMARY MALIGNANT GROWTHS OF THE LUNG toward giving up the mesoderm as a primary germinal layer and is depending more and more upon the ento- and ecto- derm, with only secondary and varying assistance from a secondary mesoderm. It is impossible to go further into details. Let it suffice to say that at present there is little doubt, though the various workers on this subject have not arrived at a uniform opinion as to what cells should be classed as endothelium and what as epithelium, that there is a form of cell which may rightly be called endothelium, which occu- pies a unique position in so far that it lines the banks of seas and streams of fluid, where it is not only acting as a mere mechanical agent, but has certain other physiological properties which will be touched upon presently. Suppose the endothelium to be derived from the meso- derm and to be an integral part of the connective tissue system, it follows, and rather absurdly, that a tumor pos- sessing alveolar structure and cells, not to be distinguished from the true epithelial (carcinomatous) cells, — a neoplasm, in short, that acts altogether like a carcinoma, — must be classed among the malignant connective tissue tumors; in other words, must be called a sarcoma. Thus Remak, Thiersch, Billroth, and Waldeyer classed as sarcoma all tumors that develop in localities where normally no epithe- lium is found. This may in part be responsible for such designations as adeno-sarcoma, alveolar carcinoma, lympho- sarcoma, etc. Koster^ does not employ the term ''endo- thelioma," but assumes that all carcinomata take origin from the lymph vessels. Of late the opinion is gaining ground that the intimate structure of the tumor is not dependent upon certain phases of embryological develop- ment nor upon the morphological relations of the three germinal layers. It is held that whatever tumor possesses carcinomatous structure and behaves clinically as a carci- noma is a carcinoma, no matter whether its component epithelial constituents be derived from the mesoderm, the entoderm, or the ectoderm. In other words, it is said that, .while the germinal layers are of utmost importance 1 Die Entwicklung der Carcinome und Sarcome, Wiirzburg, 1869. PATHOLOGY (Continued) 59 as regards differentiation, topography, and ultimate devel- opment and function of the tissues, their influence to a great extent ceases when the organism is complete and the foetus is fully developed. Extra-uterine pathology should not be tyrannized over by embryology.^ Klaatsch^ also points out that the concept of a mesoderm is gradually disappearing and that the ectoderm is of paramount importance. He shows, moreover, the necessity of being guided in one's judgment more by the physiological requirements and functions than by the merely morpho- logical and embryological point of view. He demonstrates convincingly that the morphological character of cells may be changed to a considerable extent, consequent upon changes in the surrounding tissues, especially when gaps in the con- tinuity of the tissues are formed. He is totally opposed to a classification of tumors in their relations to the three germinal layers. It is to be noted that both functionally and physiologically the endothelium appears closely related to typical epithelium. It is not necessary to go into all the finer distinctions between endothelium and epithelium. It is best, in the opinion of the writer, to agree with Borst that there are tumors undoubtedly taking origin from endothelium, and as the endothelium occupies a peculiar position, on the one hand appropriating to itself some of the functions of epithelium,^ on the other hand being intimately associated with connective tissue, even forming fibro-plastic cells, it is best to call these tumors by the special name of endothe- Uomata. That there are malignant endotheliomata, we cannot doubt, such perhaps as the much discussed primary cancer of the pleura, concerning which there is still no unity of opinion and a lack of clear and sharp definition. This is ^ Marchand, Uber die Beziehungen der path. Anatomie zur Entwicklungs- geschichte, besonders der Keimblattlehre, Verhand. Deut. Path. Ges., II, 1900, pp. 38 ff. 2 t)ber den jetzigen Stand der Keimblattfrage mit Rucksicht auf die Patho- logie, Miinch. Med. Woch., 1899, N. 6, p. 169. ^ Haidenhain, Verhand. des X. internat. Congresses, Berl. 1891, Vol. II; also Archiv. f. Physiol, v. Pfltiger, Vol. 49, 1891, and Vol. 56, 1894; also Orlow, Recklinghausen, Adler and Meltzer, Meltzer, and others. 60 PRIMARY MALIGNANT GROWTHS OF THE LUNG shown by the various names, as for instance ''lymphangitis carcinomatodes " ^ or "lymphangitis prolif erans. " ^ As to the lung, however, the writer has not as yet been so fortunate as to be able to diagnosticate an endothehoma of the lung, though Borst and his pupils and others^ have published a number of cases. If one beheves, as does the writer, that these malignant tumors, carcinoma and others, grow not peripherically, but centrally, out of themselves, as it were,'* then the mere fact of the lymph spaces and lymph vessels at the periphery of the growth being filled with endotheUal cells 1 Schottelius, Table I, No. 289. 2 A. Frankel, tlber primaren Endothelkrebs der Pleura, Berl. Klin. Woch., 1892, 21 and 22. In this connection it might be well to mention the case of Bostrom (Das Endothelcarcinom, Diss. Erlangen, 1876). It concerns a female twenty-eight years of age who had complained of no lung symptoms whatever, but who suffered mainly from the stomach, and the diagnosis of ulcer of the stomach was made. She died suddenly from profuse gastric hgemorrhage. At autopsy the ulcer of the stomach was found and carefully examined, by as high an authority as Zenker, and no trace of anything that could be taken for car- cinoma was detected. Nevertheless, besides about half a litre of bloody sermn in both pleural cavities without any adhesions of the lungs, there was extensive carcinomatous lymphangitis on the pleura of both sides and carcinomatous infiltration of the bronchial, tracheal, and retroperitoneal glands. Cases of carcinoma of the stomach with extensive carcinomatous lymphangitis cover- ing the lungs have been frequently reported (Hilliarie, I'Union m4d., 1874, Nos. 53, 54, and 55; Frantzel, Charite-Annalen, 1878, III, 306; Debove, Gas. Hebd., 1879, N. 43, p. 688). But in these cases there was usually a con- spicuous primary carcinomatous nodule to be found in the stomach. In this case of Bostrom's we have a practically certain assurance that there was no carcinoma in the stomach. By means of very careful examination, the bronchial mucous glands, the bronchial and alveolar surface epitheUum could be positively excluded, and the author, after most painstaking study, by means of serial sections of both pleura, comes to the conclusion that the pleural affec- tion has nothing whatever to do with the gastric ulcer, but is an independent carcinoma of the endotheliima of the pleural lymph vessels. 3 Wack, Ein seltener Fall von primarem Endotheliom der Lunge, Diss. Wurzburg, 1898; Klemm, "Cber ein primares Endotheliom der Lunge, Diss. Miinchen, 1905; Bostrom, Endothelcarcinom der Lunge, Diss. Erlangen, 1876; Cahen, Diss. Wurzburg, 1896; Neelsen, Deut. Arch. Klin. Med., Vol. 31, p. 375. * Borrman (Die Entstehung und das Wachstum des Hautcarcinoms, Z. f. Krebsforsch., II, 1904) is an enthusiastic adherent of imi-central or possibly multi-central growth of carcinoma. He calls attention justly to the fact that nobody has ever yet seen the conversion of a normal epithelial cell into a can- cerous epithelial cell, and as his material consisted of carcinoma of the skin in its very earliest stages of development, his findings possess considerable weight. PATHOLOGY (Continued) 61 means nothing as to histogenesis, while on the other hand it will never be possible to study a tumor at a stage early enough to show a possible development of the endothelium into maUgnant cells. Thus the diagnosis of primary endo- thelioma of the lungs is at present not possible, and it is preferable to call these tumors, not endothelioma, or sar- coma, on purely theoretical grounds, but carcinoma, if they are built and act like one, and sarcoma imder similar conditions. There are many microscopic pictures which are adduced as characteristic of endothelioma, especially those show- ing ramifications simulating a network of deep interlacing meshes, strongly suggesting a system of lymphatics, more or less completely filled with fiat, endothelial-like cells. Plate 15, taken from the same tumor as Plate 9, shows this rami- fication. Neither Plate 9 nor Plate 15 can possibly be taken for an endothelioma, as other parts of the same tumor show typical carcinoma. In the same way Plate 16 shows very prettily the injection of the lymph vessels and lymph spaces with carcinomatous material, but it is from the same tumor from which Plate 7 is taken, in which was shown the mechanical injection of cells from a large typical carci- nomatous alveolus into a lymph vessel, and it is not possi- ble to prove, with any kind of magnification, that lymph endothelium was converted into carcinomatous cells. CHAPTER VII PATHOLOGY (Continued) THE aphorism of Bard/ "Omnis cellula e cellula ejusdem generis," has been mentioned. If each kind of epithe- lium be considered a specific genus, then, according to him, cyhndrical epitheHum should produce only cylindrical epi- thelium; cuboid, or fiat, or horny, should always and under all conditions produce a similar kind of epithelium. It soon became evident, however, that histology did not completely bear out the theory of the strict and hmited production of cells of a certain character and structure from cells of identically the same character and structure. A long, and at this writing still unsettled, discussion has taken place concerning these questions, which are summarized under the title of '^ Metaplasia." It is necessary to touch briefly on some of the problems of metaplasia in order to obtain a proper notion of certain changes in structure and char- acter of the cells that occur here and there, perhaps not infrequently, in lung tumors. Virchow, as is well known, assigned a very great role to metaplasia in pathology, which meant for him something entirely different from what is understood to-day by the term. He attributed, especially to the connective tissue cells, all sorts of possible metaplastic changes, deriving osseous tissue therefrom as well as the epithelial cells of carcinoma. It is useless to enumerate the multitude of pathologists who have devoted time and no slight labor to this question of metaplasia. Opinions differ as to whether such a process actually exists, and, if it does exist, what the meaning of the process is. Ribbert defines metaplasia as a sort of regression, the cells losing their speci- ficity and attaining a simpler structure, or in other words 1 Loc. cit. 62 PATHOLOGY (Continued) 63 returning to some lower state of differentiation through which, in the regular course of development, they had already passed, and this without regaining new properties. Hansemann speaks of histological accommodation and of anaplasia as being a lower grade of differentiation along embryological lines, to which the metaplastic cells return. It is a mooted point whether this metaplasia of the cells proceeds under the laws of strict embryonal development and is ruled by the theory of the three germinal layers. If this hypothesis were true, then the metaplastic alterations to which, say, an entodermal epithelial cell is subjected would result only in such types of cell as normally originated from the entoderm. On the other hand, it is maintained that metaplasia is entirely independent of embryonal influences and that the alterations in the character of the cell are produced by mechanical and physical conditions and in a great measure by causes as yet unknown. Finally, there is a theory entertained by many that the so-called metaplasia of cells and tissues, especially when occurring in tumors, is the outcome of congenitally displaced germinal remnants.^ It is not necessary to go into further details on this point. For further reference to these questions in regard to tumors see Lubarsch.2 Most important, and throwing light also on the metaplasia in tumors, is the work of Schridde.^ Speak- ing only for lung tumors, and indifferent to what may take place in other tumors or organs with reference to metaplasia, it is to be noted that only such cells can justly be considered as metaplastic cells that reproduce not only the superficial character of the cells, such as localization, general appear- ance, etc., but the cell must exhibit the intimate and charac- teristic structure of the type of cells which is supposed to be represented. Thus, an ordinary flat epithelium can by no 1 Ernst, Table I, No. 82. * Lubarsch, Die Metaplasiefrage und ihre Bedeutung fur die Geschwulst- lehre, Arbeiten aus der path. Anatom. Abteilung des Kgl. Hyg. Institut in Posen, 1901, N. 305 ff. ' Schridde, Die Entwicklungsgeschichte des menschlichen Speiserohren- epithels und ihre Bedeutung fur die Metaplasielehre, 1907; Die Ortsfremden Epithelgewebe des Menschen, Jena, 1909. 64 PRIMARY MALIGNANT GROWTHS OF THE LUNG means be considered as an epidermal cell unless it shows the pecuhar structm-e, the fibres, and protoplasmatic bridges of the latter. A high cuboid or a laterally compressed flat cell is not converted into a cylindrical cell unless it shows at least some of the typical characteristics of the latter, — the nucleus at the base, the colloid, mucoid, or other secretion, etc. It is reasonable to assume, and seems to be the result of common experience, that the nearer the epithelia are related to each other, the more readily they will interchange in form and structure.^ The transforma- tions of one sort of epithelium into another, usually of cylindrical or cuboid epithehum into squamous epithelium, as has been frequently found in many kinds of inflamma- tory processes, in granulations, in pneumonias, ^ in the gall bladder,^ in the urinary bladder, in the uterus, in the pan- creas,^ and other organs, are well known. They are usually the results of acute or chronic inflammations. It would indeed be strange if similar metaplasia of the epithelium were not also found in the bronchi and in the lungs. Under purely physiological conditions and under perfectly normal development, certain epithelial changes in the bronchi are regularly found. The largest and larger bronchial tubes are lined with ciUated cylindrical epithehum. In the smaller orders of the bronchial tubes these cylindrical cells lose their ciha. In still smaller orders the cells become cuboid, and finally, and without break in the continuity, the very small- est bronchioles and the pulmonary alveoles are lined with flat epitheUal cells. Metaplastic changes in the epithelium under pathological conditions are shown by the work of Kitamura,^ who finds in almost every grade of catarrhal 1 Let it be understood that even in the question of metaplasia, the speci- ficity of cells as postulated by Bard is still maintained to a certain extent. Metaplasia can take place only among cells embryologically closely related. 2 Conf. the work of Friedlander, tjber Epithelwucherimg und Krebs, Strass- burg, 1877, 57 S. mit 2 Tafeln. » Dietz, Virch., Arch., Vol. 164, p. 381. * Lewisohn, Zwei Seltene Carcinomfalle zugleich ein Beitrag zur Meta- plasiefrage, Z'tschrift f. Krebsforsch., Ill, 1905, p. 528. ^ Kitamura, Uber secundare Veranderungen der Bronchien und einige Bemerkungen uber die Frage der Metaplasie., Virch. Arch. 190, 1907, p. 160. PATHOLOGY (Continued) 65 inflammations of the severer types, and especially in tuber- culosis, the transformation of single layers of cyhndrical ciliated cells into cuboid or polygonal cells. He does not consider this a true metaplasia, but simply a change in form, a "histological accommodation" in the sense of Hansemann.^ On the other hand he finds genuine stratified epidermal epi- thelium with typical keratohyalin in the uppermost strata. This occurs in the large bronchi that are in open communica- tion with tubercular cavities. Later, islets of this epidermal epithelium are found. There are many other metaplasias throughout the bronchial system, such as chalky degenera- tions and the formation of bone in the bronchial wall, etc. These metaplasias seem to occur very frequently as phe- nomena secondary to tuberculosis. In this connection, too, there is the work of McKenzie.^ His conclusion, after very careful study of four cases in very young children, — the oldest only two years old, — is that real genuine metaplasia exists. Not only chronic inflammatory processes, as Sim- monds beheves, but also acute inflammations in the lungs may lead to metaplasia. The existence of such islets of pavement epithelium in the lungs after acute inflammation may have some connection with the development of pavement celled cancer in the lungs. The assumption of dislocated germinal cells is not needed to explain the development of pavement epithelium cancer in the lungs. Eichholz,^ in his very excellent experimental researches concerning the conversion of the epidermis into mucous mem- brane, and conversely, is inclined to think that metaplasia is not to be excluded with certainty, but on the whole it does not seem likely to him. In most of the cases where true epidermis was formed it could be demonstrated that it was due to a proliferation of the epidermis from without. 1 Loc. cit. 2 Ivy McKenzie, Epithelmetaplasie bei Bronchopneumonie, Virch. Arch. 190, p. 351. (Note, by the author. — We know of many cases of conversion of cyhndrical into pavement epithehum; we know of none as yet of pavement into cyhndrical epithehum.) ' Eichholz, Experimentelle Untersuchungen iiber Epithelmetaplasie, Lan- genbecks Arch. f. klin. Chir., Vol. 65, p. 959. 6 66 PRIMARY MALIGNANT GROWTHS OF THE LUNG Cylindrical epithelium, according to him, is able to produce epidermis. If, however, epidermis occurs in tissue of cylin- drical epithelium, it is to be explained either through the proUferation of the epidermal epithelium from without or by the assumption of a dislocated embryonal germ. It is, therefore, not difficult to explain the occurrence of true cancroid, to use the old name, — that is to say, of nodules consisting of typical epidermal cells with the charac- teristic structure and the formation of cancer pearls. It appears natural, too, according to the views of Kitamura, that these cases generally occur in connection with tubercu- losis, as in the cases of Friedlander,^ Perrone,^ Gougerot,' and a number of others. The tumor either came from with- out and penetrated through the wall, and thus projected into the tubercular cavity,* or developed directly from the wall of the cavity. In the case of Ernst ^ the cancroid took its origin from the wall of the main bronchus of the right upper lobe. As from this location no epidermal tissue could normally be expected, Ernst attributed his tumor to develop- ment from a germinal remnant. In view of this widespread instability in the types and forms of the epithelial cells and the apparent lawlessness with which these transformations from cylindrical to cuboid and from flat to cylindrical, from ciliated to non-ciliated, recur, one is tempted to share with John Marshall ® the belief in a complete anarchy as the essence of cancerous proliferation. This anarchy Mar- shall is inclined to attribute to the lack of nerve influence, no nerves having as yet been demonstrated in any malignant tumor, with the exception of a very few perivascular nerve fibrils. According to this view there would be no meaning in metaplasia and no reversion to embryonal types or conditions. The process would simply be anarchy, which might be subdivided into anarchimorphic, anarchibolic, 1 Friedlander, Table I, No. 87. 2 Perrone, Table I, No. 257. 3 Gougerot, Table I, No. 98. * Perrone. " Ernst, Table I, No.82. * Marshall, The Morton Lecture on Cancer and Cancerous Disease, Lancet, II, 1889, pp. 1045 ff. PATHOLOGY (Continued) 67 anarchisynthetic forms. Beneke^ does not agree with this view. According to him the nervous system can only regulate the forces contained in the cell, and he suggests a disturbed equilibrium in the relations and proportions of the cell function as a causal factor. In the writer's opinion all these facts and theories lead necessarily to the conviction that epithelium is a highly plastic material, designed to accommodate itself in manifold ways to the demands which local, physiological, and pathological conditions require. The changes thus produced, however, can only take place among the specific epithelial cells, whether derived from entoderm, ectoderm, or mesoderm. The divisions into squamous, epidermal, cylindrical, ciliated, and epithelial depend upon more or less functional and often unstable qualities and are employed more for the sake of con- venience than as a description of the character of the cells. The numerous studies with reference to the ques- tion of metaplasia 2 do not appear to give much enlighten- ment as to tumors, but seem to corroborate the opinion here upheld. The theory of persisting and abnormally dispersed germinal centres and remnants, while it cannot be dis- proven, is not necessary for the explanation of the so-called metaplastic transformations.^ 1 Beneke, Neuere Arbeiten zur Lehre vom Carcinom, Schmidts Jahrbiicher, 1892, pp. 73 £f. 2 Kawamura, Beitrage zur Frage der Epithelmetaplasie, Virch. Arch., Vol. 203, No. 3, 1911. ' Fixtterer, Uber Epithelmetaplasie, Lubarsch-Ostertag, Ergebnisse, IX, 2, p. 706. Simmonds, Munch. Med. Woch., 1898, p. 189. Watsuji, Zeitschr. f. Krebsforschung, Vol. 1, No. 5, 1904. CHAPTER VIII CLINICAL UNTIL very recently it was the conunon consensus of medical opinion that the diagnosis of primary carci- noma or sarcoma of the lung, if it could be made at all, was one of a more or less high degree of probability, but never of certainty and precision. Within the last few years, how- ever, decided advances have been made in our diagnostic methods, rendering it possible to diagnosticate a timaor of the lung with nearly as much certainty as the present status of our diagnostics permits a cancer diagnosis for any other internal organ of the body. Stokes's remark, speaking of the diagnosis of primary cancer of the lung, that "though none of the physical signs of this disease are, separately considered, peculiar to it, yet the combinations and modes of succession are not seen in any other affection of the lung,"^ has been true for nearly a hundred years and has been a source of stimulation and hope to many. The clinician's ambition to-day is not, at the conclusion of long and anxious obser- vation, to make a diagnosis of lung tumor that is merely probable. His object should be to diagnosticate the tumor at the earliest possible stage of its development, and with such accuracy as is needed for the basis of surgical treat- ment. This, however, is by no means an easy task. Note. — It will be necessary to refer frequently to the writings of Stokes (Table III, No. 78), Hughes (Table I, No. 121), Graves (Table III. No. 30), Frankel (Table I, No. 85), Passler (Table I, No. 241), Leopold (Table I, No. 174), and Lenhartz (Table II, No. 46), and to that most recent and excellent pubHcation of Wolff (Die Lehre von der Krebskrankheit, Vol. II, Jena, 1911). In making this general statement of indebtedness, the writer hopes to be ex- cused from special references to these authors where such reference is deemed unnecessary. 1 Diseases of the Chest, New Sydenham Society, London, 1882, pp. 420 and 421. 68 CLINICAL 69 In many cases the diagnosis is impossible because there are no symptoms pointing to the lungs and the tumor is an unexpected discovery on the autopsy table. To illustrate this, some cases may be singled out, — that reported by Colomiatti'^ and that of Bernouilli.^ The latter was a case of a female fifty-one years of age, without chnical history except that she died of peritonitis after operation for um- bilical hernia. Autopsy was held the day after. A small round celled sarcoma of the size of a walnut was lodged in the right upper lobe and evidently had not caused any symptoms. There were no metastases, not even of a single gland. In some cases there are symptoms, but none pointing toward disease of the lungs, and therefore the observer is misled. The patient of Beveridge,^ it is true, had a shght cough and some pressure over the chest, but not sufficient to interfere with his work. He worked until death, which came suddenly from haemorrhage of the lungs. Kliiber ^ reports an apparently healthy woman, dying suddenly from a bum, without any lung symptoms. In the case reported by Walshe,^ there was no cough, nothing pointing to the lungs, but the symptoms were exclusively psychic. Davy's patient^ was healthy until he acquired jaundice and pain in abdomen; physical examination of lungs was negative, no symptoms pointing to lungs, no cough, no pain. Degen^ reports a patient healthy and strong; sudden death from haemorrhage of lungs; no other cUnical symptoms. The much cited case of McAldowie ^ is that of a child five and a half months old, — no dyspnoea, no cough, percussion clear over both lungs. It is obvious that tumors such as the malignant neoplasms of the lungs, varying so widely in type and localization, entering into so many unstable relations with other organs of the chest and, through metastases, with almost every 1 Table II, No. 14. 2 tlber primare Lungensarkomatose, Diss. Miinchen, 1907. » Table I, No. 38. « Table I, No. 56. * Table I, No. 145. ^ Table I, No. 59. <• Table I, No. 329. s Table III, No. 53. 70 PRIMARY MALIGNANT GROWTHS OF THE LUNG organ in the body, cannot be expected to present a perma- nent and characteristic set of symptoms. One is reminded of Graves/ who, reporting a case of maUgnant disease of the lungs, probably sarcoma, gives a minute analysis of the cUnical symptoms and shows how both he and Stokes were misled. He candidly confesses that he should have made the proper diagnosis during hfe, but adds, in his characteristic manner, "I became quite tired of the difficulty of attempt- ing to explain the phenomena observed and gave up all further attempts at diagnosis." It may be said in a general way that the possibility of a clean-cut diagnosis depends largely upon the anatomical localization of the tumor and upon the degree of development which the disease has reached when the patient is presented. It is not probable that the actual beginning of the blastomic development will ever be perceived, since it is necessary that the tumor attain a certain size before it can be recognized. Again, in the last stages, the clinical picture may be so complicated, nearly every organ of the body participating in the morbid process and causing symptoms which almost completely mask the pulmonary lesions, that the difficulties are greatly augmented and a diagnosis rendered practically impossible. There are, however, certain symptoms which are common to all malignant neoplasms and some which are more or less peculiar to malignant neoplasms of the lungs, to which brief attention must be given. I. Pain. This is frequently not a real, acute pain, but rather a sense of discomfort and pressure in the chest. According to Schmidt ^ the pulmonary parenchyma is prob- ably insensible to pain, therefore the acute or chronic genuine stabbing pain is brought about when the pleura participates in the inflammatory processes which are apt to accompany the progress of the disease. Taking into account the well-known relations between the two folds of the pleura and the nerves, — the brachial plexus, intercostal nerves, phrenic nerve, — and the diaphragm, it is clear that 1 Table III, No. 30. * Die Schmerzphenomene bei inneren Krankheiten, etc., Wien, 1906. CLINICAL 71 the pain produced in one place may be referred to localities quite distant from the point of origin. The pain in the shoulder and around the clavicle, the neuralgias of the arm, the intercostal pains along the chest and in the abdomen and diaphragm, which so often occur both in carcinoma and in sarcoma, are thus easily explained, and it is understood that where there is no pain the pleura has evidently not been involved. Schmidt also points out that a large area of dulness, without spontaneous or pressure pain, excludes any inflammatory process of either fold of the pleura and suggests the possibility of a neoplasm. Figures represent- ing an approximate estimate of the occurrence of pain in malignant lung tumors can be obtained from Tables I and II. In Table I pain is not mentioned in 206 cases out of 374. This, of course, does not mean that pain was not present, but merely that any reference to pain was omitted. The probability therefore is that the cases in which pain was a fea- ture are much more numerous than would appear from the Table. In eighteen cases it is distinctly stated that there was no pain during the entire course of the disease, while pain is mentioned as present in one hundred and fifty cases. In Table II, dealing with sarcoma, pain is given as a symptom at some time during the disease in fifty-two cases, in two cases only is it distinctly stated that there was no pain whatever, in six cases there is no clinical history, and pain is not mentioned in the history of thirty-four cases. The possible irradiations along various nerve tracts are illustrated by the case of Demange,^ in which the pain was constantly referred to the healthy side. In two cases the pain was mostly abdominal, while in the case of Harris ^ the pain was referred to both sides of the chest. If one could draw deductions from these figures, it would seem that sarcoma causes more pain than carcinoma. This result, however, is probably illusory and caused by the imperfect statistics. 11. Cough. This complication is one that would natu- rally be expected in any malady of the lungs, and therefore 1 Table II, No. 17. ^ Table II, No. 33. 72 PRIMARY MALIGNANT GROWTHS OF THE LUNG in tumors of the lung. Indeed, cough is probably the most common of all symptoms appertaining to lung tumors, and there are but few cases in which it is not a factor. A rather insignificant, but fairly constant, irritating cough, mostly without expectoration, may be the earliest symptom of tumor. Where this cough exists and nothing abnormal is found in the chest, the upper air-passages, oesophagus, etc., the possibility of the presence of a lung tumor should, in the writer's opinion, suggest itself. A case observed by the writer, which does not appear among the material collected, may serve to illustrate this rather important point. It con- cerned a lady of some sixty-odd years, fairly healthy, and so far as known, without any hereditary strain of malignancy. She began to cough this same short, hacking cough, without pain, without expectoration. Both lungs on close examina- tion gave no indication of anything abnormal and nothing abnormal could be detected anywhere, except a trifling pharyngitis. Very gradually some loss of flesh and strength became apparent, and after several months a very small area of dulness at the right hilus, together with some fairly loud cornage, could be made out. The dulness gradually extended. For some time previous a tumor had been sus- pected, principally from the cornage, and the diagnosis was corroborated when the dulness and cornage were also found at the apex. There was never much expectoration, and no blood. The emaciation and weakness increased, the area of dulness on the right lung extended over the entire lower and middle lobes, with diminished voice and breathing, secondary plainly palpable nodules appeared, especially in the hver, accompanied by jaundice, and death from exhaus- tion took place in about a year from the beginning of the cough. No autopsy could be obtained, but there is httle room for doubt that this was a genuine case of carcinoma of the lung. Besides this slight hacking cough, accompanied by little or no distress, all varieties of cough, up to the most violent, explosive, and harassing forms, are reported. The cough may, as just mentioned, be an early symptom of the disease; CLINICAL 73 on the other hand there may be no cough until shortly before the fatal end. As bronchitis is one of the ordinary features of the case, the fairly loose cough, accompanied by large and small mucoid rales, is present in the majority of cases. If bronchiectatic cavities, or cavities of other origin, are present, there will probably be attacks of coughing of an explosive character, discharging large quantities of muco- purulent or purely purulent expectoration, often mixed with blood. When the cavities are sufficiently refilled or com- munication with the bronchus is again restored, these spells are apt to recur. The distressing, rasping, but usually dry cough that is caused by compression or irritation of the larger bronchi and the trachea is often noted. At times this cough is accompanied by considerable stridor. Schwalbe ^ claims that carcinoma produces very little stridor, if any at all, but that it occurs in its greatest intensity and most frequently in sarcoma, and his explanation of this is that sarcoma gives rise to earlier and more extensive involvement of the mediastinal organs than carcinoma, thereby exerting more pressure on the trachea and nerves. This does not, perhaps, quite correspond with the actual facts, and it can be seen from the material collected here that carcinoma also can, and frequently does, involve all the mediastinal organs. There is, furthermore, the hoarseness, also the well-known laryngeal cough, both of which usually occur in late stages of the disease, when either one or both superior larjmgeal recurrent nerves have become involved and paralyzed. In Table I cough in its various forms is mentioned in 174 cases, while in 191 cases it is not mentioned. In nine cases it is distinctly stated that there was no cough. In Table II cough is mentioned as a symptom forty-six times; five cases had no cough, and thirty-nine passed without any mention of it. III. Sputum. Much more important than the cough, — in fact, one of the principal signs to be depended upon for the diagnosis of malignant lung tumors, — is the character of the sputum. This, however, can only be satisfactory as the result of close study. It is necessary to bear in mind that 1 Deut. Med. Woch., 1891, No. 45. 74 PRIMARY MALIGNANT GROWTHS OF THE LUNG a single examination of the sputum will rarely give reliable results. The ordinary routine examination of the expecto- ration, such as is the common practice, which consists in a search for tubercle bacilh or elastic fibres, and at best a few cells, is entirely insufficient when so delicate a diagnosis as that of primary lung tumor is the object. It is necessary to examine the sputa systematically and thoroughly, both morphologically and bacteriologically, and under certain conditions even chemically, as frequently as possible, until the diagnosis is assured. In Table I there are 143 instances out of 374 in which no mention is made of the sputum. It is, therefore, not ascertainable whether in these cases there was any expectoration or what its character may have been if present. In thirty-six cases it is clearly stated that there was no expectoration. Stokes^ was the first to speak of a pecuharly homogeneous and tenacious sputum, the color of which he compared to black currant jelly and which is spoken of by others as resembUng raspberry jelly or prune juice. The latter designation is particularly used in American textbooks. Stokes considered this sputum as pathognomonic of lung tumor, especially of carcinoma, and many textbooks still spread this behef. It has been shown, however, that this peculiar sputum is per se not pathognomonic for malignant tumors of the lung. It occurs in other diseases, and even in primary carcinoma of the lungs it is not constant and is recorded in but few cases. Looking over Table I, it is foimd that the currant, rasp- berry, and prune juice sputa have been placed on record in only six out of the 374 cases. This may not absolutely coincide with the actual facts, but it is reasonable to suppose that where there is a clinical history given, so characteristic a symptom would be mentioned. In Table II only two cases are recorded out of a total of ninety. But though this kind of sputum cannot be considered pathognomonic, it should, in the writer's opinion, if associated with other symptoms that all point toward tumor of the lung, be considered corroborative of the diagnosis. The processes ultimately ^ Loc. cit. CLINICAL 75 at work in the production of this peculiar type of sputum are entirely unknown up to date. It seems certain that the peculiar color is not merely due to the presence of blood; there must be other conditions involved. Perhaps it is not unreasonable to suspect that some specific kind of haemolysis, caused, it may be, by some toxic product of the tumor, formed only under certain conditions (perhaps oleic acid — conf. Faust is responsible. The subject has been insufficiently studied and is well worth further research. Bloody expectoration is associated with most cases of lung tumors at some period of their development. The sputum, either mucoid or mucopurulent, as the case may be, may be intimately mixed with the blood, or the latter may appear in the form of haemoptysis, varying in profuseness. It has been claimed ^ that haemoptysis is uncommon in lung tumors. According to the writer's own experience and his study of the hterature of the subject, which is to a great measure collected in the Tables, this statement cannot be verified. It seems, on the contrary, that haemoptysis is of rather frequent occurrence. A number of cases are reported in which the very first symptom was a profuse haemoptysis, others where haemoptysis occurred frequently in the course of the sickness, and in quite a number of cases, sev- eral of them under the writer's own observation, death was caused by very profuse haemorrhage. The mere bloody sputum, too, may appear as one of the very first symptoms, though it sometimes requires all the skill of a trained cross-examiner to elicit the fact that there has at one time been some slight bloody expectoration. On the other hand, blood may appear at a later stage, or even at the very last stage, and sometimes, again, be constantly present throughout the course of the disease. The records in Table I show about one hundred cases in which the sputum was bloody, not counting the currant, raspberry, and prune juice sputa mentioned before, and not counting ^ 'Ober chronische Olsaurevergiftung, Archiv. f . exp. Path, und Phar. Festschrift f. Schmiedeberg, p. 171. 2 West, Table I, No. 326. Also Hampeln, €ber den Auswurf bei Lungen- carcinom, Z'tschrift f. klin. Med., Vol. 32, 1897, p. 246. 76 PRIMARY MALIGNANT GROWTHS OF THE LUNG sixteen cases of profuse haemoptysis. In sixty-five of these one hundred cases pure blood seems to have been expecto- rated, representing, as it were, small hsemoptyses. The others were various kinds of sputa, — mucoid, mucopuru- lent, purely purulent, etc., — all of them mixed more or less with blood. In three cases tubercle bacilli were found in the bloody expectoration. In thirteen cases the sputa were entirely free from blood. In forty-five cases the expectoration was ordinarily without blood, and character- istic merely of the condition of the bronchi and the lungs, without reference to tumor. Greenish expectoration is mentioned twice, and one case is reported of olive-green sputum.^ Just what kind of sputa these are cannot be ascertained, as there was no detailed examination recorded. They are probably not characteristic. In Table II sputum is not mentioned in thirty-one cases, in eight cases no expectoration took place, in ten others there was not even a cough, while twenty-five were bloody, three with profuse hsemoptyses. In twelve cases haemoptysis is the main charac- teristic of the sputum. Green sputum is noted five times, and it is believed that Bell ^ was the first to mention it as occurring in sarcoma. There are no means of judging of its character or its relation to sarcoma. In Janssen's case^ the sputum was not merely green, but grass-green, and he believes this to be characteristic of sarcoma of the lung. Traube ^ finds grass-green sputa associated with pneumonia or bronchitis, accompanied by jaundice, — the so-called ''bilious pneumonia," — and also in chronic pneumonia without icterus. He claims that the varying colors of these sputa are due to the red blood cells and the hsematin going through the same cycle of discolorations as an ordinary haemorrhage into the skin, the last being green and repre- senting, according to Traube, the last stages of oxidation of the haematin. He does not mention tumor. That grass-green sputum cannot be characteristic of sar- 1 Elliott, Table III, No. 24. » Table II, No. 3. 3 Table II, No. 39. * Gesammelte Beitrage f. Path. u. Phys., Vol. II, 1871, p. 699. CLINICAL 77 coma of the lungs may be deduced from the fact that it does not appear in the majority of cases, while sputum, mentioned as merely green, is seen in carcinoma, as well as in other diseases of the lungs and bronchi. Moreover, grass-green sputum is said to occur rather frequently in cases of chronic pneumonia and of pulmonary abscess. Here, also, further study is imperative, not only to determine the diagnostic value, but also the conditions under which such peculiar sputa are produced. Perhaps there is some special conjunc- tion of circumstances in cases of sarcoma of the lung which, while not occurring very frequently, produces when present this peculiarly characteristic sputum. The writer feels that in a case of suspected sarcoma of the lungs the grass-green sputiun of Janssen would be strong corroborative evidence. It seems at first glance almost self-evident that sputa from a malignant growth of lungs and bronchi must necessarily contain tumor elements, and that thus the diagnosis of such tumors could easily be made certain beyond doubt. Some reflection will show, however, that this is not so simple as it seems, and must in fact be a rather rare occurrence. There are first to be considered the quantities of various kinds of epithelial cells that can normally be present in the mouth and air-passages; the cylindrical cells, ciliated and without cilia, that come from the bronchi, the nose, etc., the possible admixture of cells from the oesophagus, etc., all of which would prevent the direct recognition of tumor cells. It is, therefore, always hazardous to suspect lung tumor merely from the presence of scattered epithelial or round cells. On the other hand, if the cells in question occur in unusually large quantities and more or less constantly, or if cells which normally are not found in the expectoration are constantly present, the suspicion of tumor is permissible, provided the clinical symptoms correspond. The tumor elements are not apt to be expectorated unless there is open communica- tion with a bronchus and the tumor itself has softened and is in a state of incipient disintegration. Tumor cells, also, that are expectorated under such circumstances are as a rule in such a state of degeneration that their character as 78 PRIMARY MALIGNANT GROWTHS OF THE LUNG derivatives of a neoplasm can only be recognized if some remnants of their blastomic structm-e and organization remain. This, of com"se, would make the diagnosis abso- lutely certain, especially as secondary lung tumors seldom cause marked symptoms, and never such as are peculiar to primary growths. Some cases in point are on record. It has even happened that a portion of necrosed lung tissue has been expectorated before any other symptoms of pulmonary disease were apparent, as in the case of Claisse.^ In the case of Ehrich,2 villous and bloody masses containing can- cerous material were expectorated. Pearson^ records a case in which pieces of necrosed lung tissue were coughed up, accompanied by tubercle bacilli, and the tumor was diagnos- ticated by him as ''encephaloid." A similar case was that of Turnbull and Worthington,^ in which a lump the size of a walnut, of alveolar structure and containing cylindrical and cuboidal ceUs, was expectorated. Still another, was the case recorded by Peacock,^ in which masses were expectorated consisting of spindle and round cells. There are a number of other cases which can be found by reference to the Tables, most of which are doubtful, however, because they lack the all-important microscopic examination. Most of the cases in which the expectoration is recorded of larger or smaller portions of tumor, which are degenerated but nevertheless distinctly recognizable as either carcinoma or sarcoma, belong as a rule to late stages, and while they clinch the diagnosis they do so at a time when all hope of beneficial therapeutic interference is practically gone. It is quite natural therefore that anxious search is made for elements whose appearance in the sputum, while characteristic of lung tumors, is not delayed until the later stages of development. Hampeln ^ found certain cells in the expectoration from cases of carcinoma of the lungs which, according to him, if only ^ Table I, No. 52. In the discussion of this case, Troisier reports a case of primary cancer of the lung in which the diagnosis was confirmed by tumor particles in the sputum. Menetrier also reports similar cases. 2 Table I, No. 78. ^ Table III, No. 59. 3 Table I, No. 249. e Loc. cit. « Table I, No. 321. CLINICAL 79 seen but a single time, assure the diagnosis of carcinoma. He says, '^ Polymorphic, polygonal cells that are entirely free from pigmentation are seen in the sputum where there is carcinoma of the lungs, and in no other case but carcinoma. In all other cases, if there are epithelial cells at all in the sputa, they are principally round or oval cells, pavement or ciliated cells, highly pigmented." These cells do not seem to have gained favor in the eyes of diagnosticians. The writer is not aware that Hampeln's views have been corrob- orated by others, and he himseK has never seen the cells in question. He must confess, however, that his examinations with reference to them have not been sufficient to warrant a definite conclusion. Lenhartz^ finds large spherical cells filled with a multitude of fatty granules and associated with abundance of epithelial cells that are strangely deformed and possess club-like or tail-like projections. He is of opinion that these fatty or granular cells are pathognomonic of pul- monary carcinoma. Tuberculosis may be present without changing anything in the character and diagnostic value of these cells. In Table I the granular fatty cells are found in the sputum seven times. The writer is inclined to agree with Lenhartz that these cells are strictly pathognomonic, at least of carcinoma of the lung, there being as yet insuf- ficient experience as to sarcoma. Since the writer's attention was drawn to these cells he has found them in every case of primary carcinoma that has come under his observation (about twelve cases), and a very long and close study of sputa from all manner of other lung diseases tends to show that they occur in carcinoma alone. The technique of examina- tion is very simple, inasmuch as no staining is required, and a spread of sputum, not too thin, perhaps in a little glycerine and water, or perhaps without any addition, if examined carefully with a moderate magnification, will not fail to show these ''Kornchenzellen" if they are present. The cells can sometimes be obtained, also, by puncture of the pleura or the tumor. 2 It is to be remembered that the 1 Miinch. Med. Woch., 1898, No. 1, p. 28. 2 Muser, Table I, No. 209. 80 PRIMARY MALIGNANT GROWTHS OF THE LUNG conditions under which these cells are formed are still un- known. Lenhartz believes that they are produced by fatty degeneration of the large epithelial cells of the tumor. This, however, is merely hypothesis. Their appearance in the sputum, — for what reason is not known, — is, moreover, very inconstant and irregular. It may be necessary to hunt for them for days in succession before they are found; it may be, on the other hand, that the first examination will show them. They may occur in great profusion, or again only scattered singly here and there through the smear. But it is the writer's conviction that when found they are pathog- nomonic of pulmonary carcinoma, and furthermore that a daily, systematic examination of the sputum is necessary and that one should not be discouraged if the cells are not found at once. IV. That respiratory difficulties constitute one of the most frequent symptoms in lung tumors is obvious. An insignificant shortness of breath on slight exertion is fre- quently reported as the first symptom. This may be present long before percussion and auscultation give evidence of any lesion in the lungs. The difficulty in breathing is often so slight that only a rigid inquiry will elicit the fact of its existence. Its gradual increase may be the first thing to alarm the patient and cause him to submit to a medi- cal examination. Beginning with this slightest form of dyspnoea, all transitions up to the severest orthopncea occur. Among the material here collected, numerous examples will be found of death from suffocation. No physician who has ever seen the intolerable and hopeless suffering of those unfortunates who are doomed to the awful death by suffocation accompanied by intensest orthopnoea extending over weeks, sometimes even months, will ever forget it. Fortunately, it is not always continuous, but is apt to come in spells. Nevertheless, it is one of the most cruel tortures to which man can be subjected and before which the physi- cian has stood powerless. Not only is he unable to cure, but even to relieve, as morphine loses its virtue and surgery is helpless. Complete closure of a bronchus does not cause CLINICAL 81 these worst forms of suffocation, but at most only a very moderate degree of dyspnoea following exertion. The in- tensest forms are brought about mainly by compression or obstruction of the trachea. The tumor may grow up from below through a main bronchus into the trachea and thus obstruct it, or, as is perhaps more frequently the case, in- volvement of the mediastinal glands may form large masses pressing upon the trachea from without so as to produce almost entire closure. Though a most frequent symptom, dyspnoea does not necessarily complicate lung tumors. In Table I there is a record of twenty cases in which no dyspnoea of any kind was found throughout the disease. There are 189 cases where dyspnoea is not mentioned. In 165 instances dyspnoea was present, and this number includes all the differ- ent forms of respiratory disturbance, from the slightest incip- ient dyspnoea to the most terrific orthopnoea. In Table II appear two cases in which it is recorded that no dyspnoea was present, fifty-two cases in which dyspnoea is recorded as present at some stage of the disease, leaving thirty-six cases in which no mention is made of this symptom. V. Cachexia, the usual companion of malignancy, is also a very frequent accompaniment of lung tumors. Its incidence, however, is extremely irregular. There are cases on record, as the Tables show, in which loss of flesh and weight are apparently among the earliest symptoms, cer- tainly before anything abnormal could be detected on the lungs. ^ In other cases there is no apparent loss in flesh and weight throughout the course of the disease. In one of the writer's own cases,^ though there were profuse haemorrhages and the disease lasted about four years, the man kept stout and florid and apparently without any loss of strength until his death, which was caused by suffocation from a profuse and sudden haemorrhage. A positive gain in weight during the progress of the disease has been observed by v. Fetzer' 1 Rottman, Table I, No. 277. 2 Table I, No. 3. ' Bronchuscarcinom, Correspondenzblatt Wiirtemberg artzlicher Landes- verein, Feb. 25, 1905. 7 82 PRIMARY MALIGNANT GROWTHS OF THE LUNG and also by Rothman.^ Le Sourd ^ reports a distinct ten- dency to obesity throughout the disease. Notwithstanding all that, a great number of cases are recorded in which death ensued from exhaustion. VI. There is still considerable diversity of opinion as to fever in carcinoma and sarcoma of the lungs. Kast^ and Ebstein and others recognize a somewhat typical intermit- tent, but usually not very high, fever in the course of the growth of sarcoma. DaroUes ^ is of opinion that there is no fever in uncomplicated cases of carcinoma of the lungs. On the other hand Hampeln ^ finds an intermittent fever similar to the malarial type in cases of occult visceral carcinoma. The same is maintained by Kast^ and a number of others, who also find fever of an intermittent character, especially in cases of cancer of the stomach. Without going into the details of this subject for carcinoma in general, but consid- ering only the carcinoma of the lungs, it appears, looking over the list of cases, that such as seem to be uncomplicated have, as a rule, no rise of temperature of any significance. That fever in an absolutely uncomplicated case of cancer of the lungs is possible, cannot be denied, in view of the modern researches on auto-intoxications and metabolic disturbances caused by the carcinoma itself. In the case of cancer of the lungs, however, it is hardly possible to determine whether the tumor is uncomplicated or not, and in the overwhelming majority of cases it will probably be sufficiently complicated by bronchitis, inflammatory conditions of the lung tissue, bronchiectatic dilatations, etc., to account for whatever temperatures may occur. VII. Difference in pulse in the two radials has fre- quently been reported. This is easily explained by the tumor pressing upon one or the other of the subclavian arteries. 1 Table I, No. 275. » Table I, No. 179. ' Jahrbuch der Hamburger Staatsanstalten, 1889, I. * Du cancer pleuro-pulmonaire au point de vue clinique. These, Paris, 1877. »Z't8chrift f. klin. Med., 1884, Vol. 8, p. 221; and 1888, Vol. 14, p. 566, Zur Symptomatologie okkulter visceraler Karzinome. • Loc. cit. CLINICAL 83 Japha^ reports a distinct bradycardia in one of his cases, but no cause for it is mentioned. So far as one can see from the clinical and post-mortem notes, it does not seem to have any connection with the lung tumor. VIII. The blood count has not thus far been of much assistance in the diagnosis of lung tumors. There are but a few cases in which the blood count is reported, — in all less than a dozen, — and even these lose greatly in value inasmuch as it does not appear from the records how the haemoglobin was estimated and how often and under what varying conditions the blood count was done. One almost involuntarily gets the impression that the blood count was done only once, while it is obvious that it should be repeated at stated intervals. Here also is a fruitful field for further investigation. Of the few blood counts that are on record, it may be well to mention, first, that of Kappis.^ He finds cancer cells with mitosis in the sputum. The blood he reports as follows: Hb., 120; red cells, 6,200,000; white cells, 50,560-40,700; eosinophiles, 33-39^-12%; polynu- clears, 56.9%. The pleuritic effusion was a sanguinolent serum which contained no eosinophiles. In this case the blood count appears to have been taken repeatedly, but is thus far inexplicable in that there is nothing in the history as given by the author to explain the enormous leucocytosis, the accompanying polycythsemia, and the very high per- centage of eosinophiles, the polynuclears, at the same time, being rather low. The autopsy also throws no light upon this curious condition. The author remarks in his descrip- tion of the microscopical structure that enormous heaps of eosinophiles were found in places free from tumor. It is best in this case to indulge in no hypotheses as to the possible cause of this blood picture and its contradictions. Another imperfect blood count is given by Naun^: Hb., 40; leucocytes, 15,000. It is to be regretted that the number of erythrocytes is not stated, because without knowing the number of red cells one is left in doubt whether this is a 1 Table I, No. 136. » Table I, No. 139. ' Table I, No. 224. 84 PRIMARY MALIGNANT GROWTHS OF THE LUNG mere haemoglobin anaemia with a moderate leucocytosis, or whether the red cells also are diminished. A complete blood count, including differential, and repeated several times during the course of the disease, should in the future be considered an essential requirement. In a similar way Musser^ records merely increased leucocytosis, without fur- ther details, in both his cases. In two of the writer's own cases, 2 where the advantages of hospital observation could be had, the blood count was taken repeatedly with the average, in Case No. 2, of: Hb., 65; red cells, 4,500,000; leuco- cytes, 15,000. This corresponds very nearly with the blood count given by Cohen and Kirkbride^: Hb., 60; red cells, 4,400,000; leucocytes, 18,000; differential count of leucocytes not stated. In Case No. 4 the blood count was as follows: Hb., 62; red cells, 3,980,000; leucocytes, 14,300; differen- tial fairly normal. In this case, besides the haemoglobin anaemia, there is a distinct reduction in the number of red cells, but no deformation or other alterations in them. The case of Ebstein^ is very similar to this latter case: Hb., 62; red cells, 3,492,000; but the leucocytes are unusu- ally high, there being 32,000 (differential not stated). It is impossible at present, there being so few blood counts avail- able, to come to any definite conclusion. The leucocytosis is easily accounted for by the inflaromatory and often puru- lent processes going on in the lungs. Whether there is a real disproportion between the number of red cells and the percentage of haemoglobin, thus pointing perhaps to some haemolytic process, or whether in the majority of cases there is only the usual anaemia, both of red cells and of haemo- globin, to be expected in any case of increasing malignancy, — especially if there is considerable loss of blood, — is a problem that awaits further study. In the case of Cohen and Kirkbride the disproportion between 4,400,000 red cells and only sixty haemoglobin is very striking. The blood counts given by Faust ^ show some resemblance to the 1 Table I, Nos. 222 and 223. * Table I, No. 76. 2 Table I, Nos. 2 and 4. ^ Loc. cit. 3 Table II, No. 13. CLINICAL 85 blood counts mentioned here, inasmuch as his rabbits showed a continuous decrease in the haemoglobin with a comparative increase in the red cells and a tendency to some leucocytosis. The interesting coincidence is certainly worthy of note. Miiller^ has among his cases no case of lung tumor. As a result of his careful blood counts nothing character- istic is shown. The haemoglobin has a tendency to go down steadily, as also the number of red cells, and there is a tendency to leucocytosis and to an increase of the polynuclear cells, but nothing characteristic of the blood in lung tumors is shown. IX. Incidentally, there should be mentioned two cases in which diabetes was a complication of the disease, as in the cases of Kratz^ and Liibbe.^ There is no evidence, so far as can be seen, that the diabetes stands in any relation to the lung tumor. X. The clubbed fingers which are sometimes reported have, it is obvious, no specific relation to malignant growths. They are not different from the clubbed fingers that we see in other chronic diseases, especially of the lungs, and more particularly where pus is present. 1 Oswald Miiller, tjber den Blutbefund bei Krebskranken, Diss. Berlin, 1909. 2 Table I, No. 151. » Table I, No. 187. CHAPTER IX CLINICAL {.Continued) WHEN one is compelled to face the almost infinite variety of pathological lesions and compUcations that are associated with most of the primary malignant neoplasms of the Imigs, the clinical pictm^es and their symptomatology appear to present an almost hopeless con- fusion. A larger experience and comparative study will show that there is, after all, a certain monotony of essen- tial sjTuptoms, around which the varying complications and lesions are grouped. It is possible in this way to arrange the entire clinical material at our disposal into certain groups which, with their subdivisions, supply a fairly well-classified arrangement of the clinical phenomena. A certain number of tumors, as has been shown above, are apt to withdraw themselves from diagnosis by causing no symptoms whatso- ever, and others in which a diagnosis is not likely because symptoms caused by metastatic deposits^ completely domi- nate the chnical picture and successfully mask the pulmonary disease. For the great majority of tumors which do produce symptoms, the remark of Stokes, that ''the faciUty of diagnosis mainly depends on the anatomical disposition of the disease," is still true. According to Passler,^ the clinical pictures accom- panying pulmonary mahgnant neoplasms can be aptly arranged in two main groups. The first group contains 1 There is much difference of opinion among authors as to the frequency of metastases in maUgnant tumors of the lung, some claiming that secondary deposits are very rare in carcinoma and correspondingly numerous in sarcoma, others expressing directly opposite opinions. By consulting Appendices C and D the reader will obtain a fair idea of the occurrence of metastases in the various organs both in carcinoma and in sarcoma and he will find very little difference between carcinoma and sarcoma in this respect. 2 Loc. cit. 86 CLINICAL (Continued) 87 the cases in which the symptoms referable to diseases of the lungs and bronchi largely predominate. These tumors, mostly carcinoma, nearly always take their origin from the bronchial ramifications from the second order downwards to the smaller and smallest bronchioles, and as a rule do not directly implicate the hilus. The second group embraces to a large extent the tumors of the root of the lung. This group may be accompanied by intense and agonizing symptoms on the part of the respiratory organs: lungs, bronchi, etc.; but these are usually of a secondary nature, though they may dominate the clinical picture. The typical symptoms of this variety of lung tumor are largely mechanical and composed mainly of such symp- toms as result from pressure on or compression of the tho- racic organs, especially of the mediastinum, and from the overcrowding of the intrathoracic spaces. The elementary symptoms mentioned above are common to both groups. The classification of Marfan,^ identical in principle with that of Passler, is perhaps a little more convenient, and is adopted here. It reads as follows: I. The acute or galloping form of pleuro-pulmonic cancer. II. Chronic pleuro-pulmonic cancer. 1. Broncho-pulmonary type, being the classical type of carcinoma of the lungs. 2. Type suggesting tiunor of the mediastinum. 3. Pleuritic type. (a) Pleuritic type of the pleuro-pulmonary tumor without effusion. The first main division, the acute or galloping miliary car- cinoma of the lungs, runs an extremely rapid course, accom- panied by cough, dyspnoea, and asphyxia; death usually in a month or thereabouts. The clinical picture in many respects resembles that of acute miliary tuberculosis, and at autopsy both lungs and pleura are found studded with miliary nodules which, however, on microscopic examination, are found to be cancerous. This form is extremely rare and only a very few scattered cases have been reported. The case of Elisberg2 may possibly come under this heading. In * Quoted from Chauvain, loc. cit. * Table I, No. 80. 88 PRIMARY MALIGNANT GROWTHS OF THE LUNG this case the primary tumor was in the bronchus. It is generally denied that this form of carcinosis ever occurs as a primary pulmonary lesion. This statement, however, cannot be supported by absolute proof. Granted that it does occur as a primary lesion, it seems that at present there are no means of obtaining a correct diagnosis during hfe. II. The chronic pletjro-pulmonary cancer. This is the ordinary chronic form of cancer of the lung, in which the lungs, bronchi, and pleura are mainly affected by the tumor. The subdivisions which have been mentioned are, it is necessary to insist, merely for the convenience of the clinician and do not represent strictly defined and firmly established independent syndromes. With the progressive development and extension of the blastomic lesion, accom- panied by a varying degree of destruction of the lung and the secondary effects of the tumor on its environment, the symptoms must necessarily vary, and the so-called subor- dinate groups may merge one into the other. It may often be observed that several or all of the various types here mentioned are exemplified in the course of a single case. 1. Pulmonary cancer. The classical type of cancer of the lung. This represents the ordinary bronchial carci- noma which, as shown above, is by far the most frequent form of the disease. The dominant symptoms are referable mainly to the lungs and bronchi. The earlier stages usually suggest merely a chronic bronchitis. It is commonly said that in the very earliest stages of the development of the tumor, percussion will fail to show any appreciable difference from the normal. This may, in the main, be true. It is, however, the writer's deep conviction that, even in very early stages, percussion may be found significantly altered, if a sufficiently dehcate technique be adopted. It cannot fall within the scope of this study to enter in detail into a discussion as to the relative values of the vari- ous methods of percussion or into the manifold theories that have been put forward in this most important chap- CLINICAL (Continued) 89 ter of diagnostics. But it is the writer's opinion that the ordinary loud, resounding, finger to finger or hammer to finger or plessimetre percussion cannot be made to give proper results in these earher stages. The writer has employed for years the " Schwellenwerthperkussion " and orthopercussion as elaborated by Goldscheider, Plesch, and Curschmann, in combination with the auscultatory percussion according to Ewald and the friction method of Bianchi. The results, checked by the orthodiascope, have as a rule been most satisfactory. These methods, if carried out with the dehcacy of touch and hearing which they require, may be expected to lead to the detection of compara- tively slight pathologic lesions where other methods of per- cussion will fail. It is understood that percussion must vary according to the different stages of development and the various complications that may occur in the course of malignant disease of the lungs. There are cases on record, as for instance that of Rottman/ where it is reported that physical signs on the lungs were negative, although a large tumor was found. This is only one of many similar examples reported. In early stages a dull percussion note is found at one apex or the other, or, which is much more difficult to find, at the hilus posteriorly. The anterior aspect of the upper chest is more frequently the seat of dulness than the posterior, but the dulness at the hilus, of course, can only be heard near the spine. This dulness may gradually increase from a shght change in the percussion note to absolute flat- ness. The flatness and boardlike resistance to the per- cussing finger are very often due, not to the tumor itself, but to the atelectasis caused by the tumor. Woillez 2 desig- nated as characteristic of lung tumor what he called the 'Hympanisme thoracique," which consists of a tympanitic, immediately preceding the full, percussion note. This has not turned out to be a pathognomonic sign and is wellnigh forgotten. 1 Table I, No. 277. 2 Dictionn. de Diagnost. m6d., Paris, 1870, 2d Ed. 90 PRIMARY MALIGNANT GROWTHS OF THE LUNG Characteristic of these earher stages is, further, the fact that with dull or flat percussion, auscultation shows diminished respiration. Where pleuritic effusion or pleu- ritic adhesions and thickenings can be excluded, which is comparatively easy for the upper anterior portions of the chest, this sign of increasing dulness with diminishing voice and breathing sounds is extremely suggestive, and while not absolutely pathognomonic of tiunor, should make the presence of tumor highly probable. The mechanism of the sign, — increasing dulness with diminishing voice and breathing without pleuritic effusion, — is of course given in the more or less complete obstruction of a bronchus, by which means those portions of the lung not affected by tumor are in a more or less complete state of atelectasis. Most interesting in this connection is the case reported by Korner.i In this case there was flattening of the right chest, absolute flatness of percussion, and entire absence of respiratory and vocal sounds, — in a word uncomphcated and complete obstruction of the right main bronchus, a diag- nosis that was confirmed by autopsy. The area of dull per- cussion note in these cases is usually sharply defined, as distinguished from tuberculosis and pneumonic conditions, where the delimitation is more diffused, the abnormal per- cussion merging gradually into the normal. The configura- tion of the area of dulness or flatness is, however, usually quite irregular, according to the topographical disposition of the tumor, its depth, its extension, and its surrounding reactive processes. As the tumor grows and degenerations of various kinds make their appearance, as breaking-down and irregular excavations in the tumor come about, — and it has been stated above that this happens much more frequently than most authors concede, — the percussion note and ausculta- tory signs must necessarily change in character and become variable to a considerable extent. Tympanitic percussion note, amphoric breathing, metallic rales will show the presence of a cavity, and when a case has reached this stage 1 Table I, No. 147. CLINICAL (Continued) 91 one is apt to pardon the clinician who does not hesitate to diagnosticate tuberculosis. Besides more or less profuse haemorrhages, it is not unusual to find at this stage irregular fever of considerable intensity and night sweats. The fever may resemble the hectic type. Notice is to be taken, also, of the bronchiectatic dilatations which occur so often and to so great an extent, as a consequence of obstructed bronchi. Here percussion as well as auscultation offers frequently interesting changes. If the bronchus is completely closed for a long time, the bronchiectatic cavity naturally fills with secretion, — pus, mucus, blood, and so on, — possibly continually dilating, and the percussion note over this will be dulness to flatness, and auscultation will hear neither voice nor breathing. Suddenly, as it were, the bronchus is reopened by ulceration and degeneration of the obstructing tumor, there is a free discharge of the bronchiectatic con- tents, and in the place where formerly there was abso- lute flatness, we have now the tympanitic note and the auscultatory symptoms pointing to a cavity. It is obvious that these signs can only occiu" in very late stages of the disease. The process may be varied in different ways and it may be taken as characteristic of these later ulcerative stages when such sudden changes in auscultation and percussion appear. As a good illus- tration of these conditions may be mentioned the case of Amal.^ In this case there was total absence of breath- ing, but normal percussion over the entire right lower lobe. There were all the other symptoms of a malignant growth in the lungs. Very suddenly, and only a few days before death, the respiratory murmur was again distinctly heard over the right lower lobe, — in other words, the tumor, partly compressing, partly proliferating into the right main bronchus of the lower lobe and completely filling it and preventing the passage of air, had ulcerated away to a great extent and thus again permitted communication with the air. It has frequently been said that percussion over a neoplasm of the lung offers a greater resistance to the finger » Table I, No. 13. 92 PRIMARY MALIGNANT GROWTHS OF THE LUNG than is normal. This sign, however, depends on so many varying factors, as the closeness of the tumor to the chest wall, the condition of the lungj etc., that it is not constant and not characteristic, though when present a welcome corroboration. Another sign of great diagnostic value is the auscultatory symptom, to which Behier ^ gave the name of ''cornage." This is a sound very similar to that obtained from the trachea when partially compressed. It is pathognomonic of bronchial obstruction and might be considered, especially when heard about the root of the lungs, and better still when accompanied by some dulness, as an almost certain sign of tumor. It must be remembered, however (and for that reason the word ''almost" is inserted), that certain other conditions which may result in bronchial obstruction must be excluded. This should not be difficult, for probably all the processes which may result in bronchial obstruction, and thus in an audible cornage, are acute. Thus it is not unusual to find the sign in acute, severe bronchitis or in an influenza pneumonia, or even in chi'onic bronchitis when a bronchus happens to be obstructed by masses of viscous and tenacious mucus. But in all these cases the obstruction is temporary and disappears as a rule in twenty-four hours. But in tumor the cornage is practically constant and will remain so until the bronchus is completely obstructed, or will disappear after a comparatively long time when the bronchus, through ulceration, becomes again freely perme- able to air. Cornage may be a very early symptom. 2. The mediastinal type of lung tumor. A bronchial cancer, — and it is indifferent of what order the bronchus may be, whether large or small, — has two main preformed routes of extension at its disposal. The easiest and most natural, and the one that is in the majority of cases primarily resorted to, is along the bronchial ramifications and the peribronchial tissues into the interior of the lung. This holds good also for those sarcomata that originate in the minute peribronchial glands or in the peribronchial connec- 1 Gaz. de Hop., AprU, 1867. CLINICAL (Continued) 93 tive tissue. In the later stages the bronchial wall is apt to be broken down and penetrated by the tumor, and thus the bronchial and then the mediastinal lymph nodes become involved and are occasionally enormously enlarged. The mediastinal lymph nodes, possibly both anterior and pos- terior, now take part, the mediastinum is filled with tumor masses, the pericardium may be covered or even penetrated by the neoplasm, pericarditis develops, secondary growths in the heart appear, the large vessels, both aorta and cavse, the pulmonary arteries and veins are surrounded and either compressed or penetrated by the tumor. It should be mentioned that the aorta, while often much compressed, so far as the writer's knowledge goes, never takes part in the tumor proliferation and is never penetrated by it. As a con- sequence of all this crowding of the mediastinal organs, the superficial veins of the chest are dilated, sometimes to a huge extent, and cedcema, varying from cedoema of a single arm, or the face, to a general oedoema of the entire body, arises. One or the other, sometimes both, of the laryngeal recurrent nerves are involved, the trachea, large bronchi, oesophagus, are compressed, obstructed, and even penetrated by the tumor. The participation of the oesophagus causes the dysphagia so frequently reported. And thus all the symp- toms of an intrathoracic growth, or more especially of primary mediastinal tumor, are evolved. Sarcoma, origi- nating at the hilus of either lung, differs from this group of symptoms in so far as the direction of the growth is less towards the lung and tends to advance more rapidly and at an earlier stage of the disease toward the mediastinum. It is this mediastinal type of tumor that usually causes the dreadful attacks of asphyxia and orthopnoea mentioned above. 3. The pleuritic type. In cases belonging to this type, the symptoms referable to the pleura predominate. So far as tumors of the lungs and bronchi are concerned, this form corresponds to a rather late stage of the disease. In primary mahgnant disease of the pleura, however, which is beyond the scope of this monograph, this form usually marks 94 PRIIMARY MALIGNANT GROWTHS OF THE LUNG the beginning of the lesion. The symptoms in the main are those of acute, sub-acute, or chronic pleurisy. There is stabbing pain in the chest, radiating to the shoulders or in other directions, and all the signs of a persistent pleuritic effusion, which too often tend to mask more or less com- pletely the symptoms of pulmonary disease. We have the absolute flatness on percussion, the total absence of voice and breathing on auscultation, very often the obliteration of the intercostal spaces, frequently the bulging of these same spaces. In nearly every case of lung tumor, the pleura partici- pates to a certain extent in the morbid process, sometimes with sometimes without effusion; according to Herrmann ^ in fifty per cent of the cases. In this pleuritic type, how- ever, effusion more or less profuse is always present and is hkely to recur after tapping of the chest, so that these tappings must be repeated again and again, at longer or shorter intervals. In ordinary pleurisy the aspiration of the effusion affords prompt reUef of the harassing symptoms. Even in the pleurisy associated with extensive tuberculosis, this rehef can be recognized. It is characteristic of the type of tumor under discussion here, — though it applies also to primary carcinoma of the pleura, — that relief after removal of the pleuritic effusion either does not follow at all, or lasts but a very short time. As a rule there is no abatement of the cough, dyspnoea, expectoration, and general distress, but there may be intense pain caused by the wrenching of the diseased tissues. Some exceptions to this fairly general rule are on record, such as the case of Unverricht,2 where, after one or two aspirations of sanguin- olent fluid, all symptoms seemed to disappear, the patient felt entirely well and gained in weight, until secondary tumors made their appearance in the skin where the aspirat- ing needle had penetrated. Hampeln^ also reports a case 1 Deut. Archiv. f . klin. Med., Vol. 63, 1899, p. 583. ^ Beitrage zur klin. Geschichte der krebsigen Pleuraerglisse, Z'tschrift f. klin. Med., Vol. IV, 1882, pp. 79 ff. 3 Table I, No. 101. CLINICAL (Continued) 95 in which the pleuritic effusion was absorbed without tapping and without recurrence. These cases, however, are rare exceptions. The fluid recovered by the first few tappings may be clear yellow serum, but sooner or later it is certain to become bloody. It is well known that bloody pleural effusion occurs in other diseases, especially in tuberculosis, and is in itself, therefore, not pathognomonic of malignant tumor of the lungs or pleura. It is said, however, that the change from initial clear serum to bloody effusion is charac- teristic of neoplasms of the lung. It is uncertain whether this is correct or not. It is reported, on the other hand, very often that a thick, chocolate-hke fluid is recovered in the later tappings. This, according to the writer's opinion, is certainly pathognomonic for malignant disease in the pleural cavities. Adipose and chylous effusions into the pleura are reported, but are found very rarely in malignant neoplasm of the lung, — certainly much less frequently than in the disease of the peritoneum. The same holds good for empyema. In the case of Walch^ it was evidently a pneumococcic affection and had no direct relation with the carcinoma. Nothing characteristic has as yet been found by the bacteriological examination of the pleuritic effusions. The results of the cytological examinations have been a subject of much discussion, with no positive conclusions. Ehrhch^ has called attention to the diagnostic importance of the presence of organically connected cell-groups in the effusion. Frankel has called attention to large vacuolized cells, sometimes attaining gigantic dimensions. These are probably tumor elements and this is assured if they are found to contain glycogen, but they probably belong to primary diseases of the pleura. It is therefore not very difficult to diagnose the presence of malignant tumor in the chest from the study of the cells in the effusion, if such can be found. It is, however, almost impossible, under the condi- * Cancer du poumon gauche, pleur^sie purulente pneumocoques, Soc. anat. de Paris, 1893, VII, Ser. 5. » P. Ehrlich, Charit6-Annaleii, 1880, Jahrg. VII, p. 226. 96 PRIMARY MALIGNANT GROWTHS OF THE LUNG tions given, to distinguish an endothelial from an epithelial cell, and therefore a primary endothelioma of the plem*a from a carcinoma of the Imigs, and it is wise not to depend for diagnosis on the cytology of the pleural exudate alone. This rule should hold, even though exceptions are possible, as in the case of HeUendall,^ who found in the bloody effu- sion in the chest white particles consisting of heaps of round cells, sufi&ciently characteristic to warrant the diagnosis of sarcoma of the lung, — a diagnosis which was confirmed by autopsy. Kronig,^ on making a probatory puncture, penetrated the tumor with the needle and found attached thereto white particles which microscopic examination showed to be lympho-sarcoma, and he was thus enabled to obtain an absolutely certain diagnosis during life. He devised a method based on this, by which in every doubtful case the attempt was to be made to remove particles of tumor by aspiration. There are serious objections to this method. It is not only very uncertain in its results, as the needle does not always return with tumor particles, but usually only with a little blood, but there is actual danger of causing a haemorrhage. It may be taken as a trustworthy sign of malignancy if a paralysis of the recurrent laryngeal is observed on the side of the pleuritic effusion. It has been stated above that as a rule there is no relief after removing the effu- sion in cancerous pleuritic effusions. It may also be said that, after removal of the fluid, the various phenomena of percussion and auscultation, which until then had been masked, will appear in unmistakable distinctness, and thus greatly assist in the diagnosis. The dislocated heart * which, on removal of the pleuritic effusion, will make no attempt to return to its normal place, — other symp- toms being favorable, — suggests tumor. The retraction of the affected side of the thorax, accompanied by increased dulness and impaired or entirely abolished respiratory motions, when caused by a thickening of the pleura, some- times to an enormous degree, is not at all characteristic of 1 Table II, No. 35. 2 Table II, No. 42. CLINICAL (Continued) 97 malignant growth in the lungs after the stage of effusion is over, but is well known to occur in other forms of pleurisy, especially in tuberculosis. (a) The pleuritic type without effusion. This is most typical and applies almost exclusively to those large mas- sive sarcomata or lympho-sarcomata that are apt to fill the greater part of the chest. It marks, of course, a late stage of the disease. There are all the signs of a pleuritic effu- sion, often increased circumference of the side of the chest involved, displacement of the heart, etc. There may also be present, but not necessarily so, the ordinary general symptoms of maUgnant growth of the lung, — the cough, dyspnoea, fever, sweats, haemoptysis, cachexia, etc. The exploring needle fails to discover any fluid. On the con- trary it seems to penetrate into a more or less solid mass extending to such depths as to preclude any possibility of its being merely an abnormally thickened pleura. Par- ticles of tumor may be brought away by the needle. It is characteristic of this type that, while there is complete absence of respiratory murmur or vocal fremitus, there is a very loud propagation of the heart sounds, so that if the tumor occupies, for instance, the right chest, the heart sounds can be heard very distinctly over the whole of the right chest, both in front and in back.^ This sign alone is sufficient to assure the diagnosis of a solid intrathoracic mass. Consequently in most of these cases there is dilata- tion of the superficial veins of the chest and possibly of those of the abdomen, more or less intense dyspnoea, paralysis of one or both recurrent laryngeal nerves, direct or indirect affection of the heart itself, the large vessels, etc. A few words should be said concerning some morbid processes which are found in the train of pulmonary tumors. Pneumonias, both acute and chronic, are among the most frequent accompaniments of lung tumors. In a number of cases the pneumonia is recorded as the first symptom. The patients state that they were taken acutely ill with chill, high fever, cough, rusty sputum, from which they recovered, 1 Withauer, Table I, No. 342. Budd, Table III, No. 13. 8 98 PRIMARY MALIGNANT GROWTHS OF THE LUNG but that from then on they were never quite well. These acute pneumonias may be pneumococcic pneumonias or pro- duced by other well-known bacteria. The chronic form, if not of the cheesy tubercular character, is principally of the indurative type. These pneumonias may lead to symptoms which mask the signs of the tumor, or at least are most perplexing. Sometimes, though rarely, they are followed by a genuine empyema. Atelectasis ^ has been mentioned above and is the natural consequence of the blocking by tumor of larger or smaller bronchi, resulting in the collapse of the entire territory which the bronchus supphes with air, as well as its splenification, if no change occurs in the bronchus. There will be moderate dulness on percussion, though sometimes, — particularly if the area is small, — the percussion note will remain fairly normal. But vocal fremitus and breathing sounds are completely abolished. It is on account of these secondary processes that the extent of the dull area does not coincide with the actual size of the tumor. The tumor, as the X-rays have shown,^ may be larger than the dull percussion would lead one to expect. On the other hand these secondary processes give a dull percussion note of their own, which, merging into that caused by the tumor, is apt to give an exaggerated idea of the tumor's size. Another complication which requires mention, though abeady hinted at above, is gangrene. It is easily conceiv- able, in fact it is almost self-evident, that a proliferating tumor in the lung, rapidly destroying lung tissue and pene- trating into blood vessels, can at any time envelop and, by compression, obstruct an artery of some size, or, by breaking through the arterial wall, close an artery completely, and by either of these means cause total ischsemia, followed by gangrene. According to the size of the artery involved, the gangrenous territory will be larger or smaller, occasion- ally occupying the greater part of a lobe. When a case is first seen in this condition, the diagnosis is intensely diffi- cult, — wellnigh impossible, — as even those signs in the ^ Korner, loc. cit. ' Leo, loc. cit. CLINICAL (Continued) 99 sputum which we have found to be pathognomonic are apt to be lacking. Under these conditions, too, the X-rays will not give any useful information, and it is only by most careful study of the history and the progress of the disease that a probable diagnosis can be arrived at. On the other hand, if the gangrene appears, after previous examination and observation of the patient have settled the diagnosis of tumor, or at least have caused tumor to be suspected, the gangrene will rank only as a complication. It may be casually added that there may be interesting involvements of the sympathetic which will in no wise interfere with the cardinal symptoms and the diagnosis, but which are of interest as again demonstrating the manifold complications that are constantly arising.^ It was not very long ago that A. Frankel ^ wrote that the X-rays were of little service in the diagnosis of lung tumors. Since then the X-rays have become a most remarkable and efficient aid to diagnosis in general, and there exists the well-founded hope of their increasing efficiency as further improvements in the apparatus and advances in technique are made. They have also proved, as is well known, a powerful therapeutic agent in many diseases, but not as yet for treatment of lung tumors. The hope may reasonably be entertained that with the systematic and proper appli- cation of the X-rays to the exploration of the chest, the diagnosis of lung tumor may be assured when no other means will give equally certain results. Leo^ diagnosticated an osteosarcoma of the lungs, secondary to a sarcoma of the right knee, during life, with certainty and much topograph- ical detail by means of the X-rays, which also showed a much greater extent of the tumor than could be ascertained by percussion and auscultation. It may also be possible, per- haps, to obtain this diagnosis at a time when the tumor is as yet very small and causing but little subjective distiu-bance. If this happy result is ever to be reahzed, it will be neces- ^ Kronig, loc. cit. ^ Loc. cit. ' Nachweis eines Osteosarkoms der Lunge durch Rontgenstrahlen, Berl. Klin. Woch., Vol. XXXV, 1898, No. 16, p. 349. 100 PRIMARY MALIGNANT GROWTHS OF THE LUNG sary to examine the chest with the Rontgen rays even where there are no symptoms pointing to any disease in the chest. It has been the writer's practice for a great many years, as an essential part of the routine examination in every case that presents itself at his office, no matter what the patient's complaint, to subject the chest to a thorough exploration with the Rontgen rays. We prefer the examination with the orthodiascope (de la Campe) and a very large (12'''xl6") fluorescent screen. Thus one is enabled at a single glance to observe heart, lungs, in fact, taking advantage of various positions, nearly all the thoracic contents during action. It is particularly useful, also, for watching the respiratory mobiUty of the lungs and diaphragm. It has repeatedly been noted that in lung tumor the mobihty of the lung is markedly diminished or entirely abolished. In cases of medi- astinal tumor the respiratory mobility of the lung remains unchanged or is increased, and Jacobson ^ has found this valuable in distinguishing between the two types of tumor. With good light, good apparatus, and some experience, com- paratively minute lesions in the lungs can be discovered. Any abnormality that is thus brought to notice can be per- manently fixed for further reference by the photographic plate, approximately accmrate measurements can be ob- tained, and thus the gradual enlargement of the tumor verified and its blastomic nature determined. The shadow of a carcinoma or sarcoma just starting from the hilus and gradually extending toward one of the pulmonary lobes is a very striking picture when seen with the Rontgen rays, and often suggests the tumor diagnosis when the observer, though other characteristic symptoms were present, would have been led astray. The interpretation is more difficult when the shadow extends over the upper lobe of either side, as this is the favorite localization of tuberculous processes. Sometimes the sharp hnear delimitation at the base of the shadow makes for tumor rather than tuberculosis. It speaks for tumor, also, if the affection is confined to one * Primare Lungen vmd Mediastinal Tumoren, Festschr. f. Lazarus, Berlin, 1889. CLINICAL (Continued) 101 upper lobe, for as these pictures are seen only after the dis- ease has progressed to a certain extent, the upper lobes of both lungs, if the process were tuberculous, would probably have been affected. The shadow remaining unilateral speaks for tumor. The absence of tubercle bacilli in the bloody sputum, with the increasing shadow on one lobe only, also suggests tumor. But where tuberculosis is associated with advancing carcinoma or sarcoma of the lung, the Rontgen rays are of Uttle value, and if a differential diag- nosis is possible, it must be attempted by other means. It is beyond the scope of this study to enter into further details concerning the X-rays. The reader is referred to the well-known books of Holzknecht,^ Grodel,^ Grunmach,^ and Amsperger.* The details, however, as to the value of the X-rays in malignant lung tumors may be studied by the reader in the cases recorded by Otten ^ and Muser,^ from the Eppendorf Krankenhaus, Hamburg, under the direction of Lenhartz. Another recent aid to diagnosis is the bronchoscope, that has been so successfully employed in various affections of the trachea and the larger bronchi. It has also done service in establishing beyond doubt the presence of a bronchial neoplasm. 7 Karrenstein^ reports the case of a male forty- eight years of age, in which the tumor, taking origin from the large bronchus immediately below the first division of the right main bronchus, was made distinctly visi- ble by the bronchoscope, the tumor having been suspected. H. von Schrotter ^ reports a case of a male f orty-foiu- years of age where the bronchoscope showed very plainly ^ Mitteil. aus Laboratorium fiir radiologische Diagnostik und Therapie, Jena, 1907. 2 Rontgendiagnostik in der inn. Med., Miinch., 1909. 2 tiber die diagnostische und ther. Bedeutung der X-Strahlen f. d. inn. Med. u. Chir., Deut. Med. Woch., 1899, No. 37. * Die Rontgenuntersuchung der Brustorgane, Leipzig, 1909. 6 Table I, No. 228. 6 Table I, No. 205. ^ Killian, Zur diagnostischen Verwertung der oberen Bronchoskopie bei Lungencarcinom, Berl. Klin. Wochenschr., 1900, p. 437. 8 Table I, No. 141. « Table I, No. 325. 102 PRIMARY MALIGNANT GROWTHS OF THE LUNG a prominent tumor in the right bronchus from which a piece was exsected for microscopic examination, which showed cancerous epitheUa with glycogen reaction, and thereby settled the diagnosis. It is always unwise to endeavor to prophesy as to future possibilities, at least within the domain of biology and pathology. It cannot be denied that the field of bron- choscopy may be greatly extended by improvements in appa- ratus and in technique. It is, however, the writer's opinion that its usefulness in the diagnostics of lung tumor, at this writing at least, is limited. It appears at present that from the nature of things, bronchoscopy can make visible only such tumors as have involved the upper bronchi. Of what occurs in the bronchi of lower orders and in the depths of the lung, the bronchoscope leaves us in utter ignorance. Moreover, there are undoubtedly many cases that come under observation, late in the course of the disease, where the dyspnoea, brain involvements, and other concomitant symptoms are of such gravity, and menace life to such a degree, that even the boldest would hesitate to introduce a bronchoscope, though there remained but little doubt that the instrument could make visible the involvement of the upper bronchi. In such cases the diagnosis should be made by other means, — especially as even the exact recognition of the tumor by the bronchoscope would be of little avail to the patient. In concluding the clinical part of the subject, it is still necessary to mention a few points which may be helpful in differentiating lung tumors from other diseases closely resembling them in symptomatology, and for which they might easily be mistaken. First and foremost, of course, is the question — tuberculosis or tumor? This question can be easily answered at autopsy, but it is not quite so simple in the living person. Some points in the differential diag- nosis have already been brought out. The small tumors, particularly cancroids, described as growing from the walls of a tuberculous cavity, will probably never be diag- nosticated, unless pathognomonic cells in the sputum direct CLINICAL (Continued) 103 attention to the possible existence of tumor in the respiratory system. At any rate it is always advisable to remember the exhortation of Gerhardt, — always to suspect tumor in persons of advanced age where tuberculosis is not likely and cannot be found by ordinary examination, and where there is cough with bloody expectoration. It is plain that the differential diagnosis as between tuberculosis and tumor cannot be made at once, but requires prolonged and most careful examination and observation. Even then it will often be impossible to decide absolutely. That it can be done, however, is shown, among others, by the follow- ing case of Fessen.^ This concerned a man forty-five years old, who had pulmonary phthisis and a cavity in the right apex. Tubercle bacilli were found in the sputum. The tuberculosis gradually improved and showed signs of cicatrization. Opposed to this, however, was the cough with scant expectoration, the general cachexia and sharply defined complete flatness. The puncture was negative; the Rontgen rays showed a dense shadow, very sharply defined at its lower border. This alone sufficed to justify a diagnosis of tumor of the lung. This diagnosis was corroborated by the bulging of the intercostal spaces, the dilatation of the veins, the small radial pulse on the affected side of the chest, the oedcema, and all the symptoms of a bronchial obstruction completing the clinical picture. The autopsy showed a cicatrized tuberculosis of the left lung, and in the right apex a cavity, and the lower portion of the right upper lobe cancerous. ^ The sudden changes in percus- sion and auscultation, of which mention has been made, are not likely to occur in tuberculosis, but speak for tumor. The absence of bacilli in the sputum, it is hardly necessary to mention, may persist for a long time in tuberculosis, but in advanced cases, especially where extensive ulceration has taken place, tubercle bacilli are sure to make their appear- ance. The modern tests for tuberculosis, — the injection test, the Wolff-Eisner and von Pirquet tests, — will only be helpful if persistently negative, as only in that case do they 1 Centralbl. f. innere Med., 1906, No. 1. « Wolff, loc. cit., p. 817. 104 PRIMARY MALIGNANT GROWTHS OF THE LUNG help to exclude the presence of active tuberculosis. Further experience and improvement in methods may possibly result in greater facility and precision of this diagnosis. Enough has been said to show that no hard-and-fast rules can be given to diagnosticate lung tumor in a tuberculous individual. The hints as to differential diagnosis that have been given may serve in a general way as guides, but the physician must mainly depend upon his own insight and judgment in each individual case. If a lung tumor happens to be first seen when it is far advanced, the suspicion of the presence of an aneurysm may arise. This is hardly to be expected in the ordinary case of carcinoma of the lungs, where the history, the train of symptoms as outlined, the cells in the sputum, etc., will speak against aneurysm, although as a matter of fact an aortic aneurysm is rarely to be absolutely excluded. The differentiation as between sarcoma and aneurysm is some- what more difficult, as sarcoma naturally tends to grow more towards the mediastinum and away from the lungs than does carcinoma. In some cases the Rontgen rays may help, although as a rule they are useless. A tumor lying upon or adherent to the aorta will pulsate. The pulsation is generally of a lesser extent and more definitely circumscribed in aneurysm, while in the case of tumor it is of a more diffused character, involving sometimes the entire chest. The difference in the radial pulse, as mentioned above, a common sign in pulmonary tumor, will not aid in recog- nizing an aneurysm unless the smaller pulse is found on the side opposite to that to which all indications point as the seat of the tumor. A. Frankel and others called attention to the fact that lung tumors usually cause a paralysis of both recurrent laryngeal nerves, while in the ordinary forms of aneurysm of the arch of the aorta it is only the left laryn- geal recurrent that is affected. Only in exceedingly rare cases, in cases of enormous size of the aneurysm or of mul- tiple aneurysms, has paralysis of both laryngeal nerves been observed.^ As the case proceeds, secondary visible or pal- » Baumler, Deut. Archiv. f . klin. Med., Vol. II, p. 563. CLINICAL (Continued) 105 pable tumors, the usual characteristics, etc., will assure the diagnosis of tumor, to the probable exclusion of aneurysm. The tendency for the spreading and enlargement of aneurysm is natm-ally more toward the left than toward the right side. This fact may occasionally be of some use in diagnosis. Stokes and Graves mentioned a certain asymmetry of the thorax in cases of malignant neoplasm of the lung. A. Frankel and others have in recent times called attention to this as an almost pathognomonic symptom. The asym- metry consists in the retraction of that side of the chest where the tumor is supposed to be localized, especially in its posterior and lateral aspects, after tapping of the pleuritic effusion. This ^'r^tr^cissement thoracique" is supposed to be caused by the rapid involvement of the pleura, with its consequent thickening, by which the proper expansion of the lung is prevented. As a curiosity which does not occur very frequently, but which, when it does happen, can hardly be distinguished from primary malignant tumor of the lung, see the case of Boris. ^ In this case there were all the symptoms from which a diagnosis of primary malignant neoplasm of the lung could have been made, though the clinical diagnosis was tuber- culosis. At autopsy no positive anatomical diagnosis was attainable and it was only through microscopic examination that the tumor was found to be chorionepithelioma, the primary focus being an insignificant and easily overlooked spot in the broad ligament. The case of Couvelere ^ may also be mentioned as one of those congenital cystadenoma- tous structures which might occasionally be confounded with primary malignant tumor. A glance at some of the other cases recorded in Table IV will show a number of instances of congenital adenomatous, cystic, and some secondary, tumors of the lung which might be confounded with pri- mary malignant neoplasms, and in many cases the differ- ential diagnosis will be almost impossible. There are some of particular interest, as the case of Dionisi,' the case of » Table IV, No. 1. » Table IV, No. 6. » Table IV, No. 7. 106 PRIMARY MALIGNANT GROWTHS OF THE LUNG Lesieur et Rome.^ In the latter there was a large massive cyhndrical celled typical carcinoma in the lung, where only a careful autopsy showed the primary focus to be a very insignificant nodule in the rectum. The tumor in the lung had precisely the character of the rectal cancer and is further remarkable for the fact that it is the only secondary tumor of the lung on record which consists of one large massive growth. The case of Laseque ^ is also to be noted as a case of lympho-sarcoma, where the primary focus could not posi- tively be determined, but may have been in the lung, and the case is remarkable for the very unusual generalization of the lympho-sarcoma simulating a primary tumor. The cases of dermoid tumor of the lung, — that of Sommers ^ and Sormani,^ — though they may in many respects, for a time at least, be mistaken for primary malignant neoplasm of the lung, will soon appear in their true nature by the expectoration of hair and other dermoid components. Of great interest, also, is the case of Linser,^ which might easily have been mistaken for a malignant tumor of the lung, but which on autopsy turned out to be a congenital cyst-adenoma of the lung with a profuse production of mucus. Boecker,^ when presenting his interesting case of the production of mucus in a case of carcinoma of the lung, speaks also of the cases of Lohlein^ and Helly.^ He be- lieves that Lohlein's case is a genuine case of carcinoma with profuse production of mucus. The character of Helly's case is not yet satisfactorily determined. There is also to be mentioned the case of Jores.^ In this case a dermoid cyst of the left lung was connected with a maUgnant cysto-sarcoma. It is not necessary to go into the details 1 Table IV, No. 13. 2 Table IV, No. 12. » Table IV, No. 17. * Table IV, No. 18. ^ t)ber einen Fall von congenitalem Lungen-Adenom, Virch. Archiv., No. 157, p. 281. ^ Loc. cit. 7 Table IV, No. 14. 8 Table I, No. 122. ® tlber die Verbindung einer Dermoidcyste mit malignem Cystosarcom der linken Lunge, Virch. Arch., No. 133, p. 66. CLINICAL (Continued) 107 of the case. There seems no doubt that the sarcoma was developed secondary to the congenital dermoid cysts. It is customary, in the study of any clinical subject, to conclude with a careful discussion of the treatment. The treatment of primary malignant growths of the lung has not required much discussion in the textbooks up to date, and if mentioned at all is finished off with one or two lines. The diagnosis of a cancer of the lung was the death-warrant of the patient. In former times, before medicine determined to become one of the natural sciences, the patients were treated, not for cure, but for relief, by all sorts of barbarous means. It is about one hundred years ago that Heyf elder, ^ disgusted with the treatment that these unfortunates were receiving under all sorts of diagnoses, — the blood-letting, the purging, the salivation, etc., — urged upon physicians the necessity of recognizing these cases as cancer and as hopeless, and begs them not to add the torture of medical treatment to the sufferings consequent upon the disease itself. "Optima hie est medicina, medicinam non facere." Present-day medicine treats these cases purely symptomat- ically with the sole object of relief, and the interest attaching to an accurate diagnosis is mainly theoretical and scientific. It is not to be wondered at that the physician takes little interest in types of diseases that offer not the slightest hope of therapeutic success. It cannot really, he thinks, if he thinks at all, make any difference to the patient if he is to die of a pulmonary phthisis or of a far advanced pulmonary cancer. It is not very many years ago that Benda^ was justified in asserting that cancer of the lung occupied a unique position, inasmuch as it was the only cancer that was absolutely beyond the reach of the surgeon; but he went a step further and added that no matter what progress surgery might make, it could never hope to deal satisfactorily with lung cancer, as it would always remain impossible to make the diagnosis early enough for any reasonable expecta- * Loc. cit. ^ Zur Kenntniss des Pflasterzellenkrebses der Bronchien, Deut. Med. Wochenschr., 1904, p. 1454. 108 PRIMARY MALIGNANT GROWTHS OF THE LUNG tion of a cure by surgical interference. This is a practical illustration of how unwise it is to attempt to set hmits to the progress of science. Since Benda made this daring state- ment, matters have completely changed. The technique of thoracic surgery and especially of lung surgery, — thanks to the efforts of Brauer,^ Friedrich,^ and Garre and Quincke, ^ and in a more practical maimer the efforts of Sauerbruch, Willy Meyer, Meltzer, and Lenhartz, — though evidently still in its beginning, has already developed to a marvellous degree. Lenhartz ^ succeeded in operating several cases of cancer of the lung, and in one case, to all appearances desperate and hopeless, by removing the affected lobe in its entirety, prolonged the patient's life for a year and a half, and with comparative comfort. There is every reason to hope that the technique of this new branch of surgery will be still fiuther developed and that in the near future thoracotomy and operations on the lungs will be attended with no more risk than are peritoneal operations to-day. If this is so, a new and great responsibility is placed upon the shoulders of internal medicine. It will be necessary, not only to educate the opinion of the laity so as to induce them to submit to these operations with the same readiness with which they now submit to peritoneal operations, but it will also be the sacred duty of the physician to recognize these cases and to recognize them as early as possible. The physi- cian must be imbued with the conviction that malignant pulmonary disease occurs much more frequently than is commonly beUeved and that he may meet it any day in his practice among the young, as well as among the old. As at present the conscientious physician examines every chest for possible tuberculosis, so in the future every chest will have to be examined for possible tumor. The writer would go still further. Where all the means of diagnosis outlined in this httle study fail, where there is suspicion of tumor, ^ Referat uber Lungenchirurgie, Verhandl. der Gesellschaft Deut. Natur- forscher und Artze, September, 1908. * Die Chirurgie der Lungen, Archiv. f. klin. Chir., 1907, Vol. 82, p. 1147. * Grundriss der Lungenchirurgie, Jena, 1903. * Conf . the various pubhcations of the Hamburger Staatskrankenhaus. CLINICAL (Continued) 109 but no assurance is possible, there should be, — it is emphat- ically here stated, — as httle hesitation in resorting to an exploratory thoracotomy as there is nowadays in submitting to an exploratory laparotomy. A very few cases have been treated in this way.^ The writer himself has had occasion to advise exploratory thoracotomy in two cases, but neither the physicians nor the lay pubUc are as yet educated up to the proper point of view, and both cases preferred to die of cancer without an attempt at cure or relief. But even in cases far advanced, where there is apparently no hope what- ever and death seems imminent, a thoracotomy may, under certain conditions, be indicated. It is obvious that no one would think of operating on the very aged, with predominant brain symptoms, or in any case where the lung symptoms are more or less in the background; but a thoracotomy, with a possible resection of one or two or three ribs, by draining off continually recurring effusions, by the decompressing effect produced thereby, quite similar, in fact, to the opera- tions now performed for brain tumor, may give reUef and produce euthanasia, in the place of otherwise unspeakable torture. In conclusion, the writer may be permitted to express the hope that malignant disease of the lungs, so disastrous in its results, may perhaps in the near future be summarily dealt with in its incipiency, or at least modified in its progress, so as in some measure to assist in diminishing the sufferings of humanity. The writer's ideal hopes will be fulfilled if this essay contributes in ever so small a degree to this result. 1 Miiser, Table I, No. 208; Benda, loc. cit., and a few others. APPENDICES Carcinoma — Duration Not stated 226 No autopsy 1 Doubtful 1 "Several years" 1 6 years 2 4 years 2 3 years 1 2| years 2 2 years 7 1^ years 6 1^ years 3 1 year 16 11 months 1 10 months 7 9 months 9 8 months 4 7 months 9 6 months 15 6^ months 4 6 months 11 4| months 1 4 months 4 3| months 1 3 months 15 2| months 2 2 months 10 "Several months" 1 li months 5 5 weeks 3 3 weeks 2 2 weeks 2 374 B Sarcoma — Duration Not stated 48 6 years 1 3\ years 1 3 years 2 Between 2 and 3 years 1 2f years 1 2 years 2 22 months 1 16 months 1 15 months 1 1 year 4 11 months 1 10 months 2 9 months .- 2 8 months 1 6 months 2 6 months 4 4 months 4 3^ months 1 3 months 3 21 months 1 2 months 3 1| months 2 1 month _1 90 C Carcinoma METASTASES Lymph Nodes Bronchial lymph nodes 117 Mediastinal lymph nodes 45 Tracheal lymph nodes 26 Cervical lymph nodes 23 Retroperitoneal lymph nodes . 23 Hilus nodes 16 Regionary lymph nodes 15 Axillary glands 15 Mesenteric glands 14 Supraclavicular 13 Peribronchial 6 Inguinal glands 3 Posterior mediastinal 2 Peritracheal 2 Clavicular 2 110 APPENDICES 111 Epigastric glands 2 Portal glands 2 Subclavicular Glands of neck Glands of chest Subdiaphragmatic glands Substernal Perigastric Retrogastic Periaortic Thoracic glands Peritoneal glands Parotid glands Lumbar Celiac "Lymph nodes" not specified . Liver 103 Gall-bladder Left Lung . . Right Lung . Both Lungs . Root Lungs . 1 28 22 16 2 Pleura ?5 Pleura 10 Right Pleura q Left Pleura 8 Pericardium Heart . . 39 Left Ventricle 7 Right Ventricle ?: Left Auricle 6 Right Auricle 3 Myocardium Interventricular Septum of Heart 3 3 Origin Aorta ? Large Vessels ? Pulmonary Veins '?, Lower Cava 1 Both Kidneys Left Kidney 32 15 Right Kidney 11 Left Suprarenal 17 Right Suprarenal 7 Both Suprarenale Spleen 14 17 Capsule Spleen 1 Pancreas 6 Thyroid 1*;^ Brain ?8 11 Dura Mater Corpus Striatum Cerebral Hemispheres Hypophysis Medulla Cerebrum Spinal Cord Nerves (Left Vagus) . Peritoneum Intestines Ileum Diaphragm (Esophagus Stomach Pylorus Gastro-hepatic Ligament . . . Mediastinum Posterior Mediastinum .... Bladder Right Testicle Uterus Ovaries (1 Left) Skin Left Eye Left Leg Finger-tip . . . . Tip of Nose . . Nasal Septum Skeleton "Bones" Skull Frontal Bone Parietal Bone Sternum Clavicle Chest Wall . . Ribs Upper Ribs . . . 1st to 7th 5th rib 6th rib 7th to 8th Vertebrae Dorsal 3d dorsal 7th to 8th dorsal 3d cervical 7th to 10th Lumbo-sacral . . . 10 1 1 1 1 1 2 1 7 1 1 6 3 4 1 1 4 1 112 PRIMARY MALIGNANT GROWTHS OF THE LUNG Femur Right Humerus Long Bones , . . Iliac Fossa .... Shoulder Joint Muscles Intercostal Trunk Back and Abdomen Chest Back Not Specified No Metastases Metastases not Mentioned D Sarcoma METASTASES Lymph Nodes Bronchial Mediastinal E-etroperitoneal Axillary Cervical Peribronchial Hilus Inguinal Posterior mediastinal Regionary Mesenteric Infraclavicular Supraclavicular Retrobronchial "Lymph nodes" Various Liver 3 1 1 1 1 2 33 57 15 10 5 5 4 3 3 2 Right Lung Left Lung Side not Specified Pleura Pericardium . . . Heart Muscle . Left Ventricle Left Auricle . . Right Auricle . Auricles Brain Spinal Dura . . . . Spinal Cord . . . . Left Recurrent Anterior Mediastinum Diaphragm Hepato-duodenal Ligament Pancreas Spleen Peritoneum QilSOPHAGUS Kidneys Right Kidney Left Kidney 16 Skin Lower cava Vertebrse Right iliac Left shoulder Scapula ; . Ribs (2, 3, 4) (9, 10, 11) Right humerus Humerus (side not stated) . No Metastases Metastases not Mentioned 24 15 Note. — It was found practically impossible to classify the metastases accord- ing to a uniform system. They were, therefore, recorded as reported by the authors and grouped as nearly as feasible according to the various organs and tissues affected. TABLES 114 TABLE I Adleb Abler M 66 LUNG IN- VOLVED M Adleb 4 Abler, I Packard, M., Med. News, Feb. 18, 1906 M 67 R 67 M Adleb 55 R M 26 R CLINICAL SYMPTOMS Admitted to hospital in moribund condition with symptoms interpreted as pulmonary phthisis. No history obtainable In hospital for 3 weeks. For 3 months cough and pain in right chest. Progressive loss of strength and flesh, anorexia and nausea. Flatness and absence of voice and breathing over greater part of right lung. 800 c.c. of bloody serum aspirated from right pleura. Irregular fever up to 102. Acetone in urine. Haemoglobin 65; reds 4,500,000; whites 15,000 No heredity. Inveterate smoker. Stout, healthy-looking. Harassing cough, pain in left upper chest, dyspnoea on slight exertion. For several years repeated profuse haemop- tysis. Flatness, absence of voice and breathing over left anterior chest. No fever. Sudden death from profuse haemoptysis. Approximate duration of disease about 4 years No heredity. For 6 years cough and pain in right chest. Had periods where cough and pain would disappear. For 2 years cough permanent a,nd more harassing; gradually increasing dyspnoea. Veins over chest and upper abdomen enormously dilated and tortuous. Complete flatness, absence of voice and breathing over anterior right chest. No bulging. Occasional profuse haemoptysis. Haemoglobin 62 ; red cells 3,980,000; white cells 14,300; lymphocytes 24%. Later enlarge- ment of axillary and supraclavicular lymph nodes. 600 c.c. clear serum aspirated from right pleura. Death in a hansom-cab from haemoptysis Father died of cancer of stomach. Patient always in good health until about I2 months before admission. Pain in right chest; no cough; no expectoration. Increasing debility. CARCINOMA 115 AUTOPSY NOTES Scant, muco- punilent, at times bloody, no tuber- cle bacilli or tumor elements Muco- purulent, some- times bloody for weeks, no tuber cle bacilli or tumor elements None at first, then muco- purulent and re- mains bloody; no tuber- cle bacilli or tumor elements None Heart dislocated to right; right lung normal. Sanguin- olent effusion in left pleura; pleura much thickened. In upper left lobe a tumor size of two fists with cavity in centre Medullary carcinoma METASTASES Region- ary lymph nodes, liver, both kidneys and spleen Large tumor involving upper portion of lower and lower portion of upper lobe of left lung, containing an irregular cavity filled with blood and broken down tumor material, and into which stumps of vessels and bronchi infiltrated with tumor material still project. The rest of left lung diffusely infiltrated with tumor along the track of the bronchial ramifications Tumor of the right main bronchus extending to the posterior portion of the left bronchus. Tumor pene- trates the right lung in all directions to the pleura along the track of the bron- chial ramifications. Numer- i bronchiectatic dilata- tions. Compression of upper cava, right pulmonary and right innominate arteries Right pleural cavity com- pletely filled with huge masses of old fibrinous blood clot, and entire lung pushed against posterior chest wall Pericar dium, heart muscle, kid neys, left suprarenal, bronchial and medias- tinal lymph nodes Pericardium, bronchial, mediastinal, and retro- peritoneal lymph nodes and liver MICROSCOPE Medullary carcinoma Pleural surface of right dia- phragm, pericardium, regionary lymph nodes and left lung It was practically impossible in micro- scopic examination of the main tumor in the left lung to say whether we had to deal with a round- celled sarcoma or with a carcinoma. Only the study of the metastases made the diagnosis of carci- noma absolutely cer- tain Typical car- cinoma of glandular type Epithelioma Right auricle, cer- vical, medi- astinal, and bronchial 116 TABLE I Adleb Adleb, Garbat, A. L., American Joum. of Med. Sciences, 1909, Vol. cxxxvii, p. 857 Adleb Allan, Geo. A., Lancet, Oct. 6, 1907, p. 961 Primary Cancer of Left Bronchus with Unusual Associa- tion of Pressure Symptoms: Sec-_ ondary Growth in Thyroid and Lym- phatic Glands BEX AGE M M M M 63 63 52 38 LUNG IN- VOLVED R R R CLINICAL SYMPTOMS Subsequently hoarseness, swelling of right side of face, right chest, arm, and foot. Impaired respiratory motion of right chest. Flatness over right chest except a rather large area pos- teriorly where there is increased vocal fremitus and some tympany on per- cussion. Heart 8 cm. beyond left mammillary line. Irregular areas of bronchial breathing and dulness on left chest. Tyrnpanitic area in right chest steadily diminishes in size No heredity. Harassing cough with profuse mucopurulent, sometimes bloody expectoration for some years. Lately loss of weight and strength. Pain and slight dyspncea on exertion. Complete flatness, diminished voice and breathing sounds to 4th rib on right side. Diagnosis of tumor during life Loss of weight for over a year. Cough, hoarseness, night sweats. Impaired respiratory motion of right chest with diminished voice and breathing anteriorly, flatness pos- teriorly. In November 150 c.c. bloody serum withdrawn. No characteristic elements. 6 weeks later increasing dulness, high fever. Aspiration 60 c.c. chocolate-colored pus. Thora- cotomy. 6 weeks later cholecystitis; 3 stones removed by cholecystotomy. 6 months later soft tumor over right scapula; tumor excised; carcinoma. Increasing weakness; death Uncertain history of malignancy in family. Always healthy; no syphihs. For 2 months spitting of blood in the morning. Increasing cough. Slowly diminishing weight and strength at first; later rapidly diminishing weight and strength. Increasing pain in up- per right chest; dulness over right upper lobe; diminished breathing and respiratory motion. 2 weeks before death signs of cavity in apex. No previous history; no syphilis. DoulDtful heredity. Pain in left chest radiating into shoulder and down left arm. Increasing loss of strength and weight; dyspnoea on slight exertion. Hoarseness; harassing cough. Flat- ness over greater portion of left chest in front and behind, with absence of voice and breathing, but distinct transmission of heart sounds every- where. No rales. Right chest nor- mal. Hard mass above left clavicle. Enlarged nodes in left neck and CARCINOMA 117 Mucopuru- lent, fre- quently- bloody, no tuber- cle bacilli Profuse, purulent, bloody, no tuber- cle bacilli, no tumor cells No tuber- cle bacilli, but very numer- ous large "Korn- chenzel- len"(Len- hartz) Never bloody, no tuber- cle bacilli AUTOPSY NOTES and compressed. Anterior half of right lung completely replaced by tumor. Right auricle, pulmonary artery, and upper cava compressed by tumor. There are throm- boses reaching into the right internal jugular and sub- clavian arteries Confirmed diagnosis. Records could not be ob- tained Right pleura and dia- phragm thickened and ad- herent. Middle and lower lobe almost entirely replaced by tumor. Bronchiectatic dilatations Cavity in right apex sur^ rounded by tumor extending along bronchial vessels to the hilus and to the pleura Gray hepatization around the tumor Clear serum in right pleura. Cancer encircling left main bronchus from bi- furcation downward and obstructing its lumen. Bron- chiectatic abscesses; throm- bosis of left subclavian vein Degeneration of left recurrent METASTASES lymph nodes Both lungs, liver, bron- chial and retroperito- neal lymph nodes Right pleura ; su- praclavicu- lar gland Bronchial and medias- tinal lymph nodes, left pleura, peri- cardium, and left lobe of thyroid MICBOSCOPE Cylindrical- celled carci- noma. Un- doubted ori- gin from bron- chial mucous glands Squamous carcinoma probably originating from small bronchus Scirrhus with unusua- ly large cells having ten- dency to ne- crosis 118 TABLE I 10 11 Anderson, J. W., Glasgow Med. Jour., 1883, 146-148 Angelhoff, .. Diss. Miinchen, 1905 tjber das primare Lungencarcinom 12 13 14 M Antze, Diss. Kiel, 1903 (After Angelhoff) ijber primaren Lun- genkrebs Aknal, Gaz. des H6pitaux 1844, p. 78 Cancer gpitheloide du Thorax, etc. ASCHENBORN, M Arch, f . Klin. Chirur., 1880, 171 M LUNG IN- VOLVED 66 75 M 40 R R 64 12 R R CLINICAL SYMPTOMS axilla. Intermittent fever up to 103. Paralysis of left recurrent; left pupil contracted; slight ptosis of left eyelid. Local hyperhidrosis of right face and head. Death 5 months after first definite symptoms Severe dyspnoea. CEdoema of upper part of body, including face, chest, and both arms. Superficial veins dilated. Slight cough and expectoration. No fever. Dulness on right chest from clavicle to nipple; both bases dull, with diminished respiration and voice For 3 months cough, expectoration, dyspnoea; some fever. Pain in left chest; night sweats. Increasing emaciation; impaired respiratory mo- tion of left chest. Dulness to 5th spinous process posteriorly; bronchial breathing; a few rales. Flatness and loss of breathing and voice at base. Bloody serum removed several times by aspiration. Clinical diagnosis: pul- monary phthisis Cough, expectoration, pain, jaun- dice. No dulness. Temporary im- provement. After 1 year dulness over whole right lung; tjonpanitic percus- sion note and amphoric breathing at right base. Some fever. _ Intense pain and dyspnoea. Clinical diag- nosis: phthisis and gangrene of right lung While in perfect health sudden chill, fever, sore throat, cough and symptoms of bronchitis, diagnosed as influenza. Soon after dyspnoea, aphonia, stenotic respiration to right of sternum. Loss of breathing sounds over lower lobe, but normal percussion note. Left lung normal. Later oedoema of face, neck, and arms ; dilatation of veins of right chest and abdomen. Subse- quently effusion in right _ chest and oedoema of lower extremities. A few days before death respiratory murmur is again heard over lower right lung. Sudden death. Duration of disease about 9 months Sick more than 2 years. Right chest expanded by tumor pushing heart to left and liver downward. Flatness, absence of breathing sounds, extreme dyspnoea, cyanosis, and ca- chexia CARCINOMA 119 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE BEMARKS No details Fluid in both pleurse. Tu- mor at root of right lung. Compression of upper cava No details Not given Author says: "Tumor is probably sarcoma, originating from bronchial glands at root." This seems doubtful; more prob- ably a bronchial car- cinoma Mucopuru- Bloody fluid in left pleura. No details Alveolar lent, no Whole left lung retracted structure. bacilli and compressed ; studded with tumor nodules. Bron- chi filled and surrounded with similar tumors. Tu- mor nodules over costal and pulmonary pleura and dia- phragm voluminous stroma, poly- morphous and typical cylindrical epithelial cells; areas of glandular ar- rangement Not stated Cancer of right main Bronchial, Alveolar bronchus and its branches. mediastinal, structure, ori- Chronic pneumonia and cervical, and gin from sur- bronchiectases; gangrene of retroperito- face epithe- lung; compression of upper neal lymph ium of main cava nodes. Per- foration of cancerous lymph nodes into oesophagus Dronchus Bloody Serious effusion in right Right lung. Not given Probably carci- pleura. Tumor in right bronchial. noma of bronchus of lower lobe with cavity in its mediastinal. right lower lobe centre. Right main bron- and cervical chus obstructed by larda- lymph nodes ceous neoplasm, also bron- and right chus of lower lobe almost kidney completely occluded. Com- pression of upper cava and recurrent laryngeal Not stated Entire right lung except a small remnant at apex converted into tumor, erod- ing several ribs. Tumor contains several large cysts filled with dark fluid. Ev- None Not given Tumor is called cysto-carcinoma of lung erything else in body normal 120 TABLE I 15 16 AUFRECHT, Nothnagel Handbuch d. Spec. Path. u. Therapie, Vol. XIV, 1st Ed., 1899, p. 370 ff. Das Lungencarcinom Loc. err. 17 Loc. CIT. 18 19 AtTGIEH, G. AND Desplats, N., Journ. de Soc. Med de Lille, 1883 AirVAED, Biillet. Soc. Anat. de Paris, 1882, 9&-99 M M M M M 65 58 LUNG IN- VOLVED R 46 69 56 R R 20 21 Bargtjm, Diss. Kiel, 1897 Ein Fall von primarem Krebs der Trachea und des rechten Bron- chus Baeth, H. Le Bull. M6d. Paris, 1902, Vol. XVI, Pt 2, p. 757 62 37 R clinical symptoms Dulness over right middle and lower lobe. Diminished breathing; loss of fremitus. No fever. Nutrition good. Dyspnoea on exertion. Aspiration negative. Increasing weakness. Dura- tion of disease 14 weeks Father died of cancer of stomach. Patient always healthy. Commenced with cough and dyspnoea; later effu- sion in left pleura. Aspiration 2300 c.c. bloody serum; breathing becomes better; dulness remains. Sudden death from pulmonary oedoema. Dura- tion about 1 year. Clinical diag- nosis: pleurisy For 8 months " inflammation of lung and pleura." For 4 months dysp- noea. On admission immediate resec- tion of ribs with discharge of 3000 c.c. of pus from right pleura. No relief after operation. Increasing stridor and dyspnoea. No fever. Enlargement of supraclavicular glands. Tumor size of apple in liver. Paralysis of right vocal cord. Death 26 days after operation. Diagnosis made during life Fever, dyspncEa, dysphagia, pain in chest. Flatness to 3d interspace; absence of breathing Sick 5J months. Dyspnoea, pain in left chest. Dulness over entire left side. Diminished fremitus; absence of breathing at base ; further up harsh bronchial respiration. Heart dis- placed toward right. No cachexia. Later anorexia; some fever toward evening. Chest aspirated without result. Later cedoema and albuminuria No heredity. 6 weeks after re- covery from some acute disease with cough and fever, swelling of face and neck, later of chest. Dyspnoea and cough especially after eating. Cyano- sis. Area of dulness with diminished voice and breathing over right lower chest. Nothing else on lungs. Some effusion in right pleura Small, poorly nourished woman. Repeated attacks of bronchitis. Pres- ent illness began only 5 days before admission with cough, fever, and chill. CARCINOMA 121 AUTOPSY NOTES METASTASES MICROSCOPE Mucopu- nilent, mixed with blood Not stated Occasion- ally bloody Bloody Not stated None Abundant,' purely mucous, no blood. Diffuse medullary carci- noma in lower portion mid- dle lobe Left lower lobe converted into a firm tumor in which only the larger bronchi can be distinguished; centre broken down Carcinoma probably of right main bronchus ob- structing trachea and bron- chus Mediastinal lymph nodes Liver Not given Not given Mediastinal and tracheal lymph nodes and liver Not given Upper right lobe almost completely replaced by soft cheese-like tumor. Pleura thickened; bronchi com- pressed. Remainder of right lung pneumonic hepa- tization Entire left lung one mass of white encephaloid tumor containing many cavities. Granulated tumor on peri- cardium Beginning of right main bronchus and wall of trachea infiltrated with tumor. Sec- ondary bronchus also oblit- erated by tumor. Bronchi- ectatic cavities in right lower lobe. Compression of right jugular, innominate, and ax- illary veins, also upper cava. Abundant effusion in right pleura Right lung healthy except old and healed tubercular foci in apex. Left pleura adherent and whole left lung Bronchial and tracheal lymph nodes Mediastinal and bron- chial lymph nodes Regionary lymph nodes Not given Tumor sim- ply desig- nated as encephaloid cancer No details Tumor simply des- ignated as cancer Absolutely not a second ary deposit throughout Alveolar structure ; polymor- phous epithe- Remarkable points about this case are the pleurisy with little effusion, the 122 TABLE I Cancer primitif oblit6- rant de la grosse bronche gauche; _ Bronchopneumonie tuberculeuse du Pou- mon correspondent 22 23 "24 26 Beale, Med. Times & Gaz., London, 1869, II, 382 Beattftim^, Bull, et M6m. de la Soc. Anat. de Paris, 1902, Jom., IV, No. 7, p. 664 Cancer massif primitif du Poumon avec Le- sions multiples Beck, Hugo, Zeitschr. f. Heilk., Vol. V, 1884, p. 459. (Path. Festschrift, Prag) Zur Kenntniss des pri- mS,ren Bronchialkreb- Log. ciT. M M 41 Not stated 67 LUNG IN- VOLVED R R M 65 R CLINICAL SYMPTOMS 4 days before admission pain in left chest. On examination impaired res- piratory motion of left chest; slight dulness at base ; feeble respiration and pleuritic friction. Fine rales over whole of chest. Fever up to 40° C. Diagnosed as grippe (which was then epidemic) with pleuritic complications and the possibility of tuberculosis. Next day everything improved except left lung, which remained the same. Puncture over left chest withdrew clear serum without tumor elements, tubercle bacilli, blood, or lymphocytes. Later severe pain over left nipple, intense dyspnoea, high fever, diarrhoea, and vomiting. Later series of severe chills and hectic fever. About month after admission retraction of left chest, marked dyspnoea, much cough, rapid emaciation. Later absolute absence of voice and breathing; flat percus- sion note; later cyanosis and signs of cavity in left upper lobe. Death about 3 months after admission to hospital Loss of flesh, pain in left chest, profuse perspiration; dry cough. Flat- ness over left chest; no fremitus. Heart displaced ; some bulging of lower intercostal spaces. Dilatation of superficial veins. Progressive in- crease of dulness ; increasing cachexia. Later painful secondary tumor in left axUla Old syphilitic with tertiary lesions. Large liver, dyspnoea, cachexia. Bloody effusion in right pleura. Rapid de- velopment in 3 months. Clinical diagnosis: cancer of liver with in- volvement of lung and pleura No details Clinical diagnosis: tumor of right pleura CARCINOMA 123 AUTOPSY NOTES no tuber- consolidated and much cle bacilli smaller than normal. Lower lobe atrophic and retracted Blood and pus flow from trachea on taking out lung 3 cm. below bifurcation a round soft tumor arises from wall of left main bronchus, almost completely obstruct- ing bronchus. The whole left lung like a sponge filled with pus is a series of small round tumor areas sur- rounded by lung tissue ap- parently not much altered — some solid some softened and broken down in centre, alto- gether like tubercular foci. Bronchial tumor is not ul- cerated but is surrounded by apparently healthy mucous membrane; penetrates down to cartilage None No details No details No details METASTASES the entire body, not even bron- chial or tra- cheal glands Entire left lung occupied by tumor; only a thin shell of lung tissue remaining be- hind and at base Liver merely congested. Cancer right lower lobe. Aneurysm of descending aorta; thrombosis azygos Medullary tumor of right main bronchus and its rami fications. Bronchiectatic di- latations and lobular pneu- monic consolidation in right lung, also some tubercular granulations. Upper cava compressed and infiltrated by tumor Cavity in right upper lobe, walls infiltrated with cancer. Medullary cancer in right main bronchus and branches obstructing lumen. Neo- plasm extends through lung along bronchial ramifica- tions directly into cavity. Infiltration and compres- sion of upper cava and vena azygos Bronchial, retroperito- neal, and su- praclavicu- lar lymph nodes, axilla, and pericar- dium Diaphragm, pericardium, and medias tinal lymph nodes Bronchial nodes at hilus MICROSCOPE lial cells. Origin from bronchial mucous membrane. The foci in lung are proven to be tubercular, consisting mainly of typ- ical tubercles in all stages of develop- ment and degeneration complete atelectasis of lung, and the tu- bercular afifection of one side only No details Right bron- chial lymph nodes, pleura, thy- roid, liver, both supra- renals No details Alveolar structure ; spindle celled stroma Author thinks tumor spread along bronchial ramifica- tions and believes that thoracic duct was involved Origin from bron- chial mucous glands Alveolar structure ; large epithe- lial cells with frequent mu- coid degener- ation Origin from bron- chial mucous glands 124 TABLE I NO. AUTHOR SEX AGE LTTNG IN- VOLVED CLINICAL SYMPTOMS 26 Begbie, J. Wahburton Archiv. of Med., II, London, 1860-61, p. 145 Case of Mediastinal and Pulmonary Cancer M 50 R Always healthy. Cough, husky voice, intense dyspncsa; rapid emacia- tion. (Edcema right face, neck, arm, and over upper sternum. Dulness to 2d rib; diminished respiratory motion and fremitus. Feeble, stridulous, highly bronchial respiration. Tap- ping of chest gave temporary relief. In 23 days was tapped 10 times, total amount of clear seruin being 550 ounces. Duration of disease about 6 weeks 27 Behiee, Hop. de la Petie, Gaz. des Hop., 45, 1867 F 35 R Cough, headache, vomiting, fever. Emaciation, intense dyspnoea, neural- gia in right arm. Right chest 3 cm. larger than left. Dulness with tubular breathing and amphoric voice on right upper chest. Enlarged glands over right clavicle 28 Belcher, W. N., Brooklyn Med. Jour., Vol. V, 1901, p. 703 Primary Carcinoma of the Lung F 47 L Always in good health until attack of "grippe pneumonia." Effusion in left pleura; aspiration withdraws seropurulent fluid. Patient improved, but there was an early recurrence and several more aspirations were neces- sary. One week before death a nodule appeared under the skin on the anterior of left chest 29 Benkert, Diss. Freiburg. No date Das primare Lungen- carcinom M 49 R Pain about sternum; increasing dyspnoea and cyanosis. CEdoema of upper part of body, especially left arm. Dilatation of veins of chest. Left limg normal. Flatness over upper right chest; dulness below. Bronchial respiration. Enlargement of axillary lymph nodes 30 Benkeet, Loc. cit M 58 R Burning pain in right arm and neck. Cyanosis of face, ffidoema of neck and both arms. Clubbed fingers. Dul- ness posteriorly from 2d dorsal to angle of scapula. Below clavicle anteriorly, bronchial respiration 31 Benkert, Loc. cit. M 71 L No clinical history CARCINOMA 125 AUTOPSY NOTES METASTASES MICROSCOPE None None No details Bloody, contains spirals and nu- merous large epi- thelial cells No tubercle bacilli, numer- ous epi- thelioid cells No details Large " encephaloid " can cer under upper f of ster- num involving nearly all of right upper lobe and ob structing main bronchus. Compression of upper cava and large thoracic veins Irregular nodular, hard, white tumor, size of fist in right middle lobe Bloody fluid in left pleura, thickening of left pleura, pericardium, and left half of anterior mediastinum with hard nodular tumor masses connecting directly with nodule under the skin. Entire anterior left lung infiltrated with hard white tumor Bloody serum in right pleura and in pericardium In mediastinum a tumor ex- tending downward to the right, which involves right upper lobe. Compression of right auricle; thrombosis of jugular veins; compres- sion of innominate and sub- clavian, also trachea No details 1000 c.c. clear serum in left pleura. Right apex firmly adherent to ribs by tumor masses which extend through lung and penetrate trachea immediately above bifurcation Upper part of left lung ex- tremely soft tumor, nodu- lated with fibrous strands between nodules. Erosion of 2d to 5th dorsal verte- brae by neoplasm Right pleura, glands of neck, medi- astinal lymph nodes com- pressing trachea Bronchial glands, pleura, and pericardium "Distinct cancer cells" Probably bronchial carcinoma Axillary lymph nodes, tracheal, bronchial, mediastinal, and mesen- teric lymph nodes. Pericardium left supra renal. Small nodule, 2 cm in diameter in ileum Tracheal and bron- chial lymph nodes No details Author states that tumor con- tains typical cancer cells Scirrhus with cuboidal cells Typical medullary carcinoma T3T)ical pavement epithelium No details It is probable that the small tvmaor in the ileum was primary 126 TABLE I 32 33 34 35 Benkeet, Log. cit. Bennett, J. Hughes, Edinburgh, 1849, p 43 Cancerous and Can- croid Growths Beenheim and Simon, Revue M6d. de I'Est Nancy, 1886 Bernstein, A., Diss. Miinchen, 1909 Zur klinischen Diag- nose des primaren Lungencarcinoms 36 37 M M 66 45 39 53 LUNG IN- VOLVED R Betschaet, Vircho"ws Arch.," .. 142, 1895 Uber die Diagnose mahgner Lungentu- moren aus dem Spu- tum Bevacqua, a., Giornale internazio- nale delle Scienze Me- diche, 1904, p. 625 Sul Carcinoma cilin- drico primitive del Pulmone M 54 39 R R CLINICAL STMPTOM8 No clinical history Pain, dry cough, dyspnoea. Left chest less voluminous than right. General dulness over left chest. Flat- ness below clavicle. At apex bronchial respiration; below faint and dimin- ished. Increasing emaciation and cachexia Pain, radiating into arm and back. Dyspnoea; effusion in right chest. By aspiration 2000 c.c. of clear serum; smaller quantities are subsequently aspirated, later becoming hsemorrhagic History of lues and urinary troubles. Well until 5 years before admission, when urinary difficulties began. Three weeks before admission painful mictu- rition, feeling of great weakness, fever, much cough, stabbing pain in chest, mmabness in both hands. Right apex slightly dull; many rales. Later dulness left base with diminished respiration. Albumin in urine. Clini- cal diagnosis: tabes dorsalis, phthisis pulmonalis; neoplasm. Death about 5 weeks after admission No clinical history No heredity. Slight dulness, in- creased vocal fremitus and some moist rales in right subscapular region. All the rest of lung normal. No fever; very little cough at first. History of syphilitic infection. Pain for about a year, particularly in arms, head, and tibiae. Increasing cough_ and expec- toration; fever and night sweats. Pain at right base; signs of cavity in lung. Diarrhoea. Clinical diagnosis: tuberculosis CARCINOMA 127 BPUTTJM AUTOPSY NOTES METASTASES MICROSCOPE REMABE3 No details Tumor at hilus of left lung Lymph Pavement Author considers adherent to pericardixmi. nodes celled carci- the alveolar epithe- Right lung normal noma lium the starting point of the main tu- mor in the last 3 cases No details Upper left lobe dense yellowish-white tumor size of a large orange. Isolated nodules of cancer in left lung surrounding large bronchial tubes. Heart, right lung, and all other organs normal Bronchial glands and pericardium No details One small Chocolate colored fluid in Left pleura Merely hgemop- right pleura. Right lung and perito- stated that it tysis infiltrated throughout with neum, both is medullary firm, white tumors; bron- of which are cancer chiectatic dilatations studded with small nodules like tubercles Abundant, Simply says carcinoma of Left peri- Carcinoma mucoid, left lower lobe. A typical bronchial simplex (sic) no tuber- catarrhal hsemorrhagic glands and originating cle bacilli pneumonia in liver from bron- chial mucous membrane Sputum Cancerous infiltration of Right upper Cylindrical Bronchial surface contained right lower lobe ; also a sep- lobe and celled carci- epithelium stated aa numerous arate nodule not sharply corpus stri- noma starting point epithelial bounded. Lymphatics large- atum of the cells from ly injected with tumor brain which di- masses agnosis of tumor was made during life At first Left lung normal; right Bronchial, TjT)ical cylin- scant, lung adherent; grayish infil- subclavicu- drical celled later tration in centre of lower lar glands carcinoma. abund- lobe in which pulmonary and kidneys which author ant, never structure is no longer dis- considers as tubercle cernible. Cheesy deposits originating bacilli broken down and forming cavities surrounded by nu- merous miliary nodules. Bronchial glands enlarged; contain cheesy deposits, miliary nodules; some dif- fusely infiltrated. Anatom- ical diagnosis : tuberculosis of bronchial glands of lower from bron- chial mucous membrane 128 TABLE I NO. ATTTHOB SEX AGE LUNG IN- VOLVED CLINICAL SYMPTOMS 38 Beveeidge, Medical Press & Cir- cular, June 2, 1869 Case of Sudden Death M 64 R Slight cough; pressure over chest. Able to work until death. Sudden death from haemoptysis 39 BiRCH-HlRSCHFELD, Arch. f. Heilkunde, 19, 1878 (after Reinhard) M 50 R Cough, dyspnoea, weakness and ema- ciation; insomnia. Dulness over right upper lobe ; rough breathing in front; bronchial breathing behind right upper lobe ; rales. CEdoema and dilated veins of upper part of body. Glands over both clavicles enlarged to size of fist. Left lung normal 40 Blumenthal, Diss. Berlin, 1881 (quoted after Fuchs) Zwei Falle von pri- maren malignen Lun- gentumoren M 25 L Repeated haemoptysis; increasing dyspnoea. Gradually increasing dvil- ness over whole of left lower lobe with bronchial respiration and increased vocal fremitus; later bulging of left lower chest. _ First aspiration no fluid ; later aspiration effusion which later becomes bloody and under the micro- scope contains tumor particles. Fre- quent aspirations become necessary; repeated attacks of haemoptysis 41 Borx, Emile, Soc. Anatomique de Paris, 1891, p. 398 Cancer primitif du Pou- mon gauche, etc. F 59 L No previous history. Patient on admission pulseless; cedoema of lower limbs; arrhythmia. Extensive peri- cardial dulness; flatness and absence of voice and breathing over both sides of chest posteriorly 42 BOTESATO, Diss. Berlin, 1863 De Carcinomate Pul- monum et Pleurae F 43 L For 5 years dyspncsa and palpitation on slight exertion ; more recently ema- ciation and weakness, increasing dysp- noea, and severe pain in left chest. Dul- ness and impaired respiratory motion over whole of left chest; bronchial breathing over upper portion; dimin- ished voice and breathing over lower portion. Right lung normal. Mitral regurgitation. 2000 c.c. bloody fluid aspirated from left chest 43 B6TTGEH, Miinch. med. Woch., 1902, p. 272 Ein Fall von primarem Lungencarcinom M 68 R Oppression in right chest soon fol- lowed by cough, pain, fever. Right lower base: dulness, rales, diminished breathing. Diagnosis influenza. Six months later increased dulness involv- ing the entire lower lobe posteriorly; slight bulging appears ;_ impaired res- piratory motion, diminished fremitus. Progressive loss of strength and weight. Increasing dyspnoea, cachexia and pain. Death about 2 years after first com- plaint CARCINOMA 129 AUTOPSY NOTES METASTASES MICROSCOPE Not men- tioned Moderate, occasion- ally streaked with blood Repeated hsemop- tysis Not men- tioned Scant Scant, mu- coid, occa- sionally bloody; later raspberry jelly, no tubercle bacilli; a little later elas- tic fibres lobe of right lung; tubercU' lar, possibly syphilitic nod' ules in kidneys Two tumors in right lower lobe size of a hazel nut, one of which ulcerates into the bronchus Entire right upper lobe except at very top converted into nodular medullary tu- mor extending to enlarged lymph nodes in anterior m& diastinum. Compression of upper cava, trachea, and left bronchus Bloody fluid in left pleura. Solid tumor of left lower lobe from hilus to upper part of lobe. Tumor has invaded wall of left main bronchus and extends into its ramifi- cations, completely obliter ating the smaller bronchi Lower part of left lower lobe consists mainly of tumor nodules Large tumor occupying greater portion of upper left lobe. Numerous nodules of various sizes throughout re- mainder of left lung and pleura. Right lung normal. Effusion of yellow serum in both pleurae and pericardium Bloody serum in left chest; clear serum in right. Left pleura studded v/ith tumor nodules; injection of lymphatics with tumor. Large masses of tumor about the root of lung pene- trating into the lung itself Right lower lobe not ad- herent ; no bronchial glands. In the lower lobe surrounded by a thin layer of lung tissue a large tumor, grayish-white, partially firm and hard, par- tially soft; not sharply de- fined, but merging into sur- rounding lung tissue. All other organs healthy None No other metastases Not given Not given Left auri cle, pulmon- ary veins, right auricle, mediastinal and bron- chial lymph nodes No metas- tases Bron- chial and mesenteric lymph nodes, both suprarenals None, not even a single gland Microscopic diagnosis somewhat uncertain. Probably car- cinoma of scirrhus-like structure Alveolar structure ; isomorphous epithelial cells Scirrhus Alveolar structure, much necro- sis. Alveoli lined with cylindrical, sometimes cuboidal epi- thelium; also large giant cells Probably of bron- chial origin Author suggests possibility of alveolar origin Notice the very slow and chronic pro- cess of the disease, lasting over two years with but very slight systemic disturbance 10 130 TABLE I NO. AUTHOR SEX AGE LUNG IN- VOLVED CLINICAL SYMPTOMS 44 BOUILIAND, Journ. complimen- taire du Dictionnaire des Sciences medi- cales, 1826, Vol. 26, p. 289 Observations sur le Cancer des Poumons, etc. F 50 L Pain in chest, harassing cough, fever. Increasing weakness and emaciation. Right lung normal. Absence of breathing over left chest. Duratiott of disease about 7 months 45 BOTJTGTJES, Bull, de la Soc. Ana- tom. de Paris, 1888, 657 Cancer primitif du Pou- mon gauche F 64 L No previous serious illness. For 3 months pain in left chest, loss of strength and appetite and much ema- ciation. Occasionally bloody stools. Some cough; no expectoration; never bloody sputum. Tenderness and some resistance in epigastrium. Flatness over the whole of left lung. Almost entire absence of vocal fremitus. Heart displaced. Hardly any dyspnoea. Some few infraclavicular glands. Clin- ical diagnosis: tumor of lung secondary to cancer of stomach. Death a few days after admission with intense pain and dyspnoea 46 Boyd, Lancet, 1887, II, 60 Cancer of Bronchial Glands and Lungs M 38 R No clinical history 47 Log. cit. F 50 L No clinical history 48 Bremker, Arthur, Am. Jour. Med. Sci- ences, Vol. 136, 1903, No. 6, pp. 1020-29 Case of Probable Pri- mary Cancer of the Lung F 50 L Pain in left chest, cough. (Shortly before beginning of disease had been assured that heart and lungs were sound.) Dulness, later flatness over lower left lung. Heart displaced to right. Later dyspnoea, bulging of left chest. Bloody serum aspirated 49 Bristowe, Lancet, 1860, 1. 496 Not mentio ned Not mentioned CARCINOMA 131 SPTTTUM AUTOPST NOTES METASTASES MICROSCOPE BEMABES and large polymor- phous pave- ment cells; once a nest of concen- tric epi- thelial cells as- suring the diag- nosis Occasion- Left lung closely adher- Bronchial Not given ally ent; pleura much thickened and medias- bloody, and shrunken; left pleural tinal glands mucoid, cavity | smaller than right. later Nearly whole of left lung putrid transformed into scirrhus- like tumor with broken- down areas in its interior. Left main bronchus com- pletely obliterated by tumor None Left pleura thickened and infiltrated with tumor, also diaphragm. Tumor infil- tration throughout whole of left lung. Walls of bronchi thickened. Pericardium in- vaded by tumor. Heart, stomach and all other organs healthy Right lung, left pleura, liver, medi- astinal, bronchial, retroperi- toneal Ijonph nodes, right kidney Not given Not given Cancer of right main bronchus reaching to bifur- cation. Large solid tumor in right lung involving pleura and pericardium Bronchial lymph nodes Carcinoma Not given Cancer of root of left lung. Upper Not men- Obstruction of left main left lobe tioned bronchus by proliferating tumor masses in its lumen Not given 1500 c.c. bloody iSuid in None Cyst-adeno- Possibly from bron- left pleura. Tumor in left carcinoma chus. (I. A.) lower lobe Not given Specimen exhibited to il- Not men- Not men- This is undoubted- lustrate peculiar growth of tioned tioned ly a case of primary 132 TABLE I LUNG IN- VOLVED CLINICAL SYMPTOMS 60 61 BuHD, E. Ltcett, Transact. Path. See London, 1891, p. 55 Primary Carcinoma of Lung Chiabi,' Prag. Med. Wochen- schr., 1883, p. 497 Zur Kenntniss der Bron- chialgeschwulste Not giv- en 62 63 54 Claisse, Bulletin a Memoires de la Soci6t6 Medi- cale des Hop. de Paris, 1899, p. 46 Diagnostic precoce du Cancer du Poumon par I'etude histolo- gique des Crachats Coats, Transact. London Path. Soc, Vol. 34, 1888, p. 326 A Case of Multiple Can- cerous Tumors, many of them Cystic, in Lungs, Brain, Bones, etc. Primary Tumor probably in the Lung CoHN, Pattl^ .. Diss. Leipzig, 1903 Uber verhornenden 55 R 70 M M M 50 17 60 Not stated R Admitted for right pleurisy; dis- charged 3 weeks later much relieved. Readmitted 16 days thereafter with stitch in side, cedcema o2 face, s,rms and chest; much dyspnoea; dilatation of veins over shoulders and front of chest. Slight dulness over limited area in front on right chest. No adventitious lung sounds; no heemoptysis. Death about 6 weeks after admission No clinical history except "marked marasmus present" Health had been perfect but began to fail. Nothing could be found on lungs. Expectorated 2 particles about the size of a cherrypit from which diagnosis was made many weeks before sjrmptoms of tumor of lung appeared Entire clinical picture dominated by symptoms from nervous system — vomiting, headache, strabismus, choked disc. Normal temperature, normal respiration. Nothing pointed to disease of lungs. Tumors appeared in both femurs, various ribs, and around lumbar spine. Convulsions, coma, death. Duration of disease about 8 months No clinical history CARCINOMA 133 SPUTUM AUTOPSY NOTES METASTASES MICHOSCOPE BEMAHK3 cancer in lung, radiating cancer of the lung along bronchial tubes with infiltrations along the bronchial ramifications Not men- Upper lobe of right lung Medias- Not men- tioned infiltrated with new growth. Right bronchus occluded tinal lymph nodes form- ing large mass adher- ent to peri- cardium, root of lung, oesophagus, and great vessels tioned • No details Primary tumor in left Right Papillary lower lobe starting from lung, both structure hilus pleurae, bronchial and supra- clavicular lymph nodes, liver, spleen, and in cortex and medulla of both cere- bral hemi- spheres covered with cylindrical epithelium. No ciliated epithelium. Alveolar epi- thelium and bronchial mucous glands not involved No details Autopsy confirmed clini- cal diagnosis No details Sections of the particles expectorated showed epi- thelioma None In upper part of lower Bronchial Alveolar Cystic adeno-car- right lobe large ragged cav- lymph and cystic cinoma, probable ori- ity, the walls of which are nodes. structure gin from bronchial formed of grayish neoplasm. bones, lungs, with cylindri- mucous glands Solid tumor adherent to bi- pancreas. cal epithe- furcation and bulging into liver, peri- lium_ at base both main bronchi; at two toneum, _ and irregular. places tumors proliferate retroperito- cuboid, and into right main bronchus neal and mesenteric lymph nodes, ver- tebrae, fe- murs, and at least 22 cystic tu- mors in brain polymor- phous cells in interior of alveoli. Much colloid and mucoid material in alveoli and cysts No data Cavity in left upper lobe Ribs, Typical with necrotic sequestrum. clavicle, fe- cancroid Tumor infiltration and nod- mur, spleen, with horny, 134 TABLE I 65 56 57 68 59 60 61 62 Plattenepithelial- krebs der Lunge Davy, Lancet, 1882, II, 257 Degen, .. Dis3. Ziirich, 1897 Uber einen Fall von primarem Lungen- carcinom Delorme, ,. Diss. Jena, 1901 Uber primares Lun- gencareinom DiNKLEH, Verhand. d. Path Gesell., 1900, p. 59 Ein Fall von primarem Lungencarcinom Loc. CIT, Discussion by Ponick Loc. CIT. Loc. CIT. Discussion by Langen- hans DOEMENT, Zeitschr. f . Heilkunde, 1902, III M M M M M 43 50 LUNG IN- VOLVED 25 21 47 27 40 75 Both Both R CLINICAL SYMPTOMS Cough; dulness and bronchial respi- ration at left apex; pain in left side, impaired respiratory motion. No fremitus, feeble breathing ; interspaces flattened; emaciation. Later swell- ing of liver and ascites No heredity; always healthy until half year before admission when jaun- dice and pain in abdomen. Physical examination of lungs negative. Large, nodulated liver. Clinical diagnosis cancer of liver, possibly cancer of stomach. At no time any symptoms pointing to lungs; no cough; no pain No heredity; no previous illness. Cough, fever, scant expectoration, re- traction of left chest from 1st to 4th ribs; dilated veins; dulness. Dimin- ished respiration but normal vocal fremitus. Large bronchiectatic dila- tation at left base. Later clinical picture dominated by paralytic symp- toms in left arm and right face. Severe headaches and neuralgias. Later secondary nodules in numerous places — lymph nodes, ribs, sternum, skull. Duration not quite one year Diffuse bronchitis and broncho- pneumonia Healthy and strong. Sudden death from haemoptysis. No other clinical symptoms Irritating laryngeal cough for some weeks; sudden fever. Clinical diag- nosis pneumonia. Death in 6 days No clinical history. Diagnosis made correctly during life Cough, pain in side. Dyspnoea CARCINOMA 135 AUTOPSY NOTES METASTASES MICROSCOPE Abundant mucous expecto- ration ; no blood None Scant, occasion- ally tinged with blood No details None Bloody No data Purulent ules around cavity. Wall of afferent bronchus de- stroyed by tumor but com municates with cavity. Tu bercular cicatrix in right apex and at Bauhini's valve Clear serum in both pleurae. Left main bron chus compressed by tumor at the hilus penetrating into lung and invading pleura Small, primary infiltrat- ing cancer of left lung with miliary nodules along lym- phatics of left pleura. Be- sides the cancer an eruption of miliary tubercles Primary carcinoma of left bronchus; right pulmonary vein perforated by tumor Both lungs uniformly dis eased, gross aspect resem- bling most a cheesy pneu- monia Degenerating carcinoma of left main bronchus pene- trating into a large branch of the pulmonary artery Hard carcinoma of left main bronchus. Compres- sion of left pulmonary ar- tery. Hgemorrhagic infarc- tion of left lung Extensive diffuse infiltra- tion of both lungs resem- bling pneumonia Carcinoma of inferior right lobe extending into in- ferior cava. Chronic tuber- culosis of lung liver, right kidney, left adrenal, ret- roperitoneal glands. No metastases in bronchial glands Bronchial lymph nodes Liver, tracheal and bronchial lymph nodes Pericardi- um, pleura, bones of skull, both suprarenals, liver, vari- ous long bones, ster- num, ribs, lymph nodes Stomach No details No details Bronchial lymph nodes Diaphragm, right lobe of liver pavement epithelium No details Squamous celled carci- noma of scirrhous type Cylindri- cal celled car- cinoma Tumor is simply called cancer Carcinoma No details No details Cylindri- cal celled car- cinoma Epithelioma said to origi- nate from pulmonary alveoli 136 TABLE I NO. AUTHOH SEX AGE LUNG IN- VOLVED clinical symptoms 63 Log. cit. F 67 R Fever, dyspnoea, palpitation, pain in right side, cedcEma of both legs. Bloody effusion in right pleura 64 LOC. CIT. M 47 R No clinical history given 65 Log. err. M Not stated R Headaches, pain in left chest, dysp- noea; tenderness over right ribs; cyano- sis, salivation, clouded vision; cough 66 Log. cit. F 63 R No clinical history 67 Log. cit. F 79 Not stated No clinical history 68 Log. cit. M 41 L Severe headaches, disturbances of vision and hearing; somnolency and paralysis. Clinically diagnosed as tumor or tuberculosis of brain 69 Log. cit. F 66 R Fever, cough, pain in right chest, dyspnoea. Flatness over right pos- terior base 70 Log. cit. M 51 R Severe cough ; flatness right apex anteriorly, bronchial respiration and rales 71 Log. git. M 29 L Cough, pain in left chest, paresis left arm; fever, severe pain in back. Dulness, diminished breathing in left interscapiilar space. Bloody fluid in pleura 72 DOHSCH, Diss. Tiibingen, 1886 (quoted by Passler) Ein Fall von primarem Lungenkrebs F 54 R No clinical history CARCINOMA 137 Mucoid and haemop- tysis Not stated Scant No details No details Not stated Abundant Haemop- tysis Bloody No details AUTOPSY NOTES Carcinoma of middle and lower right lobes; carcinosis of right lung Carcinoma of bronchi and right lung; also tuberculosis METASTASES Medias- tinal lymph nodes, liver, and thyroid Liver, bron- chial lymph nodes Bronchial cancer of right upper lobe ; stenosis of bron^ chus. Old apex tubercu- losis Carcinoma of right bron- chus Carcinoma of left inferior lobe Two medullary tumors in right upper lobe, starting from right main bronchus at root of lung and extending into bronchus and upper Bronchial lymph nodes left kidney Not stated Tumor in main bronchus of right lower lobe ulcerat- ing into lumen and almost completely obstructing it. From bronchus tvunor pene^ trates into right lung Carcinoma of right in- ferior lobe; tuberculosis of right lung Carcinoma proliferating Bronchial along bronchi of lower lobe lymph nodes In left lower lobe, sur- 7 metas- rounding main bronchus, tases in cancerous mass radiating in- brain ; no to surrounding lung tissue others MICKOSCOPE No details B.ronchial ele- ments found normal and origin of tumor re- ferred to alveolar epi- thelium Carcinoma originating from bron- chial epithe- lium Not stated No details Bronchial and medias- tinal lymph nodes, peri- cardium, both pleurae Bronchial lymph nodes perforating into auricle Cranium, 6th rib, Uver, bron- chial and retroperito- neal lymph nodes, brain, right kidney Bronchial lymph nodes, lungs, liver, spleen, kid- Cylindrical cells of ade- nomatous structure originating from bron- chial mucous glands Cylindrical celled adeno- matous can- cer, originat- ing probably from bron- chial mucous glands No details No details Large poly- morphous epithelial cells tending to fatty degen- 138 TABLE I 73 74 76 76 77 Dbtsdalb, Medical Press & Cir- cular, Vol. LIII, N.S., London, 1892, p. 628 Case of Cancer of Left Liing Ebert Virch. Arch., Vol. 49, 1870, p. 61 Zur Entwickelung des Epithelioma der Pia und der Lungen Ebstein, Deut. Med. Wochen- schr., 1890, p. 921 Zur Lehre vom Krebs der Bronchien und der Lunge Log. cit. Ehrich, .. Diss. Marburg, 1891 Uber das primare Bronchial- und Lun- gencarcinom M M M LUNG IN- VOLVED 51 47 67 64 52 R CLINICAL SYMPTOMS Sick for 3 months with bronchitis; coughed up much pus. Dulness over left base, diminished fremitus and moist rales. Dulness gradually ex- tends; emaciation. At one time cough less troublesome and felt better. More breathing heard over left lung. Later increasing diilness, symptoms of cavity, diarrhoea and death. During life diagnosis was doubtful and malig- nancy suspected only towards end. Duration about 10 months Clinical history refers mainly to brain symptoms. Repeated examina- tions of chest negative. A few days before death, fever and cough. Dysp- noea and some cyanosis. Examination showed extensive dulness over left lower lobe and bronchial breathing; some friction Family history of cancer. Clinical nosis myocarditis, dilatation of heart, emphysema, bronchitis, effu- sion in right pleural cavity, diabetes. Disease extended over a number of years with occasional improvement. For several years no signs on lungs except some rales. Sudden death from heart failure Pain in left chest extending later to back and right chest. No cough, in- creasing emaciation, slight tempera- ture; dyspnoea; dulness at left base which remains stationary. Ribs un- even and tender; slight area of dulness on right side. Exploratory puncture negative. Tenderness of liver with enlargement of left lobe. Two days before death tumor appeared on 6th rib right side. 3 days before death stupor and paresis of left upper eyelid. Hemoglobin 62; reds 3,492,000; whites 32,000 For some months pain in both sides of chest and between scapulae, later paralysis of both legs. Very slight cough. Clinical picture dominated by typical symptoms of transverse mye- litis. Nothing characteristic in lungs. Fever up to 104 CARCINOMA 139 SPUTUM AUTOPSY NOTES METASTASES MICHOSCOPE REMARKS cava. Compression of pul- ney, frontal eration monary arteries bone, and dura mater Mostly pro- Pleura firmly adherent. Not men- Not men- Probably bronchial fuse, at Left lung contains numerous tioned tioned carcinoma from hilus times of- abscesses. Large cavity at fensive, apex containing pus; larger some- cavity at base containing times blood, pus and debris. Rest much of lung infiltrated with can- pus; occa- cerous growth radiating sionally from posterior mediastinum bloody. Several hsemop- tyses. No tubercle bacilli None Left lung completely infil- trated with whitish medul- lary mass; small nodules of similar character in right lung None Alveolar structure lined with ciliated epi- thelium None Main tumor in peribron- Peritracheal Cylindrical chial tissue of right lower and retro- celled carci- lobe; strands of tumor in peritoneal noma both lungs along peribron- lymph nodes chial and perivesicular lym- phatics None Carcinoma from left main Regionary Cylindrical bronchus at root, proliferat- lymph celled carci- ing into left lower lobe nodes, pleura, liver, gall-bladder, kidneys, both supra- renals, brain, pan- creas, peri- toneum, and various bones noma Scant, mu- Carcinoma in bronchus Bronchial, _No details; copuru- and tissue of left upper lobe. cervical and origin from lent, no Continuous propagation to retroperito- bronchial mu- tubercle pleura and 6th to 8th dorsal neal lymph cous glands bacilli, no vertebrse with compression nodes, liver. elastic myelitis. Diffuse carcino- spleen, kid- fibres sis of pleura and lung neys, right suprarenal, thyroid, hy- 140 TABLE I NO. AUTHOR SEX AGE LUNG IN- VOLVED CLINICAL SYMPTOMS 78 Log. git. M 51 R No heredity. Always well until short time before admission when some bronchitis and later haemoptysis. No dyspnoea; not much pain. Dul- ness, diminished respiration and voice over right upper lobe which dis- appeared later. Marked emaciation. Bloody effusion in right chest; large lymph node in right a,xilla 79 Log. cit. F 56 R Clinical diagnosis; tumor of anterior mediastinum 80 Elisbebg, Diss. KSnigsberg, Uber disseminirte^ Miliarkarzinose; besonders der Lungen ohne makroscopisch erkennbaren prima- ren Tumor M 27 R No heredity. Spasmodic dry cough worse on lying down; increasing dyspnoea and weakness; some cyanosis; no emaciation; no fever. Right chest somewhat sunken, drags in respira- tion. Dulness over right chest with loss of breathing and voice. Left chest normal. Blood and urine nor- mal. Duration of disease 4 to 6 months 81 Ennet, Diss. Greifswald, 1902 (after Angel- hoff) Ein Fall von primarem Krebs der rechten und Tuberkulose der linken Lunge M 62 R Cough and dyspnoea dating from fall; later flatness over right chest, dulness above. On aspiration turbid bloody fluid containing clumps of large epithelial cells. Increasing dyspnoea. Duration about year and a half. Clin- ical diagnosis: pulmonary tuberculosis 82 Ernst, Ziegiers Beitrage, Vol. XX, 1896, p. 155 M 50 R Abrupt onset of disease with obscure clinical symptoms suggesting menin- gitis or cerebral haemorrhage ; at same time cough, dulness at right apex. Patient died shortly after he began to complain CARCINOMA 141 SPTTTUM AUTOPSY NOTES METASTASES MICROSCOPE EEMARKS pophysis, dura and 1st and 7th left ribs Mostly Carcinoma from right Pericar- Alveolar Supposed origin bloody ; main bronchus involving dium, chest structure from bronchial mu- at one pleura and chest wall. Ribs wall, ribs, with large cous glands time ex- perforated by cancer. In pleura. polymor- pectora- lower lobe of right lung a bronchial phous cells tion of large cavity filled with nec- nodes and villous rotic tissue and communi- diaphragm and cating with right bronchus, bloody which is nearly completely masses obstructed by large prolifer- which ating tumor con- tained cancerous material No details Tumor lower part of tra- Bronchial Same as chea and right main bron- and medias- above chus and its branches. Com- tinal lymph plete atelectasis of right nodes, left tung. Hard, firm, white lung, liver, tumor at the root matting heart together pleura, trachea, _ bronchus, large vessels, peri- cardium, compressing upper part pulmonary artery. Tu- mor infiltration left lung Scant, mu- Effusion in right chest. Bronchial Transition coid, oc- Miliary carcinomatous nod- lymph from cylindri- casionally ules over both lungs and nodes, peri- cal and cu- bloody pleurae. Compression of toneum and boid to small right bronchus; extensive mucous polyhedral carcinomatous infiltration membrane cells through the lymph channels. of bladder Papillary and nodular tu- mor masses in bronchial mu- cous membrane Often _ Carcinoma of whole of No details Typical cy- bloody. right lung and right pleura; lindrical epi- contains ulcerating tuberculosis of thelial cells tubercle left upper lobe bacilli Mucopuru- Carcinoma of bronchus of Lsmiph Capillary lent right upper lobe extending nodes, dura. structure _ to main bronchus brain, cere- bellum, left suprarenal covered with epithelium resembling epidermis with prickle cells and ker- ato-hyaline; also spindle shaped giant 1 cells 142 TABLE I 83 84 85 FiNLET & PaBKEH, Medical Chirur. Trans., London, 1877, Vol. LX, 313- 324 Primary Cylindrical- celled Epithelioma of Lung FOA, Giorn. della R. Acad. di Med. di Torino, Vol.42, 1894, p. Ill Un Caso Cancro primi- tive del Pulmone Frankel, a. Spezielle Pathologie u. Therapie der Lun- genkrankheiten, 1904 86 Loc. ciT. 87 Fbiedlander, Fortschr. d. Med., 1885, 1, p. 307 (after Passler) Cancroid in einer Lun- gencaverne Froelich, .. Diss. Berlin, 1899 Uber das primare Lungencarcinom M M 37 Not St 40 M M M 52 Not stated 42 LUNG IN- VOLVED ated CLLNICAL SYMPTOMS Pain in left chest, cyanosis, dyspncea, clubbed fingers, cough, diminished respiratory movement of left chest. Flatness, feeble breathing, diminished fremitus. Aspiration negative. Later enlargement of 5upracla\'icular glands No cUnical history In perfect health until taken with chill and fever up to 104; dyspnoea flatness over whole of right lower lobe, loss of fremitus, diminished respira- tion. Pneumonia with gangrene of lung was diagnosed. Death before 2nd week of disease • For 2 years pain, cough, dulness over left lower lobe, feeble bronchial respiration, abundant rales. Dulness gradually extends over greater part of left chest. Puncture negative. Roentgen raj^ showed complete in- duration of entire left lung. Later flatness gradually diminishes until percussion note becomes normal every- where except one small area. Later again becomes tympanitic and finally absolutely flat until death. Inguinal IjTuph node had been removed and found carcinomatous, which corrobo- rated clinical diagnosis of carcinoma of left lung. Duration about 2| years No clinical history No heredity. Cough, pain in left chest, debility, anorexia; irregular flat- ness over left chest; diminished voice and respiration. Hsemorrhagic_ effu- sion in left pleura; later retraction of left chest, cyanosis, intense dyspnoea; later still amphoric breathing in lefti CARCINOMA 143 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE EEMAEK8 Pink Large, soft, pulpy tumor Mediastinal Alveolar in upper left lung and supra- arrangernent clavicular with typical lymph cylindrical nodes, cells pleura, both lungs, liver, right kidney No details Author calls tumor a Liver, Partly cy- broncho-pulmonary cancer kidneys lindrical, partly polyg- onal pave- ment epi- thelium. Author at- tributes ori- gin cylindri- cal epithe- lium to bronchi; pavement to alveoli Mucopu- Right lower lobe bronchi- LjTnph Cylindrical rulent, ectatic ca\dties filled with nodes at celled carci- copious; puriform secretion. Prolif- hilus noma later eration into main bronchus dirty of lower lobe of medullary brown tumor almost completely and foetid obstructing lumen and per- forating through wall Occasion- Occlusion of left main Inguinal Cylindrical ally bronchus with nodular med- lymph celled carci- bloody ullary tumor size of a man's fist at hilus, extending into lung tissue nodes; gen- eral carcino- sis of entire left lung noma No details A white medullary mass from bronchus of left upper lobe. Only in this bronchus and in a tubercular ca\'ity in left lung has cancer de- veloped None Horny pave- ment epithe- lium with typical can- croid pearls Scant, occa- Abundant bloody exudate Both lungs, Pavement sionally- in left chest. Pleura much pleura, peri- epithelium bloody; thickened and adherent on cardium. later all sides to extensive tumor bronchial. raspberry masses, so that exudate is mediastinal. jelly and completely encapsulated. cervical contains Posterior portion of upper lymph 144 TABLE I NO. AUTHOR SEX AGE LUNG IN- VOLVED CLINICAL SYMPTOMS chest. Enlargement of cer%'ical lymph nodes; nodular enlargement of liver; paralysis of left recurrent; death. Duration of illness about 9 months 89 Log. err. M 77 L No heredity. Pain in left side, cough. Increasing dulness left chest, bronchial breathing and rales. Re- traction of left chest with cessation of respiratory movements. Increasing cachexia. Clinical diagnosis pneumo- nia and marasmus 90 FrrcHS, Diss. Miinchen Beitrage zurKennt- niss der primaren Geschwiilstbildungen in der Lunge F 32 Both No clinical history 91 Log. git. F 56 R No clinical data except that the diagnosis was cerebral atrophy 92 Log. err. M 59 Both No clinical history except marked emaciation 93 Log. cit. M 64 Both No clinical history except during stay in hospital intestinal obstruction was suspected. Great emaciation 94 FUCHS, Diss. Leipzig, 1890 Beitrage zur Casuistik des primaren Lun- gencarcinoms (after Passler) M 73 R No cUnical history 95 Log. cit. M 51 R No clinical history 96 Geipel, Centralbl. f. Allgem. Pathol, u. path. Anat. X, 1899, p. 848 M 70 L Patient suffered for some time from severe pulmonary trouble. No other clinical history given CARCINOMA 145 AtTTOPST NOTES At first none, later scant, no tubercle bacilli and lower lobes contains masses of tumor in which are found numerous cavities filled with pus Encapsulated bloody exu date in left pleura. Upper left lobe a shell of lung tissue infiltrated with tumor and surrounding cavities filled with putrid and degenerat- ing tumor material Primary cylindrical celled carcinoma of both lungs ap pearing in numerous nod ules, many of them conflu- ent. Fibrinous effusion in right chest Medullary infiltration of right lung with cavity in up- per lobe. Foci of red and yellow softening in cortex of left anterior lobe of brain Primary cancer with nod- ules in both lungs in great numbers of all si^es. Chronic interstitial pneu- monia Medullary nodules in left upper lobe. Bronchial mu- cous membrane bulged by nodules. Large cavity in right middle lobe filled with pedunculated soft, reddish- brown material. Hsemor- rhagic effusion in pericar- dium with retraction of left lung Carcinomatous tumor size of an apple in right lower lobe; softening in interior METASTASES MICROSCOPE Subpleural tumor size of an apple in right upper lobe. Necrotic cavity in interior. Origin from bronchial wall Carcinoma of left main bronchus penetrating into left auricle and also into aorta, but not to the intima nodes, oeso- phagus, liver, endo- cardium of right ventri- cle, bladder Bronchial lymph nodes No details Numerous in dura None Pericardium and liver None Right lower lobe, region- ary lymph nodes, liver Not men- tioned Squamous epithelium Ciliated cylindrical celled epithe- lium No details No details No details Pavement epithelium Cylindrical celled carci- Alveolar structure, cy- lindrical cells, here and there ap- proaching pavement epithelium 11 146 TABLE I LUNG IN- VOLVED CLINICAL SYMPTOMS 97 99 100 GOLDSCHMIDT, Corresp.-blatt f. Schweizer Aerzte, 1886, XVI, p. 67-69 Medullar Carcinom der linken Lunge GOUGEROT, Bull, de la Sec. Ana- torn, de Paris, 1905, p. 294 Cancer primitif du Pou- mon (Epithelioma pavimenteux bron- cho-pulmonaire) a Globes epidermiques Geun-wald, Milnch. med. Wo- chenschrift, 1889, No. 32-33 Fall von primarem Pflasterepithelkrebs der Lunge Hall & Tribe, Lancet, 1905, 1 Carcinoma of Bronchus and Liver in a Youth of 17 with Glycosuria M M 47 46 R M 32 M 17 101 BLi.MPELN, St. Petersburg Med, Wochenschrift, 1887, No. 17 Fall von primarem Lungen-Pleura Car- M 62 Progressive emaciation, dyspnoea, pain, dilated superficial veins. Flat- ness, absence of voice and breathing over greater part of left chest. No fever; no cough. 700 c.c. clear bloody serum aspirated from left chest No heredity. Pulmonary tubercu- losis of old standing. After grippe, dyspnoea with cough and f ever._ Later polyuria and polydipsia. Rapid ema- ciation; some pain. Urine free from albumin or sugar, though over 8000 c.c. voided daily. Later painful points on vertebrae; pains along right arm. Clinical diagnosis tuberculosis Pain in chest. Abnormal sensations in throat. Dyspnoea, paralysis of left recurrent laryngeal. At that time heart and lungs found normal. Later dulness over left upper chest; absence of breathing. Physical signs vary. Clinical diagnosis tumor of posterior mediastinum compressing heart and lungs and left recurrent nerve. Aspira- tion practically negative. Some cough. Duration about one year For 3 months cough, dyspnoea, ema- ciation; thereafter intense itching, enormous appetite, polyuria; some cyanosis; oedoema of face, neck, and feet; purpuric spots partly suppurat- ing over the legs. Swellings filled with fluid over scapula, back, anus, and left arm. Bronchial breathing with some rales over left apex. Enlarged nodular liver; some fever. Urine contains much sugar; some diacetic acid. Sud- den collapse and death. Duration about 3 months. Clinical diagnosis pyaemia with suspicion of tuberculosis No heredity; disease started with slight fever and enlarged spleen; treated as malaria and improved. Later pain in left chest and dyspnoea; pleuritic effusion which was absorbed without tapping. Later slight cough followed by emaciation and general cachexia without subjective symp- toms. No pain, good breathing, good appetite. Physical signs suggested merely incomplete absorption of pleu- ritic effusion. Duration of disease probably not more than one year CARCINOMA 147 AUTOPSY NOTES METASTASES MICEOSCOPE None Mucopuru- lent, often bloody, contains tubercle bacilli Scant, occa- sionally bloody Mucopu- rulent, bloody, no tuber- cle bacilli Scant, gela- tinous, occasion- ally bloody or pink. Micro- scopic ex- amina- tion showed numer- ous epi- thelial cells sug- gesting tumor, from which alone the Entire left lung except up- per portion of upper lobe converted into medullary cancer Neoplasm, involving en- tire right upper lobe with cavity. Right main bron- chus at root obstructed by tumor up to bifurcation. Compression of tracheal and cervical plexus Solid tumor size of fist in central portion left lower lobe. No cavities. All bronchi compressed; cesoph agus matted to trachea by tumor Irregular tumor, lower lobe of left lung, starting from hilus, spreading along bronchus into lung; main bronchus almost occluded. Pancreas normal None Not men- tioned In lower lobe a tumor the size of a fist, broken down in centre, but surrounded by normal lung tissue Peritra- cheal, peri- bronchial lymph nodes; left kidney Bronchial and medias- tinal lymph nodes; left ventricle and 2 nod- ules in liver Upper lobe, liver, retro- peritoneal and cervical lymph nodes, parts of skull None Typical pave- ment epithe- lium with horny pearls. Origin from bronchus Pavement epithelium Columnar celled carci- noma. Ori- gin from bronchus 148 TABLE I 102 103 104 105 106 Handpord, London Path. Trans. Vol. 39, p. 48 Two Cases of Medias- tinal Cancer Log. cit. Handford, London Path. Trans., Vol. 40, p. 40 Primary Carcinoma of Left Bronchus Handford, London Path. Trans., Vol. 41, p. 37 Carcinoma of Root of Lung (after Passler) Harbitz, Francis, Norsk Mag. f. Lae- gevidenskaben., Aug., 1903, p. 715 Primarer Krebs in einer Lunge mit bronchiec- tatischen Cavemen ; Metastasen im Ge- hirn und in dem M M M M 45 40 64 63 49 LUNG IN- VOLVED R CLINICAL SYMPTOMS Cough and failing health 6 months before admission. Loss of flesh, pain between shoulders and at sternum. Difficulty in swallowing anything but fluids. On admission: difficulty in swallowing most urgent symptom and steadily increasing. Profuse haemop- tysis and death. Duration of disease about 7 months Cough more or less for 20 years. 5 years ago profuse haemorrhage. 2 years ago loss of voice for 2 months; unable to work for 18 months; much loss of flesh; musctilar pains. Hectic temperature, occasionally up to 104f . Dulness over nearly all of right lung, especially over lower lobe. Later pleuritic effusion in right chest; aspira- tion 30 ounces of turbid serum. Later swellings in upper humerus, right deltoid, left upper arm and left thigh. Smaller nodules in scalp. Sudden death from haemoptysis Well until 5 years before admission; then had fall and hurt chest. Cough and loss of flesh since. Deficient ex- pansion of left chest; dull percussion especially in upper part. Feeble, dis- tant tubular breathing, finally com- plete absence of breathing sounds. Paroxysms of dyspnoea; hoarseness. Clinical diagnosis: new growth or aneurysm pressing on left main bron- chus. Death from profuse haemop- tysis. Duration of disease about 6 months None given Tubercular family history. Had syphilis. At 34 years had influenza and coughed ever since. Sudden acute pains in both sides of chest ; bedridden since. Sweating; intense thirst. On admission dulness over left lung; rales over both lungs. To the left of ver- tebral column on level with 10th rib a long, pseudo-fluctuating mass. Fusi- CARCINOMA 149 AUTOPSY NOTES METASTASES MICROSCOPE Large tumor in left lower lobe covered by thickened, infiltrated pleura. Tumor proliferates into mediasti- num, where there is large cavity filled with bloody fluid communicating with main bronchus and left auricle Carcinoma of root of right lung spreading along bron- chial ramifications and large vessels. In lung tumor masses in parts softened and forming cancerous cav- ities from which haemorrhage originated Hypostatic pneumonia right lung. New growth had spread along interior of left bronchus, completely filling its lumen, and reaching up into trachea above bifurca- tion. Numerous small tU' mor nodules over left vis ceral pleura Carcinoma of root of left lung, obliterating lower sec- ondary bronchus, and pro- liferating along bronchial ramifications Mucopu- Small tumor in rectus ab- rulent, dominis, also in musculature several of back near spinal column, times Upper surface of right lung pure studded with nodules often blood, no umbilicated. On section tubercle lung shows many grayish bacilli red tumor nodules, both dis Crete and confluent. Much Medias- tinum, cer- vical lymph nodes, liver, left auricle, pericardium Bronchial lymph nodes, vari- ous muscles of trunk, various bones, skin, kidneys Bronchial and medias- tinal lymph nodes, liver Left pleura, liver Right lung brain, cere- bellum, ribs sternum, liver, kid- neys, mus- cles of back and abdo- Typical al- veolar struc- ture of scir- rhous carci- noma Alveolar structure, abundant stroma, epi- thelial cells Carcinoma of scirrhous type, origi- nating from mucous mem- brane of bron chua Alveolar structure, well devel- oped stroma and abundant epithelial cells Alveolar structure ; alveoli lined with high cy- lindrical cells. Small bron- chi contain these cells in active prolif- 150 TABLE I 107 108 109 110 111 112 113 Knochensystem Loc. CIT. p. 729 Loc. CIT. (postscript) Haebitz, Quoted from Zeit- schr. f. Krebsforsch. I, 1904, p. 154 Hahkis, St. Bartholomew's Hosp. Reports, Vol. 28, 1892, p. 73 Intrathoracic Growths Haktmann, .. Diss. Kiel, 1896 tJber Lungenkrebs vom Bronchus ausgehend Hauff, Schmidt's Jahr- biicher. Vol. 182, 88 Ein Fall von Mark- schwamm der Lunge und des Herzens Hatjte-Cceur, Progres Med., 1886, 2nd series. III, 460- 462 M M M M 49 69 40 54 69 52 64 LUNG IN- VOLVED R Both R Both CLINICAL SYMPTOMS form enlargement of 9th rib in left axilla. Puncture of tumor at 10th rib reveals brown colloid material containing round or oval cells with fatty degeneration. No fever while in hospital. Died from marasmus 9 days after admission Sick for a long time. Symptoms of chronic cedoema of lung with short per- cussion note. Ronchi over both lungs. Slight cough Sharp pain in left chest and right arm. Later dyspncsa, dulness over base of left lung, fremitus in left hy- pochondrium. On puncture sanguin- olent serum containing lymphocytes and endothelium No clinical history given in excerpt Cough, dyspnoea, night sweats. Fluid in right chest. Clinical signs those of chronic phthisis, especially at right apex. Duration 11 months Cough for years; after a cold in- creasing cough, dyspnoea and ema- ciation. Dulness with diminished bronchial breathing over left base gradually extending over whole of left chest. Aspiration 1500 c.c. serous fluid containing fatty epithelial cells. Clinical diagnosis: malignant neo- plasm of pleura Dyspnoea, pain; left apex dulnesa and bronchial breathing. Insomnia. Sudden death after 3 weeks _ Oppression, pain; signs of fluid in right chest. Swelling of right chest and dilated veins. Flatness with faint and distant breathing. Within 6 weeks 4 tappings of chest removing large quantities of chocolate-colored fluid containing cancer cells CARCINOMA 151 AUTOPSY NOTES METASTASES MICROSCOPE None caseous degeneration. Left lung adherent to thoracic wall and smaller than right. Nodules in lung tissue; cav- ities in lower lobe In main bronchus of right lung circular thickening of mucous membrane which protrudes into lumen. In substance of right lung large and small lumps and infil- trations of grayish color Mucoid, no Adeno-carcinoma with tubercle pronounced mucoid and col- bacilli loid degeneration Not men- tioned Profuse Mucoid, never bloody No details No details Bronchiectatic cavities with gelatinous tumor masses in lungs, also bron- cho-pneumonic foci with cheesy and mucoid degener- ation Large portion of lower right lobe occupied by neoplasm which is very soft. Old tu- bercular disease of both apices Carcinoma of left main bronchus with destruction of its walls. Irregular tu- DQor nodules at hilus invad- ing lung along bronchial ramifications. Suppurative pneumonia of entire left lung. Compression of tra- chea Bloody fluid in both pleurae, which are studded with tumor nodules. Large medullary tumor at left apex ramifying in all direc' tions. Right lung healthy Right lung studded with irregular cancer growths, especially in lower part. Pleura much thickened, can- cerous mass in lower portion of left lung compressing a branch of the pulmonary artery Bronchial and retro- peritoneal lymph nodes, pleura and peritoneum Pleura Pleura, bones, brain Not men- tioned Bronchial and medias- tinal lymph nodes and liver Pleura, peri- cardium, in- terventricu- lar septum of heart, diaphragm, liver and left kidney No details eration. Mu- coid degener- ation Polymor- phous epithe- lial cells un- dergoing col- loid degener- ation Adeno-car- cinoma Medullary carcinoma No details Direct origin from bronchial mucous membrane could not be established. Au- thor thinks it prob- able that tumor was primary in lung Only called "Mark- schwamm" No details 152 TABLE I NO. ATJTHOH SEX AGE LUNG IN- VOLVED CLINICAL SYMPTOMS 114 HiLLENBERG, Diss. Kiel, 1893 Ein Fall von primarem Lungenkrebs M 72 L After influenza, pain in chest, cough. Flatness with diminished respiration over left apex extending downward. Some dulness over right apex; later symptoms of cavity in left apex. Some tenderness over thoracic ver- tebrse. Clinical diagnosis tuberculosis. Duration about one year 115 HiNTERSTOISSER, Wiener klin. Woch., 1889, II, p. 374 Ein Fall von Karzinom der grossen Luftwege, etc. M 69 Always well. Contusion of chest from fall from horse. Shortly there- after cough, difficult breathing, hoarse- ness. Later enlargement of various groups of lymph nodes. Dulness over upper portion of sternum and left chest merging into heart dulness. Paralysis of left vocal cord. Painful, hard swelling tip of right 4th finger. Finger is amputated. Increasing dyspnoea and exhaustion. Duration about one year 116 HiTZ, Diss. Zurich, 1887 Ein Beitrag zur Casuis- tik des primaren Lungencarcinoms F 40 R No heredity. Syphilis admitted. Fever, cough, emaciation. Gradually increasing symptoms of obstruction of right main bronchus but no other evi- dence of pulmonary disease. An at- tack of pneumonia was followed for a time by remarkable improvement of all symptoms. Later increasing dysp- noea, dysphagia, pain in right and left chest, cough, oedoema. Death from ex- haustion. Duration about one year 117 HOPMANN, Diss. Zurich, 1893 (after Passler) tjber malig. Lungen- geschwiilste M 36 L Dyspnoea; intense pain in chest 118 Log. cit. F 56 R Intense dyspnoea 119 Horn, Oscar, Virch. Arch., Vol. 189, 1907, p. 414 Ein Fall von primarem Adeno-carcinom der Lunge mit Cylinder- epithel. F 18 L About 4 years before death dyspnceai pain in chest, cough and expectoration. Tympanitic note on left chest to 3rd rib; increasing dulness below with rales; diminished voice and breathing. Profuse haemoptysis, increasing dysp- noea, cyanosis. Sudden death CARCINOMA 153 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE EEMAKKS No tubercle Large, degenerating car- Right lung Typical cylin- bacilli cinoma of left upper lobe. Cancerous and pneumonic infiltration of left lower lobe and spleen drical celled carcinoma. Author be- lieves origin to be from bronchial surface epi- thelium Mucoid, Carcinoma of trachea and Finger-tip, Typical Diagnosis made often bronchi bronchial. carcinoma during- life from spu- bloody. mediastinal. tum Contains cervical. numerous left supra- epithelial clavicular, cells, sin- right axil- gle and lary and adherent lumbar in groups lymph nodes Mucoid, Right main bronchus al- Regionary Alveolar often most completely obstructed lymph nodes structure bloody, by tumor proliferating into with nests of no tuber- trachea. Posterior f of large poly- cle bacilli upper lobe infiltrated with morphous or tumor hard, firm, tumor; numer- epithelial elements ous bronchiectatic cavities. cells ever Enormous dilatation of left found lung None Large medullary tumor of Not men- Not men- entire left lung. Left main tioned tioned bronchus obstructed and compressed. Tumor perfo- rates pulmonary vein and left auricle. Aorta com- pressed. Tumor prolifer- ates into body of some of the vertebrae Not men- Medullary tumor of right Regionary Not men- tioned main bronchus following its ramifications to finest branches. Proliferates up- wards beyond bifurcation and into left bronchus lymph nodes, both pleurae and left lung tioned Haemopty- Left main bronchus com- A few Glandular Origin probably sis, choc- pletely closed by tumor; left glands at structure; from bronchial mu- olate-col- lung collapsed. Bronchi- hilus; no typical cylin- cous membrane ored and ectatic cavities. Out of a other metas- drical celled foetid smaller cavity in the upper tases epithelium sputum, lobe a tumor mass grows with basal no tuber- from a broad pedicle and membrane. cle bacilli proliferates into one of the larger upper bronchi, filling it and budding into a num- ber of smaller bronchi cuticula and cilia 154 TABLE I 120 HOYLE, Jour. Anat. and Physiol., XVIII, 509 Not LUNG IN- VOLVED stated 121 122 123 124 Hughes, H. Marshall, Guy's Hospital Re ports,VI, 1841, p. 330 Cases of Malignant Dis ease of the Lung Hellt, Zeitschr.f.Heilk.Vol. 28,1907. Path. Anat p. 105 Ein seltener primarer Lungentumor Heremann, Deut. Arch. f. klin. Med.,Vol.63, 1899, p. 583 Zur Symptom, u. Diag. des prim. Lungen- krebses Log. cit. M M 50 43 36 42 R Both R R CLINICAL SYMPTOMS Fever; pain in right side of back. No definite signs on lungs. Death from profuse hsemoptysis No heredity. Always healthy until two years ago when caught cold; since then occasional attacks of haemoptysis. Cough, dyspnoea. Retraction of right chest below clavicle; flatness, in- creased fremitus, tubular breathing. Dilated and tortuous veins of lower abdomen and right chest. (Edoema of legs. Enlarged lymph node in right axilla and below right clavicle. Dura- tion about 2§ years 111 for one year. Physical signs seem to point to tuberculosis. Died before full examination could be made at hospital Jaundice, oedoema of legs," enlarged right supraclavicular glands. Dysp- noea; no fever. Dulness and dimin- ished voice and breathing over right apex. Lungs otherwise normal. En- larged nodulated Uver. Ascites Cough, increasing dyspnoea, loss of weight. CEdoema of eyelids; cyanosis; no fever. Flatness and absence of voice and breathing sounds over whole of right chest. 1500 c.c. sero-purulent fluid aspirated without diminishing dulness; 2 days later 3000 c.c. with the same result. Repeated aspira- tions large quantities hsemorrhagic serum. Swelling of right cervical glands. Duration of disease a year and half CARCINOMA 155 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE REMABKS No details In upper lobe of left lung Cavity in Epithelioma irregular cavity surrounded liver; nod- with typical by tumor ules with soft centres in left kid- ney, iliac fossa, 3rd dorsal ver- tebra and 5th rib nests Bloody Entire upper lobe of right Lower lobe, No details Diagnosis made lung converted into medul- Uver, both during life on general lary tumor with strands ex- kidneys, considerations tending to middle lobe, with right supra- proliferation into right pul- renal monary artery No details Both lungs contained nu- None. Not Alveolar Evidently malig- merous nodules up to size a single structure of nant and therefore of walnut and frequently lymph node the adenoma- classed under carci- confluent. Boundary be- enlarged or tous type; noma although struc- tween tumor and lung not any sign of high cylindri- ture is that of pure sharply defined. It was im- tumor cal, non-cili- adenoma possible at autopsy to de- throughout ated epithe- termine whether it was tu- the body lium with oc- mor or some inflammatory casional gob- process let cells. Alveoli filled with coagu- lated mucoid material Jelly-like Tumor at root of right Bronchial Tjrpical car- and lung surrounding bronchi ; lymph cinomatous bloody, one large bronchus obstruct- nodes, both structure showing ed by medullary tumor. lungs, liver under mi- Foetid bronchitis, cirrhosis of croscope [iver, hypertrophic and fatty plates of tieart, interstitial nephritis epithelial cells from which di- agnosis is made dur- ing life Bloody Hard, whitish-yellow tu- Not men- Not men- expecto- mor size of a hen's egg in tioned tioned ration 2 days before region of right hilua death 156 TABLE I 126 126 Loc. CIT. LOC. CIT. 127 128 129 130 Loc. CIT. Hereman, Diss. Greifswald, 1895 Ein Fall von primarem Lungencarcinom HiLDEBRANDT, Diss. Marburg, 1888 (after Passler) Zwei Falle von prima- rem Lungentumor Hughes, Loc. cit. M M M LTJNQ IN- VOLVED 51 61 56 58 43 R R CLINICAL SYMPTOMS No heredity. Sudden pain followed by cough, dyspnoea, dysphagia, hoarse- ness, loss of weight. Flatness with ab- sence of voice and breathing over whole of left chest. Hard supraclavicular glands. Aspiration: bloody fluid No heredity. On admission com- plains of rheumatism and emaciation. There is some emphysema and bron- chitis; symptoms of alcoholic neuritis; clubbed fingers. Nothing points to disease of lungs. Two weeks before death for the first time dulness over left upper lobe with diminished breath- ing; later absolute flatness over entire left upper lobe. Some swollen cervi- cal glands Increasing emaciation and cachexia. Hoarseness; flatness with diminished breathing over left apex. Enlarged nodular liver; absence of free HCl in stomach Father and sister died _ of cancer. Increasing dyspnoea, rapid loss of strength, pain in left chest, oedcema of legs, dilated veins of neck. Impaired mobility of left chest. Absolute flat- ness with bronchial and almost am- phoric breathing over whole of left chest except apex. Dislocation of heart to right. Chocolate-colored fluid in left chest. Duration of illness about one year Not given Always healthy. First sjrmptoms incontinence of urine and oedcema of legs. Later severe pain in right chest; cough. On admission, oedcema of legs, right arm, and chest and puffiness of face. Clubbed fingers. Dulness over right chest; absence of breathing sounds. Heart pushed to left. Aspi- CARCINOMA 157 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE REMARKS Mucopuru- Hard tumor starting from Bronchial Not men- lent, no hilus and surrounding and and mesen- tioned tubercle following bronchial ramifi- teric lymph bacilli cations nodes, liver and kidneys Often Soft tumor in left upper Lung, ven- Not men- bloody; lobe, starting from hilus and tricular sep- tioned under mi- containing cavity tum of croscope heart, thy- great roid, left numbers kidney, left of large, suprarenal fatty, flat and poly- morph- ous epi- thelial cells, no tubercle bacilli. From this and cachexia and ema- ciation diagnosis was made during life Mucopuru- Cancer of apex of left lung Right lung. Not men- lent, no liver, mesen- tioned tubercle teric lymph bacilli nodes Scant, not Left main bronchus leads Secondary Pavement bloody into soft medullary tumor nodules in epithelium of left lower lobe and along right pleura with cell- bronchial ramifications to nests hilus. Entire left lung ate- lectatic. Encapsulated bloody effusion in pleura Not given Medullary carcinoma of right main bronchus slightly infiltrating surrounding tis- sue. Carcinomatous infil- tration of right subpleural lymphatics Pleura Cylindrical and polyhe- dral cells Currant Whole of right lung occu- Not men- Not men- Diagnosis made dur- jelly pied by fungus mass con- taining irregular cavity in centre tioned tioned ing life from cedcema of right arm and bloody sputum after exclusion of empyema 158 TABLE I 131 132 133 134 135 136 Hyde, Salter, London Lancet, 1869, II, July 3, p. 10 Primary Cancer of the Lung Jaccotjd, Legons de Clin. M6d. 1871-72, p. 454 Cancer de Poumon Japha, .. Diss. Berlin, 1892 tjber primaren Lun- genkrebs Log. ciT. Loo. CIT. Log. CIT. M M M M M M 43 50 49 48 51 58 LUNG IN- VOLVED R R R R CLINICAL STMPTOMS ration negative, months Duration about 6 Always healthy. Swelling of neck and face several months before any other symptoms; then sHght dyspnoea, dilatation of superficial veins of chest and upper part of body. Later cough, rapid loss of strength, hoarseness, laryngeal cough. Complete dulness in front almost to base; behind to angle of scapula. Bronchial respira- tion; no rales. Later cyanosis; absence of voice and breathing sounds No heredity. Cough for some years. Slight oppression on right chest. In- creasing loss of strength and flesh. Later dyspnoea, cough, pain in right chest. Dulness on right lung from base to angle of scapula; diminished voice and breathing. Flatness in re- gion of hilus with bronchial respira- tion. Diagnosis made during life Fever, pain in chest, cough. Dulness over right upper lobe; clubbed fingers. Later symptoms cavity right apex. Emaciation Dyspnoea, pain, cyanosis; pleuritic effusion. Several aspirations yield large quantities of clear senim, later bloody or chocolate-brown. Dilata- tion of veins of chest Severe dyspnoea, distress in stomach ; pain in left chest. Flatness over left chest with symptoms of pleuritic effusion. Repeated aspirations yield brown fluid. Increasing cachexia; enormous dyspnoea Pain in right chest; pleuritic effu- sion. Increasing debility and brady- cardia. Dulness right upper lobe with diminished respiration. Ulcerating tu- mor skin of abdomen. Swelling of head of right humerus CARCINOMA 159 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE KEMAKKS Often pro- Nearly whole of right lung _ Not men- Not men- Diagnosis made fuse and converted into "encephaloid tioned tioned during life bloody, cancer." Heart pushed al- contain- most horizontal. Almost ing pecu- complete compression of up- liar heavy per cava. Compression of pellets trachea and right main bron- chus. Cavities and soften- ing in various places Bloody, Voluminous mass of "en- Right lung, No details Clinical diagnosis ol several cephaloid cancer " at right pleurae, peri- tumor of lung made hffimop- hilus, penetrating lung and cardium. during life from analy- tyses connecting with bronchial around ori- sis of physical signs glands. Bronchi and ves- gin of aorta and exclusion of other sels throughout tumor en- and pulmon- possibilities veloped, but not compressed ary artery by neoplasm. Bloody effu- and vein; sion in pericardium liver, dura eroding into bone and reaching in- to temporal muscle Occasion- Medullary tumor with Single Very large ally cavity in right upper lobe; lymph node epithelial bloody. bronchiectatic cavities cells like no tuber- pavement cle bacilli cells, but but elas- author con- tic fibres siders alveo- and pig- lar epithe- ment lium as start- ing point Bloody, no Tumor from hilus follow- Lymph Cylindrical tubercle ing along bronchial ramifi- nodes. and pave- bacilli, cations in right lower lobe. pleura and ment epithe- later Complete conversion of pericardium lium originat- distinct bronchial wall into carci- ing from cancer noma bronchial particles mucous mem- brane Haemor- Tumor in left lower lobe. Right lung, Cylindrical rhagic Left lung dislocated and com- both pleurae, celled carci- pressed by several quarts of regionary noma prob- fluid. Pleura thickened lymph nodes, liver and spleen ably originat- ing from bron- chial wall Bloody, no Tumor of right upper lobe Right Flat pave- Diagnosis was tubercle with necrotic ca^dties com- pleura, liver ment epithe- made during life bacilli municating with bronchi diaphragm, Hum with right hu- typical can- merus, skin cer nests. of abdomen Author con- siders alveo- lar epithe- lium as origin 160 TABLE I 137 138 139 140 141 Jessen, Zentralbl. f . inn. Med., Jan. 1906, No. 1 Ein Fall von Karzinom und Tuberkulose der Lunge intravitam di- agnostiziert JosEFsoN, Arnold, . Hygiea, 1903, Ht. 2, p. 139. Zeitschr. f. Krebsforschung, 1904, I, p. 372. Schmidts Jahrb., Vol, 280, p. 220, 1903. Primares Lungen- carcinom Kappis, Max, Munch. Med. Wo- chensch, 1907, No. 18, p. 88 Hochgradige Eosinophi- lie des Blutes bei ei- nem malignen Tumor der rechten Lunge Karminsky, Diss. Greifswald, 1898 (after Cohn) Primares Lungencarci- nom mit verhornten Plattenepithelien EIarrenstein, Charitfe Annalen, Vol. 32, 1908, p. 315 Ein Fall von Kancroid eines Bronchus und Kasuistisches zur Frage des primaren Bronchial- und Lun genkrebses M M M M M 45 77 69 51 48 LUNG IN- VOLVED R L(?) R R CLINICAL SYMPTOMS Heredity of tuberculosis; active symptoms of tuberculosis. Tubercu- lar cavity of right upper lobe. After treatment at Davos, bacilli disappeared from sputum and tubercular process seemed arrested. Slight elevation of temperature and dry cough continues. Progressive area of absolute flatness in lower right lung. Dyspnoea; symp- toms of bronchial obstruction; cedcema of legs, dilatation of superficial veins. Increasing cachexia; death from suf- focation. Clinical diagnosis: cica- trized tuberculosis of lungs, tubercular cavity of right apex; carcinoma of right lung or pleura Loss of appetite, emaciation, per- sistent cough. Left lung posteriorly dulness; diminished respiration and fremitus. Effusion in left pleura No heredity. Increasing debility and _ emaciation; harassing cough, effusion in right chest. Heart dis- located to right. Aspiration yields bloody serum. Dulness with loss of breathing and voice sounds. Left lung normal. No reaction with tuberculin. Blood: hemoglobin 120; reds 6,200,000; whites 50,560-40,700; polynuclears 56.9; eosinophiles 33-39.5%. Aspira- tion: sanguinolent serum without eosin- ophiles. Eosinophilia not explained No clinical history Haemoptysis. Pain in right chest, gradual loss of weight and strength. Dulness over anterior aspect of right lung. Bronchoscope showed promi- nent tumor in right bronchus, com- pressing it, from which clinical diag- nosis of tumor of lung was made. Duration of disease about 10 months CARCINOMA 161 SPUTUM AUTOPSY NOTES METASTASES MICBOSCOPE HEMAKKS Tubercle Tubercular cicatrizations Wall of Scirrhus bacilli left lung; tubercular cavity right ven- with squa- right apex. In lower por- tricle mous epithe- tion right upper lobe firm. lium fibrous carcinoma. Tumor surrounds large vessels and is supposed to originate from hilus Raspberry No record, merely stated No details No details Diagnosis on basis jelly. that in centrifuged pleuritic of sputum made intra Cancer effusion cancer cells with vitam. Author cas- cells with mitosis were found ually mentions that mitosis since 1897 there oc- curred in Sabbatsberg Krankrenhaus 10 other cases in which autopsy showed pri- mary cancer of lung Scant, mu- Large carcinoma in right Lymph Alveolar Enormous heaping coid, no lower lobe adherent to chest nodes at structure ; of eosinophiles where tubercle wall, diaphragm, and peri- hilus and large polyg- there is no tumor bacilli cardium. Pneumonic infil- around onal epithe- tration around tumor with aorta; in lium necrosis in centre sternum, dorsal ver- tebrae, ribs, liver, left adrenal No details Tumor with cavity in left Two sec- Typical upper lobe involving afferent ondary nod- horny can- bronchus ules in left upper lobe. Bronchial lymph nodes, left pleura, left kidney, left adrenal and ventricular septum of heart croid Haemopty- Right upper and middle Liver, stom- Typical can- All metastases have sis lobes almost completely con- ach, kid- croid with structure similar to verted into tumor with soft- neys, brain. pavement that of original tu- ening in centre. Growth pericardium epithelial mor, except metas- takes origin in large bron- cells, horny tases in brain; here chus immediately below first and prickle they have no horny division of right main bron- cells and cell or prickle cells, but chus where wall of bronchus nests. _ Prob- cells are cylindrical is infiltrated and penetrated able origin and in lower layers by neoplasm from super- polygonal, and tumor 12 162 TABLE I NO. AXJTHOK SEX AGE LTJNG IN- VOLVED CLINICAL STMPTOMS 142 Kasem-Beck, Centralbl. f . inn. Med. 1898 M 57 L Dyspnoea, cough, slight fever, pain in left chest. Later severe chills. Dulness over upper portion left chest. Bronchial breathing 143 Log. cit. M 60 L Cough, dyspnoea, diminished expan- sion of left chest, dilated superficial veins, enlarged axillary glands. Dul- ness from left axilla downward ; dimin- ished voice and breathing; tenderness 144 KiDD, St. Bartholomew's Hospital Reports, 1883, XIX, 227-234 A Case of Primary Ma- lignant Disease of the Lung M 36 R Pain in right chest, cough, clubbed fingers; bulging of right chest. Di- minished respiratory movements and breathing sounds; flatness. Left side normal. Aspiration: scant, thin, gru- mous fluid. Hectic temperature, dysp- noea, ansemia. Duration about 8 months 145 Klubeb, Diss. Erlangen, 1898 Ein Fall von Bronchial- carcinom und Lun- gencyste F 34 R Apparently healthy woman. Sud- den death from extensive burn 146 Kniehiem, Verhandl. deutsch. pathol. Gesellschaft, .. 1909, p. 407 Uber ein primares Lungenkarzinom F 59 R No clinical history. Admitted mori- bund and died same day CARCINOMA 163 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE REMABKS ficial bron- has distinct papillary chial epithe- structure. Author has lium some doubt if this is genuine metastasis or a second primary tumor in brain Mucoid Primary tumor left upper lobe None No details No blood Diffuse cancerous infiltra- Bronchial "Carcinoma tion in lower f of left lung; lymph simplex" disseminated nodules in up- nodes, per third pleura, liver, head of pancreas Currant Greater portion of right Posterior "Encepha- jelly. lung converted into tumor, mediastinal, loid cancer" some consisting of white, nodular axillary and haemop- masses ; small cavities in up- retroperito- tysis per and middle lobes. Sec- ondary bronchi much com- pressed. Margin of pleura over right lobe thickened and of medullary appearance neal lymph nodes None Medullary white tumor completely obstructing right lower main bronchus, caus- ing large bronchiectatic cyst in right lower lobe None Glandular alveolar structure ; small cu- boidal epithe- lial cells. Origin from bronchial mucous glands No details Large quantity clear se- Lsnmph Two differ- rum in right pleura; right nodes of ent types — lung adherent. Under pul- right hilus; one, distinct monary pleura tumor infil- retroperi- alveoles lined tration following the lym- toneal and with cylindri- phatics. Middle and lower retrogastric cal cells, and lobe filled with diffuse gray lymph the other. tumor masses; numerous nodes patches con- discrete and confluent nod- sisting of ules in near vicinity. All large, irregu- through the lung miliary lar polygonal gray nodules between the cells arranged alveoli filled with mucus. in more solid Left lung healthy masses. Pap- illary projec- tions prolifer- ate into the alveoli; transition from flat al- veolar epithe- lium to cubic and high cy- 164 TABLE I 147 148 149 150 KoHNER, Miinchener Med. Wochenschr., 1888, No. 11 Ein Fall von primarem Krebs der grossen Luftwege, etc. Khatz, Diss. Miinchen, 1892 .. (after Angelhoff) tjber ein Fail von pri- marem Lungencarci- nom mit Metastasen im Gehirn Khetschmeh, Diss. Leipzig, 1904 Uber das primare Bronchial- und Lun- genkarzinom Log. cit. M M M M 64 38 44 56 LUNG IN- VOLVED R CLINICAL SYMPTOMS Cough, oppression in chest; flatten- ing of right chest wall. All symptoms of complete and uncomplicated obstruc- tion of right main bronchus, absolute flatness, absence of respiratory and voice sounds. Diagnosis made during life For several months dizziness, pain in head and chest. Choked disc both eyes; headache, vomiting. Slight dysp- noea. Nothing found on lungs. Clini- cal diagnosis: tumor of brain Paralysis of recurrent; consolida- tion and secondary gangrene _ of left lung; cavities and bronchiectasis; tem- porary closure of bronchus. Clinical diagnosis: neoplasm of lung Clinical diagnosis: pulmonary tuber- culosis; pleurisy with effusion in left chest CARCINOMA 165 AUTOPSY NOTES METASTASES MICROSCOPE Mucoid cyl- inders with co- agulated blood in centre ; raspberry jelly; oc- casional hsemop- tysis ; typical bronchial casts None No details No details Complete obstruction of right main bronchus by tu mor Large carcinoma in left lower lobe Bronchial carcinoma up- per left lobe. Gangrene left upper lobe; almost complete obliteration left pulmonary artery. Carcinomatous in filtration of pericardium ; carcinomatous degeneration left vagus; ulcerated can cerous masses in upper left main bronchus Almost entire left lower lobe occupied by large neo- plasm infiltrating surround ing tissue and spreading from central nodule. Wall Tracheal and bron- chial IjTuph nodes; both right pul- monary veins Both lungs regionary lymph nodes and brain Pericar- dium; left vagus Left frontal bone, left kidney, left suprarenal lindrical cells. Large and small alveo- lar spaces filled with granular ten- acious mucus, often con- taining flat or round and polygonal cells. Larger bronchi show no lesions. Lymph chan- nels in walls of lungs and bronchi con- tain large carcinoma cells. Origin, epithelium of alveoli and bronchioles Carcinoma No details Alveolar structure, scirrhous stroma ; cell nests and pearls Similar to preceding Bronchial mucous glands designated as probable origin 166 TABLE I 151 152 Loc. CIT. Log. CIT. 153 154 155 156 167 Loc. CIT. Loc. CIT. Kkiegsmann, Leipzig Klinik, 1877 (after Reinhard) Kttbb, Centralbl. f . inn.Med., 1906, No. 44 Primares tracheobron- chogenes Karzinom (Bohemian) KUHN, .. Diss. Zurich, 1904 Uber maligne Lungen- geschwiilste M M M M M 67 68 45 44 69 36 LUNG IN- VOLVED CLINICAL SYMPTOMS Clinical diagnosis: purulent bron- chitis, bronchiectasis, pleurisy, and diabetes Effusion in left chest. First aspira- tion clear serum; second, bloody serum R L(?) R 69 R Admitted moribund. No clinical diagnosis Chronic pneumonia, hydrothorax, and suspected tumor of left lung Pain in region of liver. Cough, chills, fever, anorexia, emaciation. Dulness from 5th rib downward with absence of voice and breathing Pain in chest, obstinate cough, dyspnoea, rapid cachexia with good appetite No heredity. Alcoholic dementia. Hoarseness with paralysis of left vocal cord; dyspnoea, dysphagia, stridorous breathing, emaciation, and cachexia. Dulness over right apex with dimin- ished voice and breathing CARCINOMA 167 AUTOPSY NOTES METASTASES MICROSCOPE No details No details No details No details Purulent with oc- casional haemor- rhage No details of left lower bronchus in- filtrated with cancerous ma- terial, ulcerating into lumen Wall of left lower bron- chus destroyed by tumor in- filtrating left lower lobe. Chronic fibrous pneumonia and abscess of left lung; chronic fibrous pleurisy Uneven nodiilar tumor in left main bronchus; entire anterior portion of left lung occupied by intensely firm, nodiilar tumor. Bloody se- nmi in left, clear senim in right pleura Large portion of anterior aspect of right lung infil- trated with thick, firm tu- mor extending to 4th, 5th, and 6th dorsal vertebrae. Wall of right main bronchus contains nodulated, partly ulcerated tumor masses merging into lung tumor None Mucopuru- lent ; no blood, no tubercle bacilli Bronchial, mediastinal, retroperito- neal lymph nodes; left kidney, liver, both suprarenals. (No bronzed skin) Bones of skull, verte brse, cerebel- lum, thy- roid, myo cardium, liver, and kidneys Heart dislocated to right; fluid in left pleura, which is studded with tumor nodules. Left lung everywhere infil- trated with soft tumor. Similar infiltrations in right liing with bronchiectases Right lung except a small part of upper lobe com- pletely consolidated. Tumor masses surround end of tra- chea and right bronchus, the latter much thickened, infil- trated, and compressed Carcinoma originating from mucous membrane of trachea and bronchi, extend ing along ramifications re- placing bronchial mucous membrane and obstructing lumen Large tumor in upper right lobe infiltrating surrounding lung tissue; smaller tumor compressing oesophagus and trachea. Other organs with- out lesions Alveolar structure Adenomatous structiire Origin from bron- chial mucous glands Origin from bron- chial mucous glands can be demonstrated Pleura, pericardium Regionary lymph nodes and right lobe of liver No details except diag- nosis made from metas- tases No others Alveolar structure with pave- ment epithe- lium; cuboid and cylin- drical epi- thelium in periphery of alveoli Alveolar and papillary structure. Cylindrical cells No details Origin probably surface epithelium of bronchus Cylindrical cells No details given Origin probably from alveolar epithe- lium 168 T.IBLE I 158 KUSSMAUL, Berlin klin. Wochen- schr. 1879, 413-433 Primares Lungenkar- zinom ohne Metasta- sen 159 160 161 162 163 Labb6, Makcel et BOIDIN, Bull, et Mem. Soc. Anatom. de Paris, 1903, No. 8, pp. 743- 747 Carcinome alveolaire cystique du Poumon Lammerhirt, Diss. Greifswald, 1901 Zur Casuistik des pri- maren Lungencarci- noms Log. cit. M M M M 60 49 LUNG INVOLVED CLINICAL SYMPTOMS 51 51 Laifle, Diss. Munchen, 1895 Uber einen Fall von Mediastinal und Lun- gencarcinom Lanceratjx, Bull, des Soc. Anat. de Paris, 1858, XXXIII, 515-520 164 Lange, Memorabilien, No. 3 1866, M M 37 49 63 R R R Blow on left thorax. 7 weeks there- after cough, pain in region of injury. 7 months later increasing debility and dyspnoea. Lower half of thorax in front, flat. Intercostal spaces re- tracted. Left thorax anteriorly flat- ness, absence of breathing First complaint 15 hours before admission to hospital. Only cerebral symptoms — headache and vomiting; slight congestion of optic discs. Clini- cal diagnosis: cerebellar tumor. Dura- tion about 2 weeks No heredity. Slight headaches; otherwise healthy. Four apoplectic seizures. Pain in chest; impaired res- piratory motion of right chest; dul- ness over right base; no auscultatory signs. Clinical diagnosis: tumor of brain Kick on left chest; some months thereafter weakness and cough. Some weeks later kick on right chest followed by sugillation, cough, bloody expecto- ration, local tenderness and fever. In- creasing pain; haemoptysis. Dulness over anterior right chest; diminished voice and breathing Dyspnoea; oedoema of face and neck. At first nothing on lungs ; later dulness over right middle lobe with abolished breathing sounds. Fever, night sweats. Later respiratory immobility of right chest; absolute flatness over entire right chest in front. Cyanosis. Ex- ploratory puncture negative. X-ray shows deep shadows all through right lung DyspncEa, cough, cachexia. _ Left apex anteriorly flatness; no voice or breathing sounds Sudden attacks of suffocation; in- tense irritation in throat; rapid ca- chexia. Dulness over right side with absence of breathing and voice sounds. CARCINOMA 169 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE EEMAEKS Occasion- Mediastinum and heart Absolutely Medullary ally bron- displaced towards right. none carcinoma chial Left upper lobe almost en- with alveolar bloody tirely occupied by large structure casts; no tumor. Aorta adherent to cancer but not compressed by tu- cells or mor. Bronchi obstructed; tubercle bronchiectases. Left pul- bacilli monary artery compressed None Large cyst in left cerebel- Glands of Alveolar lar lobe filled with fluid con- hilus structure ; taining numerous lympho- polyhedral cytes. One large and many epithelium smaller cavities throughout right upper lobe. Walls of cavities and cyst formed of t cancerous material. Areas of pulmonic sclerosis around cancerous tissue. All other organs healthy Scant, not Carcinoma of right lower Bronchial, Alveolar charac- lobe mediastinal structure ; teristic and mesen- teric lymph nodes ; nod- ules in brain and cerebel- lum cylindrical and cuboid cells Bloody Carcinoma of right lower Right Pavement lobe and 5th rib middle lobe, bronchial and supra- clavicular lymph nodes epithelium Occasion- Tumor nodules in right Peribron- None given aUy upper lobe; bronchiectatic chial, tra- bloody, cavities. At bifurcation a cheal, and no tuber- nodule extending into right mediastinal cle bacilli and left main bronchi ob- structing lumina. Compres- sion of upper cava lymph nodes, liver, right kidney and mesen- teric glands Abundant, Left lung converted into Left Not given mucoid; "jelly-like" mass. Dilated lower lobe, occasion- thoracic veins; cancerous right lung, ally blood thrombus in aorta liver, kid- and neys, supra- "brain- clavicular like" suh- glands stance None Numerous cancer nodes in right lung; some softening. Large cavity at apex. Can- cer nodule on superior cava. Right testi- cle Not given 170 TABLE I 165 166 167 168 169 170 171 Langhans, Virchows Archiv. 1871, LIII, p. 470 Primarer Krebs der Trachea und Bron- chien Lardillon, Thfese de Lyon, 1903 Contribution ^ I' etude du Cancer des Pou- Lardillon, Loc. cit. Lasegue, Arch. gen. Paris, 1877, I, pp. 476-482 Lebert, Compt. rend. See. de Biol. 1849-1850, I, 141-150 LeCount, E. R. Trans. Chicago Path. Soc. Vol. IV, 1899- 1901, p. 67 Primary Carcinoma of the Lung Leech, D. J. Manchester Medical Chronicle, XVI, 1892, p. 178 M M M M M 40 66 60 78 50 Not stated 53 LUNG IN- VOLVED Both R CLINICAL SYMPTOMS After 5 months painful tumor in right testicle. Duration of disease 9 months For a year ssonptoms suggesting bronchial obstruction — dyspnoea, etc. but cause of the stenosis could not be determined. Frequent attacks of suf- focation in one of which death ensued No heredity. Enters hospital on account of rheumatism. Never coughed. No symptoms pointing to heart or lungs. Examination of chest negative. Later some pain in right chest and cough; sudden profuse hsemoptysis. Repeated hsemoptyses thereafter. Gradually increasing dul- ness over entire right chest. Dimin- ished voice and breathing. Bloody serum in right pleura. Left lung normal. Finally pneumonia of right base No heredity. Sense of oppression in chest, cough, rapid loss of weight and strength. Increasing dulness over entire posterior aspect of left lung. Dimin- ished respiration; puncture negative; blood normal Pain, flatness, absence of voice and breathing over lower part left chest. Dyspnoea; left thorax increased in size Clinically merely general symptoms of asthma Cough, pain in chest, dyspnoea, ema- ciation. Bronchial breathing with flat percussion over upper left chest. Rales on both lungs. Clinical diagnosis: tu- berculosis. Duration about 2 years Always healthy. More or less cough, oppression in chest, and weak- ness, nevertheless continued to work for one year. After that cedoema of CARCINOMA 171 No details No tubercle bacilli or tumor elements Scant, mu- copuru- lent, no tubercle bacilli Abundant, mucous, no blood No details Bloody, gelati- nous, no tubercle bacilli Bloody, no tubercle bacilli, no can- AUTOPSY NOTES METASTASES almost perforating it Medullary tumor at bifur- cation following along bron- chial ramifications Right diaphragmatic pleurisy. Entire lower lobe transformed into solid tu- mor. Tumor of right main bronchus, penetrating wall and obstructing bronchus of right upper lobe Neoplasm at division of main left bronchus obstruct ing both branches. Nodules bronchial walls and in lung tissue around bronchi. Bronchiectatic cavities and patches of gangrene. Left lung collapsed and atelecta- tic — looks like Roquefort cheese Large white tumor in- volving root of left lung and posterior mediastinum, com pressing aorta and trachea; (Esophagus and left vagus adherent to it Nodules in both lungs suppurating and forming abscesses. Lymphatics throughout lungs enlarged, forming visible network of white strands Nodules of various sizes in both lungs; diffuse con solidation of upper f of left lobe; cavities throughout lung Right pleura thickened and adherent; lung pressed upward and backward. Large cavity in middle and None None Lymph nodes at left hilus No details Bronchial glands None Left lung, bronchial glands, glands MICROSCOPE Small poly- hedral cells, more rarely cylindrical cells Alveolar structure ; polymorph- ous cells often fusiform. Mucoid glob- ules in some of the cells Alveolar structure ; polymor- phous cells, some con- taining vac- uoles with colloid degen- eration Not given No details Alveolar structure with epithe lial cells; much degen- eration. Channels like veins filled with epithe- lial cells Scirrhous cancerous structure. Cuboid and Author traces ori- gin to bronchial mu- cous glands Probable origin bronchial mucous glands Cancer was sus- pected during life but the nephritis masked the diagnosis. Clear 172 TABLE I 172 173 174 175 176 177 Case of Cancer of the Lung Lehmkuhl, .. Diss. Kiel, 1893 tjber primaren Krebs der Lunge mit Meta- stasen Leloib, Bull. Soc. Anat. de Paris, 1879, LVI, 719 721 Leopold, Max, Diss. Leipzig, 1900 Klinischer Verlauf und Diagnostik des pri- maren Lungenkrebses Log. git. Leopold, Loc. cit. 1903, Lepine, J. Lyons Med. Vol. 100, p. 18 Cancer primitif du Pou mon a Globes comes M M M M M M 40 39 54 54 39 60 LUNG IN- VOLVED R CLINICAL SYMPTOMS legs, puflBness of eyelids, increasing weakness and dyspnoea. Dulness lower part right lung with diminished vocal fremitus. Slight fever. Clubbed fingers. Nephritis. 27 ounces clear serum aspirated, but dulness not di- minished. Duration of disease about year and half All symptoms mainly cerebral — headache, delirium, insomnia, paralysis right arm and leg. Nothing abnormal about chest except some impairment of respiratory motion on right side. Clinical diagnosis: hsemorrhagic pachy- meningitis. Death while patient was being prepared for operation Cachexia, pain, rales over left apex. Nodules in right cervical and inguinal region Increasing cough and general debility; some pain; dyspnoea. Heart disloca- ted to right. Dulness over both apices; bloody serum in both pleurae. Dura- tion 9-10 months. Clinical diagnosis: phthisis Cough for years. Flatness and absence of voice and breathing over all of right chest. Heart dislocated to left. Dyspnoea. Bloody serum in right pleura. Later hard nodules in skin various parts of the body; one of these nodules removed showed can- cerous structure Pain in right chest; dyspnoea; pro- fuse expectoration. Hoarseness; paral- ysis of left vocal cord. Flatness be- tween 1st and 2d ribs extending to both mammillary lines. Diffuse bron- chitis. Later bulging of entire left chest. Atelectases of left apex with amphoric breathing. CEdoema of legs. No fever Year before entering hospital severe contusions of left chest. Shortly before admission severe pain sud- denly in place of contusion. Dulness, increased vocal fremitus, absence of CARCINOMA 173 SPUTUM AUTOPSY NOTES METASTASES MICHOSCOPE EEMAEKS cer cells outer part of right lung with below dia- polymor- serum spoke against prolongations to apex and phragm. phous cells. malignancy. It is re- base. Remainder of lung Uver, kid- Origin from markable that there infiltrated with white new ney, left su- alveoli were no physical signs growth prarenal of so large a cavity None Tumor size of a cherry in Cerebrum, Cylindrical Origin bronchial right lung cerebellum, right supra- renal and kidneys epithelial cells arranged according to glandular type; cells secrete mu- cous. Same structure in cerebral metastases mucous glands No details Serous effusion in left Both "True car- pleura. Tiimor at apex of pleurae, _ cinoma" left lung mediasti- num, cervi- cal and in- guinal lymph nodes Greenish, Carcinoma of left lung Right lower no tuber- lobe, both cle bacilli pleurae, ret- roperitoneal lymph nodes. Bronchial and medias- tinal glands not involved Mucopuru- Carcinoma of right upper Skin, left lent, no bronchus. Hepatization pleura. tubercle and purulent degeneration liver, kid- bacilli of right lung neys, left su- prarenal, bronchial, mediastinal and mesen- teric glands Profuse, Carcinoma of left Skull, upper Not given bloody bronchus lobe left lung, pleura, liver, bron- chial, medi- astinal, epi- gastric and mesenteric lymph nodes Foetid, mu- At place of swelling whit- None Stratified copuru- ish tumor principally locat- pavement lent, con- ed in lung, surrounded by epithelium taining zone of gangrene. Diffuse with nests of elastic infiltration towards hilus. horny cells 174 TABLE I 178 179 180 Leplate, M Th^se de Paris, 1888 (Szeyelowski) Cancer primitif du Pou- Le Sotjrd, Bull, et M6m. de la Soc. Anat. de Paris, 1899, p. 587. Epith61iome mucoide primitif du Poumon LUNG IN- VOLVED 60 M Letttlle et Bienvenue F Bull, et Mem. de la Soc. M6d. des Hop. de Paris, Vol. XXV, 3e S6rie, 1908, p. 610 Cancer primitif de la 58 63 R clinical symptoms breathing at base. Later cough; en- larged lymph nodes below left clavi- cle and in both axillae. Exploratory needle penetrates soft mass. Dilated veins of left chest and neck. Fever; rapid decline. Death two months after first symptoms. Clinical diag- nosis: pleuro-pulmonary cancer with secondary gangrene Always well. 4 months previous to admission fever, emaciation, pain in chest, cough. Later dyspnoea, dys- phagia. Absolute flatness and loss of voice and breathing over right up- per chest anteriorly and posteriorly. Abundant rales. Death from as- phyxia. Duration about 5 months No heredity. Severe pneumonia 2 years previous to admission. For one month nervous disturbances in both lower limbs. Dulness left apex; diminished breathing; normal fremi- tus; intense dyspnoea. Right lung bronchitis and emphysema. No other lesions found anywhere. Distinct ten- dency to obesity. Increasing dyspnoea; physical signs practically the same. Death from suffocation 3 weeks after admission No heredity. Healthy until Jan. 1907; then loss of flesh, hoarseness, attacks of dyspnoea lasting 6 hours at a time. Dulness left lung below shoulder. Tuberculosis diagnosed. Shortly thereafter profuse haemoptysis CARCINOMA 175 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE REMARKS fibres, pus Tumor had penetrated in- and nu- terspace to anterior surface merous of ribs bacteria Bloody Pleura thickened, forming solid cap over right upper lobe. Whole upper lobe converted into tumor which on section looks like Roque- fort cheese. Tumor prolif- erates into bronchi, which are compressed and obliter- ated. Broncho-pneumonia of lower lobe. Left lung normal Bronchial and tra- cheal lymph nodes No details Abundant, Obliteration of left pleural Secondary Alveolar Probably alveolar mucoid. cavity; no pleuritic effu- nodules in structure of origin No sion. Both lungs studded spinal cord lung appar- special with small nodules. On tip with in- ently pre- charac- of left lung large whitish- volvement served; alve- teristics yellow hard tumor; no cav- of some ver- oles contain ity. No signs of tuberculo- tebrae cylindrical, sis. Hilus glands scarcely cuboid, poly- enlarged. No other lesions morphous • anywhere epithelial cells forming here and there ridges and papillary proliferations into alveoles. Epithelial lining in single or mul- tiple layers. Some alveoles not filled with cells contain mu- coid fluid. Some peri- bronchial lymph nodes macroscop- ically normal, are found on microscopic examination to contain tu- mor cells Mucoid, Primary cancer of left Tracheal Alveolar Origin from bron- streaked main bronchus, infiltrating and bron- structure ; chial mucous mem- with into lung along lymphatics chial lymph polymor- brane blood and into alveoles nodes; su- Dhous epithe- and rasp- prarenals ial cells berry 1 1 176 T.^LE I LTJNG IN- VOLVED CLrNICAL SYMPTOMS Bronche primitive gauche 181 Lev^he, Thfese de Montpellier, 1901 Du Cancer Bronchopul- monaire primitif M 24 R 182 Log. cit. M 52 183 LEV:feBB, Loc. cit. 43 R with violent spells of coughing. Mid- dle of April violent attack of suffoca- tion with profuse hsemoptysis. On admission right lung slightly emphy- sematous. Left lung behind may be divided into 3 distinct zones — above spine of scapula everything normal; consolidation from spine to point of scapula with absence of breathing, extreme vocal fremitus, and consider- able bronchophony; no rales; abso- lute flatness. All these symptoms end abruptly at 8th rib; below this all is normal. In front normal to 3d rib; from there dulness to base. A band 6 to 8 cm wide runs from left axilla to base of lung where there is loud sonor- ous respiration and increased vocal fremitus. Diagnosis of cancer of lung made 3 months before death. No dysphagia; hardly any pain. Death from asphj^a. Duration about 5 months No heredity. In good health until 3 weeks before admission when after drinking ice-water had chill. Treated for congestion of lung. Since then cough, emaciation, intense dyspnoea. No fever; dulness some rales on right side. Pains in loins. Clinical diag- nosis: pneumonia. Dulness base of right chest; cedcema face, right arm, and chest. No other signs on lungs. Aspiration negative. Duration IJ months No heredity. Admitted to hospital for taenia. Slight cough; dulness left base with diminished fremitus and breathing. No pain; no dyspnoea. Later increasing dulness; some dysp- noea; heart displaced to right. 1500 c.c. clear serum aspirated but dulness persists; dysphagia. Jaundice; in- creasing loss of strength and flesh; enlargement supraclavicular glands. Clinical diagnosis: cancer of oesoph- agus No heredity. Always well. For 6 months intercostal neuralgia right chest; 4 months ago herpes zoster 3d to 4th interspace. For 2 months cough ; no sputum; pleuritic effusion and 1000 c.c. bloody serum aspirated. Abscess at place of puncture and persistent fis- tula from which every day about half goblet foul, sanious fluid is discharged. Dulness over all of right chest with loss of fremitus. Incision shows 3d and 4th ribs destroyed and replaced by neoplasm. Lung is found nodulated by finger introduced. Diagnosis of CARCINOMA 177 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE KEMABKS jelly, no tubercle bacilli. no tumor elements Bloody; re- Clear serum in right Bronchial Epithelioma Author places ori- peated pleura. Left lung normal. and tracheal with areas of gin from alveolar epi- profuse In lower and middle right lymph nodes cheesy degen- thelium haemop- lobe a soft grayish-white compressing eration tyses tumor surrounded by shell of lung tissue trachea. Mesenteric lymph nodes, liver, pancreas, spleen None Left pleura much thick- Bronchial, Somewhat Said to originate ened. Nearly whole left mediastinal atypical epi- from alveolar epithe- lung converted into thick lymph thelioma lium mass, involving diaphragm, nodes, com- nodulated and traversed by pressing larger and smaller cavities oesophagus. Lymph nodes at hilus. Liver and spleen At first Right pleura studded with Mediastinal Epithelial scant, nodules; right upper lobe lymph nodes cancer several one solid mass of tumor, pro- profuse liferating through incision in hsemop- chest tyses 13 178 TABLE I 184 185 186 187 L6VI, LEOPOLD, Arch. g6n. de Med. 1895, Vol. II, p. 346 D'un Cas de Cancer Broncho-pulmonaire LOSEH, Verhandl. d. phys. med. Gesellschaft, Wiirzburg, Vol. XXXIII, 1899, p. 10 Ein Fall von Epitheliom der Lunge nach Pneu- LOWENMETER, Deutsch. med. Wo- chenschr. 1888, No. 44 LtJBBE, Diss. Kiel, 1896 Ein Fall von primarem Lungenkrebs M Not M M 49 stated 76 54 LTJNG IN- VOLVED R R CLINICAL SYMPTOMS cancer made. Increasing dyspnoea and emaciation; profuse haemoptysis; cedoe- ma of right chest and lower limbs. Increasing pain. Death. Duration about 7 months No heredity. Always healthy. For 6 months cough, pain in right chest, night sweats, clubbed fingers. Later oedcema of entire upper body with cyanosis and dilated veins. Dyspnoea. Dulness lower third right chest; am- phoric breathing upper lobe. Dys- phagia. Aspiration clear yellow serum from right pleura; no relief No clinical history. Not even cause of death No heredity. Cough; effusion into right pleura. Consolidation of right lung. No evidence of tuberculosis. Rapidly increasing cachexia. Clinical diagnosis: malignant disease of lung Diabetes and _ cough for years. Gradually increasing cough, dyspnoea. Paralysis of both recurrent nerves. In- creasing cachexia; bronchitis. Nothing distinctive found in lungs CARCINOMA 179 Abundant, mucoid, no tuber- cle bacilli No details No details Mucoid, later bronchial casts and bloody, no tuber- cle bacilli AUTOPSY NOTES Right main bronchus completely closed by tumor; tumor size of walnut, right upper lobe, encapsulated and surrounded by healthy lung tissue In connection with a croupous pneumonia it was found at autopsy that a dif fuse increase of connective tissue had taken place in the lung in which the pneumonia had occurred. Numerous larger and smaller white nodules were present which were taken to be newly formed connective tissue Under the microscope, to the astonishment of all, these nodules as well as the diffuse infiltration were found to be extensive tumor formations Pleura healthy Nodules and cancerous in filtration involving nearly entire right lung. Left lung perfectly normal Carcinoma of left upper lobe; perforation of right main bronchus and trachea by tumor. Tumor follows the ramifications of finer bronchi throughout entire lung. Left auricle and up- per cava penetrated by tu- mor; left brachial plexus and aorta surrounded and compressed. Bulging of oesophagus by tumor nodules METASTASES MICROSCOPE Bronchial and medias- tinal lymph nodes com- pressing upper cava and brachio- cephalic veins Not men- tioned Nodules in dura per- forated bones of skull with- out causing cerebral symptoms during life Cervical, bronchial, and medias- tinal lymph nodes; peri cardium and heart muscle Alveolar structure ; cylindrical, polygonal and poly- morphous cells Subpleural nodules mostly cylin- drical cells; distinct alve- olar struc- ture. Simi- lar nodules disseminated throughout entire lung. Tumor pro- liferation )ng peri- bronchial fi- brous tissues. In alveoles of lung, nests and patches of epithelial proliferation which, how- ever, did not fill the al- veoles Alveolar structure ; large epithe- lial cells Alveolar structure; epithelial cells often cyhndrical Origin probably from bronchial mucous membrane Author leaves question undecided whether this was a simple endothelial or epithelial prolifera- tion after pneumonic inflammation or a real carcinomatous pro- liferation. It was probably carcinoma, possibly of alveolar origin. I. A. Surface epithelium of smaller bronchi designated as origin 180 TABLE I NO. AUTHOR SEX AGE LUNG IN- VOLVED CLINICAL SYMPTOMS 188 LXJND, 0. Virchow-Hirsch Jah- resb. 1879, II, p. 143. Norsk mag. f. Lage- vid. R. 3, Vol. VIII, p. 142 Primar Lungekraft F 66 R Nine months before death cough and emaciation. Later general brain sjonp- tqms which completely dominated the clinical picture. Slight dulness and diminished breathing below right clavi- cle. Chnical diagnosis: tubercular disease of lung and brain 189 MacLachlan, London Med. Gaz. 1843, XXXII, p. 23 Primary Cancerous De- generation and Ulcer- ation of the Lung M 62 R Dry cough, dyspncsa ; cedoema of eye- lids, face, and arms. No pain; no fever. Dulness with absence of voice and breathing over all of right chest. Left lung normal. Duration about 3 months 190 Malassez, Archiv. de Physiol. 1876, II, 353 F 47 Both Extreme dyspnoea 191 Mandlebatjm, F. S. Personal communica- tion M 59 R Family history of tuberculosis. Healthy until 1907; then cough, pain at right anterior base, loss of weight, dyspnoea on exertion. Examination 6 months later; heart normal; dulness right infraclavicular space, broncho- vesicular breathing; flatness and dis- tant bronchial breathing at right base posteriorly. All other organs nega- tive. Clear serum aspirated from right base. Clinical diagnosis: tumor of right lung. Increasing cachexia; partial paralysis of right recurrent laryngeal 192 Makchiafava, Rivista clinica di Bo- logna, Serie II, 1873, 4, p. 150 Di un Cancro primitivo del polmone a cellule cilindriche con ripro- duzione nel cervello a nell osso frontale M 40 Both Harassing cough, emaciation, brain symptoms. Clinical diagnosis: chronic tubercular pneumonia. Duration of disease about 8 months 193 Matne, Dublin Hospital Gaz. 1857, 2. Proceedings Path. Soc. Dublin, 1856-7, p. 191 F 45 R Lancinating pain in chest, cough, dyspnoea, cachexia. Dilatation_ of su- perficial veins. Impaired respiratory motion of right chest. Flatness and bronchial breathing over all of right chest. Duration 15 months 194 McMtr>rN, Irish Hospital Gaz. 1874, II, 69-71 F 60 L Dyspncea; chronic bronchitis. Dul- ness over entire left chest with feeble voice and breathing sounds. Dilata- tion of superficial veins. Increasing pain. Enlarged glands in left axilla 195 M£N]& TRIER, M 68 R Always well. Debility, loss of flesh, CARCINOIVIA 181 No details Scant No details Abundant, bloody, no tuber- clebacilli, no tumor elements No details Scant, later gelati- nous mu cus Mucous, later abundant hsemop- tyses No details AUTOPSY NOTES Right main bronchus per- forated and obstructed by cancerous tiimor penetrat ing into right upper lobe at the hilus Whole of right chest filled with firm tumor containing numerous ca\aties. Hard nodular tumor at root of right lung compressing right main bronchus, upper cava and right pulmonary artery Numerous nodules in both lungs partly confluent and forming larger tumors Entire lower right lobe converted into tumor in cen- tre of which is large cavity containing necrotic matter. Communication between tu- mor and bronchus of large size, the tumor growing di- rectly into lumen of bron- chus Both lungs studded with tumor nodules, some with central breaking down and various kinds of necrosis Large white tumor _ at hilus of right lung involving nearly all of right lung, which consists of hard white can- cer masses interspersed with bluish-gray lung substance. Bronchi dilated Right lung normal. Left lung converted into a pur- plish shrunken mass studded with white nodules; cavity in centre of lung. Left bron- chus compressed Large tumor in right up- METASTASES Lymph nodes of hilus and cerebellvun Bronchial and medias- tinal lymph nodes None out- side of lung; None Frontal bone, brain, cerebellum Mediastinal lymph nodes, com- pressing up- per cava Axillary and bron- chial lymph nodes; pleura, liver and spleen Left lung, MICBOSCOPE Simply stated: carci- noma No details Alveolar structure with single layers of cy- lindrical cells of TjT)ical carcinoma squamous cell type with distinct cell nests and incomplete attempts at formation of homy pearls Alveolar structure ; alveoli lined with tjTjical cylindrical cells, but filled with polymor- phous cells No details Alveolar 182 TABLE I 196 197 198 199 ProgrSs M6d. 1886 436-437 Cancer primitif du Pou- mon MeRKLEN & GiRAED, Bull, et M6m. de la Soc. Med. des Hop. de Paris, Vol. XVIII, 3d S. 1901, p. 760 Cancer primitif des grosses Bronches Mbunieb, Arch. g6n. de" M6d. Vol. I, p. 208 De la Pneumonia du Vague MlNSSEN, .. Diss. Kiel, 1900 Uber prim§,ren Lun- genkreba MOIZARD, Bull, de la Soc. Anat de Paris, 1875, pp. 732-3 Cancer des Ganglions Bronchiques et du Poumon droit; enva- hissement de la veine cave superieure; Pleu resie M M M M 45 70 43 63 LUNG IN- VOLVED R R R R CLINICAL SYMPTOMS pain in right chest. Persistent diar- rhcea, cedcema of upper extremities and face. Dry cough. Dulness over right apex. Clinical diagnosis: some ob- scure visceral cancer with probable metastases in lungs. Sudden death. Duration about 4 months Mother died of cancer. Perfect health until August, 1900. First symptom: difficulty in breathing both when resting or exercising. After a cold, violent cough and severe attacks of suffocation. Hoarseness, dysphagia. Increasing dyspnoea; almost complete aphonia. Dulness over nearly entire right lung. Liver pushed downward. No pleuritic effusion. Total absence of breathing over right apex; lower down intense bronchial respiration with crackling rales at base. Diagnosis of broncho-pneumonic cancer was made during l^e. Death in an attack of suffocation. Duration about 7 months Gout and bronchitis for years. Later dyspnoea, increasing debility, loss of flesh, and severe cough. No fever. Pleuro-pneumonia at right base a few days before death Always well until influenza with pain m right chest, cough, and expec- toration. Since then increasing dysp- ncea and debility. Dulness over right apex; bronchial and amphoric breath- ing. Stridorous respiration and cyano- sis. No fever. Sudden death from haemoptysis. Duration of disease about 10 months. Clinical diagnosis: emphysema and pulmonary tubercu- losis Cough; swelling of extremities and face. Right external jugular dilated, not pulsating; right radial artery weaker than left. Heart normal. Dulness over lower § of right lung posteriorly with diminished voice and breathing. Superficial veins dilated. Fluid in right chest. Diagnosis: pleu- ritic exudate due to mediastinal tumor at root of lung with compression or thrombosis of superior vena cava CARCINOMA 183 AUTOPSY NOTES METASTASES MICROSCOPE per lobe proliferating into spinal canal. Right bron- chus and upper cava com- pressed; both vagi envel- oped in tumor both pleurae, regionary lymph nodes, liver, spleen, both suprarenals Mucopioru- lent, streaked with blood No details Bloody, no tuber- cle bacilli Trachea adherent to oesophagus; both surrounded by enlarged lymph nodes. Primary tumor in right main bronchus; lumen al- most entirely obstructed by soft, polypoid growth with pedicle at bifurcation. PrO' fuse degeneration of sur- rounding mucous mem- brane, thickened, white, and studded with bluish nodules Left bronchus and lung nor- mal. Right pleura adherent On section bronchi filled with ichorous fluid. Lung tissue studded with numer- ous white cancer nodules Mass of neoplasm at right hilua infiltrating and ob- structing main lower bron- chus. Entire lobe con- verted into cheesy, friable mass containing small cav- ities filled with pus and sur- rounded by necrotic tissue Pneumonic hepatization at the periphery. Whole looks "like sponge filled with pus." Right vagus merged into neoplasm Necrotic carcinoma of right bronchus perforating pulmonary artery; bronchi- ectatic cavities No metas- tases any- where throughout entire body No details structure containing cylindrical and poly- morphous cells and mu- coid degen- eration Large bron- chial vegeta tions, fibrous stroma, mU' cous in some places ; large alveoles and ramifying anastomosing cells, cuboid, cylindrical, and polyhe- dral. Struc- ture of pul- monary nod- ules about the same Cylindrical cells Origin from bron- chial epithelium Dark, clotted blood 1000 c.c. of clear serum in right pleura. At root of right lung a whitish medul- lary mass surrounding but not compressing right bron- chus and extending into the superior vena cava, ob- structing its lumen. _ Siini- lar medullary tumor in mid- dle lobe. Cerebral ventri- cles distended with pus Left pleura, bronchial and retro- peritoneal lymph nodes; pan creas, spleen and kidneys None men- tioned Alveolar structure, glandular cells sur- rounding lu- men and se- creting mu- cus Not given Origin from bron- chial mucous glands 184 TABLE I 200 201 202 203 204 205 Moore, London Path. Soc. XXXII, p. 32 Cancer of Right Lung with Embolism Middle Cerebral MOBELLI, Deutsch. Med. Woch 1907, May 16, p. 805 Ein Fall von primiirem Lungenkrebs MORIGGIA, Rivista Clin, di Bolo- gna, 1873, Serie 2, III, 5, p. 150 (Quoted after Meissner) MxJLLER, HeINRICH, Diss. Freiburg, 1904 Zwei Falle von pri- marem Lungencarci- nom Loc. CIT. MiJ'SER, Mitteilungen aus den M M M 56 28 40 68 62 53 LUNG IN- VOLVED R Both Both R CLINICAL SYMPTOMS Definite symptoms of pressure on right bronchus; enlarged and hard cervical lymph nodes. Aspiration yields bloody fluid. Diagnosed from this during life. Shortly before death aphasia and right hemiplegia No heredity; always healthy. After cold with fever and cough, increasing loss of flesh and strength. Chill, severe pain in right chest, dyspncea. Consolidation at right base with some pleural effusion. Endocarditis; dis- location of heart to right. Duration about 7 months Headache and increasing spasmodic cough. Nausea, depression, emacia- tion. After 3 months neuralgic pain in lumbar and hip regions. On ad- mission to hospital signs of a chronic tubercular pneumonia. After 4 weeks delirium and intense thirst. Clinical diagnosis: tubercular meningitis. Death after 2 months For some months considerable ema- ciation, pain in right leg, foot, and back. Lungs, with the exception^ of slight emphysema, normal. Clinical diag- nosis: sciatica, lumbago, and arterio- sclerosis. Some time later hard gland above right clavicle. Still later, high fever, dulness, and bronchial breathing at right base. Sudden coUapse. With appearance of gland, tumor of lung was suspected. Duration about 5 months Enters hospital for psychiatric dis- turbance. Lungs normal at this time. Later increasing emaciation; rales at both bases. Tumor on left chest ad- herent to rib; glands in left axilla. Death in marasmus; duration of dis- ease about 3 months General malaise, dyspnoea, cough, fever with chilliness, loss of weight, CARCINOMA 185 No details Bloody, shows diplococci No details No details No details On surface of right lung hard white new growth in patches, penetrating into lung and continuous with similar dense tissue spread- ing into lung from root and pressing on main bronchus Both lungs studded with small white nodules corre- sponding to blood vessels, and connective tissue strands which macroscop- ically suggested fibrous re- sults of pneumonic processes. Nothing pointing to tumor AUTOPSY NOTES METASTASES Mediasti- nal, bron- chial, and cervical lymph nodes Absolutely no others Pleura, heart, pericardium normal. In lungs numerous larger and smaller nodules confluent and degenerated; small cavities in centre. In^ ner surface left frontal bone a soft whitish prominence Meninges healthy. Numer- ous small nodules through- out brain Large tumor with soft- ened and necrotic centre in right upper lobe. Right main bronchus infiltrated and obstructed by tumor. Upper lobes both lungs studded with small nodules, Some tuberculosis Scant, mu- copuru- No others mentioned Bronchial lymph nodes, ribs, kidneys, and adrenals MICROSCOPE Bands of fibrous tissue with alveoli containing epithelium, in some parts distinctly columnar Nests of epi- thelial cells in lymph spaces of fi- brous tissue and adven- titia of blood vessels, also epithelial clusters fill- ing alveoles, in the alveo- lar septa and around blood vessels and smallest bronchi. Cells re- semble glan- dular cells Alveolar structure lined with cy- lindrical cells No details Interesting features of this case are the youth of the patient involvement of both lungs and the fact that the diagnosis could only be made with the aid of the microscope Origin bronchial mucous glands Large tumor in left lung Only in extending to pleura; no con- brain nection with bronchus. Tu- mor penetrates chest wall and extends under pectora- lis. Gangrene of right lower lobe. At autopsy tumor is diagnosed as osteoma of rib Large tumor left upper lobe containing cavity. Af Bronchial lymph Typical carcinoma- tous alveolar structure ; polygonal epithelium No details Author designates alveoli as origin of tumor 186 TABLE I 206 207 208 209 210 Hamburgischen Staats-Kranken- Anstalten, Vol. VIII, .. Heft 5, 1908 tjber den prim^ren Krebs der Lungen und Bronchien Log. cit. LOC. CIT. LOC. CIT. MtJSER, Loc. cit. Log. cit. M M M M 51 58 66 31 57 LUNG IN- VOLVED R R R R R clinical symptoms severe headaches. Choked discs; vari- ous cerebral symptoms. Small area of dulness left upper lobe in front; otherwise both lungs normal. X-ray shows spherical shadow extending from left hilus. Duration about 18 months. Clinical diagnosis: tumor of left upper lobe with metastases in cerebellum. Note. — Case II of this author is not included as there is no autopsy and it is not certain whether tumor is primary in the lung Increasing dyspnoea, pressure, pain. Later enlarged supraclavicular glands. Manubrium oedoematous and exceed- ingly tender to touch. Right lung from 2d rib down complete flatness and diminished respiration. X-rays show large shadow to right of sternum. Duration of disease about 3 years Cough, pain, loss of weight and strength. Various paralytic symp- toms. Over middle lobe flatness and diminished respiration. Secondary tu- mor in liver. Diagnosis made during Ufe. Duration about 3 months After influenza severe cough and bloody sputum. Rapid mental and physical decline. Later vertigo and paralysis. Qildoema of both lungs; clubbed fingers. Flatness right lower lobe; diminished voice and breathing sounds. On exploratory thoracotomy: a cavity filled with bloody pus and containing tumor particles consisting of polygonal and cuboid cells. At first some improvement; then rapid decline and death. Duration about 2 years Two years before admission pain in right chest ; for three months loss of weight, slight fever, cyanosis, dysp- noea, cough. Swollen lymph nodes in right axilla. Flatness right chest below 4th rib; diminished respiration in front; bronchial and amphoric breathing behind. Exploratory punc- ture shows characteristic granular cells from which diagnosis of tumor of right lung is made Pain, loss of weight and strength. Diminished respiration and slight area of flatness on right chest about 2d CARCINOMA 187 lent, pathog- nomonic granular cells Sputum contained charac- teristic cells At times bloody; charac- teristic granular cells Greenish, mucoid, fat drop- lets ferent bronchus infiltrated with tumor and ulcerated Bloody, raspberry jelly, profuse hgemop- tysis Bloody, charac- teristic granular cells None AUTOPSY NOTES METASTASES Large carcinoma of right middle lobe extending into lower lobe Bloody serum in right pleura. Large tumor in middle and upper right lobes. Carcinomatous infil- tration afferent bronchus Carcinoma of right lower bronchus, tumor cavity al- most completely filling right lower lobe Large tumor near right hilus starting from bronchus nodes and cerebellum Hilus and supraclavic- ular glands Bronchial and epigas- tric lymph nodes, liver, 5th rib, in number of vertebrge. Compres- sion of spi- nal cord Right lung and cerebel- lum Liver and lymph nodes MICROSCOPE No details No details No details Carcinoma No details Operation : Tumor of right lung contain- ing cavity. As much of tumor as possible removed. Recovered and has remained well for a year 188 TABLE I NO. AUTHOR LUNG IN- VOLVED 211 212 213 214 215 Log. cit. Log. cit. Loo. CIT. Log. CIT. Log. CIT. M M M M M 59 72 59 65 44 216 Log. CIT. M 58 217 Log. GIT. M 68 R 218 Log. git. M 74 CLINICAL SYMPTOMS to 3d rib. Otherwise both lungs nor- mal. No cough. Death from sudden collapse. Duration about 2 months Emphysema for years. Recently loss of weight and strength; cyanosis; dulness over left base with diminished respiration. Effusion in right pleura Dyspncsa, cough, pain, rapid loss of weight. Left chest flattened, impaired respiratory motion ; flatness, no breath- ing sounds. After aspiration 1050 c.c. brown serum, flatness remains Sudden cough, expectoration, slight pain. Loss of flesh and strength. Dulness over left upper lobe with feeble breathing sounds and impaired respiratory motion. Duration about 10 months Cough, rapid emaciation. Dulness over entire left upper lobe; diminished breathing, bronchial toward hilus. Duration about 2 months Cough, expectoration, increasing loss of strength and weight. Flatness over all of left lobe; impaired respira- tory motion; loss of breathing and voice sounds Cough, expectoration, loss of weight and strength. Dulness over left upper lobe and sternum; a few large rales. Greatly diminished respiration. Dura- tion about year and half Cough, expectoration, loss of weight. Retraction right upper chest; flatness right upper lobe with diminished breathing sounds; no vocal fremitus. Emphysema and bronchitis in remain- der of lungs Cough, pain, loss of weight. Dul- ness over left lobe posteriorly with diminished voice and breathing CARCINOMA 189 AUTOPSY NOTES METASTASES MICHOSCOPE No details Granular fatty cells Mucoid, bloody; no as- sured granular cells No details Mucoid, often bloody, some- times prune juice. No tubercle bacilli but gran- ular cells Nothing charac- teristic Mucoid Bloody with char- acteristic Carcinoma left lower lobe starting from main bronchus Left upper and lower bron- chi infiltrated with tumor penetrating into lung and forming nodules Ulcerated carcinoma of left main bronchus with tu- mor containing cavity in left upper lobe Large carcinoma starting from left main bronchus Carcinoma from left main bronchus involving nearly whole of left lower lobe. Embolus left pulmonary ar- tery; aneurysmatic dilata- tion left ventricle Large carcinoma from left main bronchus; bronchus left upper lobe completely closed by tumor Carcinoma at first bifurca- tion right main bronchus, al- most completely obstructing right upper bronchus and proliferating along bron- chial ramifications through upper lobe. Bloody serum in pleura Carcinoma of left main bronchus involving nearly all of left lower lobe. Puru which com- press recur- rent laryn- geal and vagus Liver Both pleurae, bronchial and tra- cheal lymph nodes Bronchial, tracheal, and medias- tinal lymph nodes Mediastinal lymph nodes com- pressing re- current No details Bronchial and tracheal lymph nodes, liver and dura. Pyloric car- cinoma is also found Pericar- dium, heart, kidneys, and suprarenals Small carci- noma in stomach No details No details No details No details No details No details No details Author implies that pyloric carci- noma is distinct and independent of lung tumor. Microscopic structure unfortu- nately not given 190 TABLE I 219 220 221 222 223 224 MtJSER, Loc. cit. Loc. CIT. MrrssELiER, Gaz. M6d. de Paris 1886, 159 Cancer primitif du Pou- mon M M MUSSBR, J. H. Univ. Penna. Med Bull. Vol. XVI, Oct 1903, No. 8, p. 289 Primary Cancer of Lung Loc. CIT. Maun, I. Deutsch. med. Zeit. XXVI, 1905, p. 537 Ein Fall von primarer Krebsentwickelung in den Bronchien 59 67 F 76 M M M LUNG IN- VOLVED R R 49 47 50 R Both CLINICAL STMPTOMa Cough, pain, loss of weight. Im- paired respiratory motion. Dulness and diminished voice and breathing over left lower lobe. Duration about 2 years Always healthy. Recently cough, dyspnoea. Dulness, diminished bron- chial breathing, impaired respiratory motion over right upper lobe No heredity; always well. Pain in right shoulder; later small hard tumor below right clavicle; subsequently sim- ilar tumor below left clavicle. Irreg- ular area of dulness in right chest posteriorly with feeble respiration. Paraplegia. No cough; no dyspnoea. Duration about 7 months. Diagnosis made during life from the bloody spu- tum, pain and tumors below clavicle No heredity. Clinical symptoms those of pleuropneumonic infection. SUght fever, physical signs of effusion; aspiration negative. Exploration re- vealed nodule in lung. Marked leu- cocytosis. Cachexia very late. Dura- tion less than 3 months _ No heredity. Sore throat _ only at night and in recumbent position. In- digestion, dyspncea, loss of flesh and strength. Moderate cough causes bringing up of large amount of fluid. Slight pleural friction in right axillary region only physical sign on lungs. Nothing characteristic in blood. Signs of bronchitis and pleuritis; rales at both bases. Intense dyspnoea; in- creased leucocytosis. Duration about 5 months Lues 20 years ago. Recently loss of weight and strength; repeated haemorrhages. Persistent pain with- out swelling in all joints. Near left costoclavicular articulation a tumor size of a walnut, hardly movable, slightly fluctuating. Dulness over both supraspinous fossse; dulness left with diminished respiration. CARCINOMA 191 BPUTUM AUTOPSY NOTES METASTASES MICROSCOPE REMARKS fatty lent exudate in left pleural granular cavity cells Bloody, Nearly whole of left lower No details No details fatty lobe converted into hard granular cancerous mass. Bloody cells fluid in left pleura Purulent, Carcinoma of right upper Bronchial No details bloody bronchus; obliteration of lymph with pleura. Bronchiectasis and nodes and "Fett- bronchopneumonic areas in liver korn- both lower lobes chen" Currant Several larger and smaller No others No details jelly tumors softened in centre in upper portion right lower lobe No details Massive tumor of right Left lung, ■ No details A second case is lower lobe liver, tho- racic lymph nodes not included because there was no autopsy but there is no doubt that it was a similar case Not bloody, Diffuse yellowish gray in- Cervical, General al- No anatomical no tuber- filtration uniformly through- bronchial, veolar ap- cause for the orthop- cle bacilli out both lungs. No pleu- tracheal, pearance of noea and sore throat ritic effusion and retrope- lung re- could be found. Clin- ritoneal tained; fre- ical diagnosis was tu- lymph quent areas berculosis nodes of necrosis. Flat epithe- lial cells re- sembling al- veolar epithe- lium; in older portion dis- tinctly papil- lary arrange- ment and cy- lindrical cells Abundant, Left lung adherent; near Areas of Abundant Practically no pain. mucopu- posterior border large cav- neoplasm in firm stroma ; no dyspnoea, and rulent; ity; numerous bronchiec- pericardium alveolar nothing characteris- no tuber- tatic cavities containing pus. and left ven- structure tic. Only significant cle bacilli; Right lung normal. A mass tricle filled with symptoms initial hae- repeated the size of an orange at bi- polymorph- moptysis and rapidly hsemop- furcation of main bronchus; ous epithe- increasing cachexia tyses; similar tumor at lower end lial cells; later of trachea toward left. Near plentiful 192 TABLE I 225 226 227 NEtTMEISTEB, Miinch. med. Wo chenschr. No. 36, 52, 1905, p. 1721 Ein Fall von primarem Plattenepithelkarzi- nom der Lunge, etc Oberthub, Revue Neurol. Vol X, Paris, 1902, p. 485 Oesteeich, Berl. klin. Wochen- schrift, 1892, p. 104, Demonstration M 63 32 62 LUNG IN- VOLVED R CLINICAL SYMPTOMS Cough. Pain left base. Aspiration, clear blood. Diarrhoea. No fever: Haemoglobin 40, leucocytes 15,000. Death from exhaustion. Duration about one year. First diagnosis was tuberculosis, then pneumonia with bronchiectasis. Only very late during life was there a suspicion of malignancy Had pleurisy some years ago. Weak, cachectic; suffered for year with pain in right shoulder joint. Clinical diag- nosis: pulmonary tuberculosis and tu- berculosis of right shoulder joint No heredity. At age of 27 both ovaries removed for cystic degenera- tion. About middle of 1899 she com- plained of vague pain along spine, in shoulder and chest even on slightest effort. Loss of appetite and flesh. End of year, frequent painful attacks, cough, bloody sputum. Diagnosis at that time tuberculosis. Patient then commenced to drink large quantities alcoholic liquors. Increasing dyspnoea, CBdcemaof lower extremities. Nervous symptoms now predominate, painful cramps in both upper and lower ex- tremities and along spine which pre- vent sleep. Rapid atrophy of muscles. Soon not only walking but almost every movement becomes impossible; intense general hypersesthesia. Details of neurological examination omitted. Continuous dyspnoea ; absolute flatness over whole of left lung. Total absence of breathing except some amphoric respiration at hilus. Dulness at base of right lung with friction; harsh breathing throughout and some rales. Continuous sweating. Chnical diag- nosis: alcoholic polyneuritis and pul- monary tuberculosis Malaise for some time. Effusion of clear serum in right pleura. In- creasing dyspnoea, cyanosis, cedoema of upper body CARCINOMA 193 AUTOPSY NOTES METASTASES MICKOSCOPE bloody No details origin of left main bronchus a } cm. whitish yellow mass destroying the cartilages and penetrating into lumen of bronchus Anatomical diagnosis: tu- berculosis of left lung; bron- cho-pneumonia of right; pu- rulent bronchitis; cheesy degeneration of right supra- renal, tubercular arthritis right shoulder joint Only in right shoul- der joint Abundant, mucopu- rulent, often streaked with blood, but no "currant jelly." Sputum not ex- amined micro- scopically No details Large quantity yellow serous fluid in left pleura; small quantity in right. Cancerous pleurisy ; cancer ous lymphangitis. Left lung retracted, atelectatic, and fi' brous at apex. Whole left lower lobe and hilus a mas- sive cancer, soft in interior and fibrous exteriorly. Large and medium size bronchi disappear entirely in tumor. Small secondary nodules especially near hilus in right lung around bron chi. Swollen mediastinal lymph nodes envelop base of trachea and main bronchi Pericardium and myocar- dium contain miliary nod- ules; innumerable miliary nodules in skin and muscles all over body Carcinoma of right main bronchus involving lung along bronchial ramifica- tions; some obstruction of 2 secondary nodules in uterus; mill' ary nodules in both kid- neys, supra- renals, pan- creas, liver, retroperito- neal glands pericardium, myocar- dium, skin, and muscles karyokinesis. Origin from bronchial mucous mem- brane Capsule of joint showed no tuberculo- sis but infil- tration with typical can- croid pearls. In the lung innumerable foci of carci noma of can^ croid type which could not be differ entiated from the tubercu- lar tissue which was everywhere intermingled Glandular epithelium with cylindri- cal cells with many karyo kinetic figures Discussion whether primary in lung. Probable origin bron- chial mucous glands. Microscopic study of nerves and muscles, also mUiary nodules, all show same char- acter as primary tu- mor. Nothing in brain, medulla or me- ninges. Lesions in nervous system and muscles by their pres- sure cause degenera- tion of nerve and muscle fibres with pseudo-hypertrophy in the latter No details No details 14 194 TABLE I 228 229 Otten, Fortschritte auf dem Gebiete der Roent- genstrahlen, Vol. IX. Heft 6, 1906, p. 369 Zur Roentgen-diagno- stik der primaren Lungencarcinome Log. cit. 230 231 232 233 Log. err. Otten, Loc. cit. Log. cit. Loc. CIT. 234 235 Log. cit. Loc. CIT. SEX AGE M M M M M M M 69 67 60 61 65 66 62 LtTNG IN- VOLVED R R R CLIiaCAIi SYMPTOMS Pain in right chest, cachexia, CEdcema of right arm; dilated veins over right chest and belly. Dulness and absence of breathing over right upper lobe. Some dyspnoea; no cough No heredity. Cough and expectora- tion for years; otherwise well. Diag- nosis at first, tuberculosis. Later pain in right shoulder, cough, dyspnoea, cya- nosis of upper body. Enormous dila- tation of superficial veins; cedcema of arm. Cachexia. Dulness right upper lobe with signs of cavity. No fever Father died of carcinoma of stomach. For 4 months pain in right chest, cough, expectoration; general debility. Enlarged axillary glands. Dulness right upper and middle lobes. Dura- tion of disease about 5 months Cough and mucoid expectoration for several years. Increasing dyspnoea, emaciation, and debihty. Enlarged glands in both axillae. Dulness over nearly entire left lung. Some fever. Death after about 5 months Mother carcinoma of uterus. Always well. For 6 weeks increasing weakness, loss of flesh, dyspnoea, cough, pain in chest and back; attacks of suffo- cation; some fever. Dulness right middle and lower lobes. Impaired respiratory motion. Haemorrhagic ef- fusion in right pleura No heredity; always well. For about On months bloody expectoration, loss of weight, cough, cyanosis, dysp- noea; moderate fever. Enlarged axillary and cla\ricular glands on right side. Hoarseness. Consolidation of right upper lobe No heredity. For .5 months cough, dyspnoea, increasing debility, and loss of weight. Signs of consolidation of right upper lobe with dry pleurisy in right chest. Bloody effusion in left chest. Paresis of left recurrent No heredity. For several months increasing weakness and loss of flesh. CARCINOMA 195 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE EEMAEKS left bronchus. Extensive gangrene of lung; bronchiec- tasis. Compression of up- per cava, aorta and oesopha- gus None Carcinoma of right upper lobe. Thrombosis right subclavian and axillary veins Glands of hilus and right axilla No details Mucopuru- lent Carcinoma of right upper lobe with cavity in centre. Thrombosis upper cava and both internal jugulars Lymph nodes at root No details No details Carcinoma of right main bronchus and infiltration of upper and middle lobes Bronchial lymph nodes and liver No details Mucoid Carcinoma of entire left lung Liver, hi- lus, and axil- lary lymph nodes No details Purulent Carcinoma of large bron- chus of right side with infil- tration of entire middle lobe Liver, right adrenal No details Bloody Carcinoma of right bron- chus infiltrating upper and middle lobes Axillary and clavicu- lar glands No details Mucoid Carcinoma of left main bronchus infiltrating a large part of left upper lobe. Pneumonia of right lower lobe Glands of left hilus No details No detaUs Carcinoma of left main bronchus infiltrating large Bronchial, tracheal. No details 196 TABLE I 236 237 238 239 240 241 242 Loc. err. Log. cit. Loc. CIT. Loc. CIT. Loc. CIT. Pabssleb, Virchows Arch. Vol. .. 145, 1896, p. 191 Uber das primare Kar- zinom der Lunge Loc. CIT. M M M M M M 49 53 Not stated 67 51 73 52 LXTNG IN- VOLVED R R R CLINICAL SYMPTOMS Cough, pain in left chest, dyspnoea, and cyanosis. Enlarged left axillary and clavicular glands. Dilated veins left shoulder. Dulness over left upper lobe. Absence of breathing over all of left chest. Paralysis left recurrent No heredity. For about 2 months cough, expectoration; later dyspnoea and palpitation. Hoarseness, cyano- sis, paralysis of left recurrent. Infil- tration of left upper lobe No heredity. For about 6 months increasing debility, loss of flesh, stomach trouble. During last few weeks fever, headaches, dizziness. Cachexia, choked discs, ataxia. Small area of dulness to left of manubrium sterni No heredity. For 2 years varying symptoms. Dyspnoea, cough, some pain in chest. No fever. Small dull area to right of sternum gradually extending over greater portion of right chest No heredity. For 6 months cough with expectoration, loss of strength and weight, increasing dyspnoea. Slight fever; physical signs of profuse bron- chitis over both lungs. Enlarged glands in right supraclavicular fossa Father probably died of cancer. For 3 months pain in left chest. Cough, increasing loss of flesh and strength, slight fever. Dulness over left lower lobe. Attempt was made to remove left lower lobe by operation. Increas- ing cachexia; steady fever. General carcinosis of left pleura Well until 6 weeks before death; then slight cough, scant sputum, paralysis of left recurrent. Pneumonia of left lower lobe. Clinical diagnosis: anexxrism or mediastinal tumor Always well. Little cough, no pain, some persistent hoarseness. Without premonition 2 sudden and profuse haemoptyses causing death in 2 days Clinical diagnosis: pulmonary phthisis i CARCINOMA 197 Scant, mu- coid Purulent Often bloody, profuse Mucopuru- lent, later bloody Bloody Scant, never bloody None AUTOPSY NOTES area of upper lobe. Sero- axillary, and sanguinolent effusion in left clavicular pleura lymph nodes Carcinoma of left main Both lower bronchus lobes Carcinoma of main bron- Bronchial chus of left upper lobe infil- lymph trating nearly all of upper nodes and lobe cerebellum Bronchial carcinoma infil- Both lungs trating right middle lobe Carcinoma of right large Lung, bron bronchus infiltrating middle chial, and and part of upper lobe. Nu- supraclavic- merous bronchial and peri- ular glands bronchial nodules through out other lobes Left lower lobe almost en- Pleura, tirely removed; remnant pericar cancerous. Carcinosis of dium, heart, left pleura ; carcinomatous left kidney, pericarditis. Old tubercu- left adrenal losis right apex Ulcerated medullary car- Lymph cinoma of left main bron- nodes at chus. Compression of tra- root of left chea; numerous bronchiec- lung tatic cavities in left upper lobe. Aspiration pneumo- nia of left lower lobe. Hsemorrhagic effusion in left chest. Compression of left recurrent Carcinomatous ulceration Large ves- of right main bronchus. sels and Erosion of branch of right nerves, left pulmonary artery. Cancer- auricle and ous infiltration in walls of pericardium large vessels and nerves, proliferates through pulmo- nary vein into left auricle and into pericardium METASTASES MICROSCOPE No details No details No details No details No details Cylindrical celled carci- noma Homy pave- ment celled cancer 198 TABLE I 243 244 245 246 247 248 Log. git. Loc. CIT. Papinio, Pennato, Riv. Ven. di Scienza Med. Anno X, Tomo XIX, p. 393, Nov. 1893 Carcinoma primitive del Polmone Parow, Diss. Greifswald, 1896 Ein Fall von primarem LungencarcLnom Passow, Diss. Berlin, 1893 (After Paessler) Zur Differentialdiagno- se der Lungentumo- ren insbesondere der primaren Lungen- krebse Peacock, London Path. Soc. IV, 1849-50 Primary Cancer of the Lung M M M 63 46 12 62 51 43 LUNG IN- VOLVED R R CLI1«CAL SYMPTOMS Apoplexy with paresis of right facial, _ hypoglossal, arm, and leg. Cachexia. Respiration normal but diffuse dry rales with some pleuritic friction. Clinical diagnosis: general paresis. Duration about 5 months No heredity. Syphilitic symptoms for many years. For a few days pain in left chest, cough, and dyspnoea. Flatness with feeble inspiration and absence of vocal fremitus on left chest. Intense dyspncea and cyanosis. Aspi- ration: clear serum; sudden death at end of aspiration. Clinical diagnosis: pleurisy and lues 111 6 months before admission with pain in right chest, sweats, attacks of cough without expectoration; prostra- tion. On admission pale, emaciated child, right chest larger than left; impaired respiratory motion of right side. Upper right intercostal spaces obliterated. Enlarged gland in right axilla. Absolute dulness over whole anterior of right chest, also laterally and posteriorly except for a small space along spine at apex which gave a little resonance. Heart displaced toward left; nothing essential in left lung. No fever. 150 c.c. blood from pleural cavity. Second exploratory puncture only a few drops of blood. Dyspncea; cyanosis. Death after 3 weeks in hospital No heredity. Indefinite symptoms for some time. Later dyspnoea, ca- chexia, dysphagia. Tumor in right supraclavicular region No clinical details Pain in chest, difScult breathing, cough, cachexia. Complete dulness over upper left chest, feeble inspiration and prolonged expiration suggesting compression of bronchus. Later in- tense dyspnoea, cyanosis, swelling of face, neck, chest, and arms. Swelling of glands on each side of neck. Entire left lung impervious to air. Duration of illness about 10 weeks CARCINOMA 199 AUTOPSY NOTES METASTASES MICROSCOPE No details No details None No details No details None Carcinoma of main bron- chus of left lower lobe Almost complete com- pression of left lung; sub- pleural carcinoma of left upper lobe Nearly entire right chest occupied by spheroid mass, soft and semi-fluctuating. Upper lobe of lung pressed upward and backward. Two lower lobes replaced by neo- plasm. All other organs normal Carcinoma right main bronchus and beginning of left. Bronchiectases and atelectases right upper lobe. Large nodiile compresses CESophagus Carcinoma involving bronchi and lung and pene trating anterior wall of chest Tumor right upper ster- num and external end left clavicle in connection with masses of carcinoma imbed- ded in upper part left lung and extending along bron- chus to bifurcation and down posterior mediasti- num. In lung, divisions of bronchus almost obliterated; branches of pulmonary ar- Lower lobe right lung, liver, and many in brain Miliary cancer nod- ules in pleura and middle and upper right lobes. No other meta- stases None ex- cept gland in right axilla Cylindrical celled carci- noma Cylindrical celled carci- noma Cervical and supra- clavicvQar lymph nodes Medias- tinum and supraclavic- ular lymph nodes No further details Probably carcinoma Cylindrical and polymor- phous epithe- lial cells Cylindrical cells Author mentions as origin surface epithe- lium of bronchi No details 200 TABLE I 249 Pearson, Chas. L. Charlotte Med. Jour. XV, 1899, p. 633 • Case of Encephaloid Carcinoma of Lung with Tuberculosis 250 Pbnsttti, v. Lavori dei Cong, di Med. Intern. Nono Cong. Ten. in Torino, neir Ottobre 1898 (Roma, 1899), p. 338 251 262 Pbpbbb, Centralbl. f. Path Anat. Vol. XV, 1904, p. 948 Pbbitz, .. Diss. Berlin, 1896 Uber Brusthohlen geschwiielste M M M LUNG IN- VOLVED 41 52 57 48 R R R CLINICAL SYMPTOMS Grandmother and 2 aunts died of cancer. Commenced with pain in left side. Aspiration: clear serum. Pa- tient worked for 3 weeks, then pain, cough, fever, and night sweats. Dul- ness over left chest. Dulness an- teriorly to nipple; bronchial respira- tion over apex; absence of breathing over rest of lung. Heart displaced to right. Good appetite. Dry cough. Aspiration negative. Dysphagia later; haemoptysis. Malignancy suspected. Duration about 5 months Always well. Sick since 7 months before admission when lipoma size of hen's egg was removed from posterior right chest. Tumor not examined microscopically. Three weeks after admission anterior right chest showed impaired respiratory motion and a zone of dulness with bronchial respira- tion from 2d to 5th rib and from axilla to margin of sternima. Diag- nosis of cancer of lung was made. Patient lost sight of for 4 months, then great marasmus, paralysis of right vo- cal cord, pleuritic pain in right side; no fever. Dulness extended to pos- terior and lateral wall of thorax. DyspncEa No clinical history Commenced with chill, pain in right chest, cough, dyspnoea, general cachexia. Dulness increasing to flat- ness over entire right chest. _ Di- minished breathing and fremitus; stridorous respiration. Paralysis of recurrent. Appearance of tumor above sternum. Enlarged axillary and cer- vical glands. Right radial pulse smaller than left. Duration of disease about 5 months CARCINOMA 201 Prune juice sputum, many- tubercle bacilli; pieces of necrosed lung tissue coughed up with haemor- rhage Always "currant jelly." No tuber- cle bacilli, but on first ad- mission showed numer- ous large flat poly mor- phous cells from which di- agnosis was made No details tery flattened and com- pressed ; pulmonary vein ob- literated. Tumor enclosed and compressed upon lower trachea and aorta and prO' truded into cavity of peri' cardium. Left innominate vein obliterated Left lung solid with nodu- lated tumor containing cav- ity AUTOPSY NOTES METASTASES Right lung almost entirely transformed into hard mass Left lung normal Right lung Glands at hilus, liver, kidney, mesenteric glands Bloody effusion in right pleura. Right lung normal in shape but ^ normal size, I grayish and yellowish white throughout; interstitial tis- sue much thickened. Bron- chi normal Occasion- ally bloody, no tuber cle bacilli or tumor elements M1CK08C0PE Encephaloid carcinoma. Tubercle ba- cilli in cavity Alveolar structure; many large polymorph- ous epithe- lial cells simi- lar to those found in spu- tum. Pleura free Left lung, brain, lymph nodes at hilus Primary carcinoma of right main bronchus pene- trating lung without sharp definition. Bronchiectatic cavities Medias- tinal, mes- enteric, axil- lary, cervi- cal lymph nodes and liver At the autopsy no connection could be traced between scar from lipoma incision and tumor of the lung TjTjical cy- lindrical celled carci- noma. Prob- able origin from smallest bronchioles and alveoles Alveolar structure ; 2 to 3 layers of smooth cylin- drical cells Diagnosis only pos- sible by microscope without which the case would have been diagnosed as chronic interstitial pneumo- nia with acute fibri- nous pneumonia in the stage of gray hep- atization Supposed origin: ducts of bronchial mucous glands 202 TABLE I 253 Log. cit. 254 255 Log. git. Log. git. 256 257 258 M M M Pehls, Virchows Arch. Vol 56, p. 437 Zur Casuistik des Lun- gencarcinoms Peerone, a. Arbeiten aus dem Path. Inatit. in Ber- Un, 1906 Entwickelung eines primaren Cancroids von der Wand einer tuberculosen Lungen caverne Pertjtz, Diss. Miinchen, 1897 Zur Histogenese des pri maren Lungencarci- M 47 LUNG IN- VOLVED 64 36 R 43 M M 74 58 R R CLINICAL SYMPTOMS Sudden onset with bronchitis, cedcema of face, increasing dyspnoea, cyanosis, dilatation of veins, pain in arms and chest. At the beginning nothing essential found in lungs, but absolute flatness over sternum extending to both sides. Feeble respiration over all of right chest. Later effusion in right chest. Heart dislocated to left. Aspiration: clear serum. Duration about 4 months Dyspnoea, pain in left chest, back, and arm. Bulging of left chest, im- paired respiratory motion. Flatness and vaiying areas of dulness over left chest. Some fever. Aspiration: tur- bid serum. Later distinct pulsation and increased fremitus over anterior left chest. Improvement; patient gets about. Gradual retraction of left chest; dulness again appears; increasing cachexia. Duration about 10 months No previous illness. Sudden fever, pain, cough, expectoration. Some im- provement, then fever and ssrmptoms of left pleurisy with effusion. Heart dislocated to right. Aspiration: 500 c.c. bloody serum; needle penetrating into hard tissue. Later chills; flatten- ing and afterward bulging of left chest. Enlargement of supraclavicu- lar glands. Aspiration: pus. Resec- tion of rib Pain, anorexia, chilliness, fever, dyspnoea, cough. Expansion right chest; dulness, feeble respiration above, absence of breathing sounds below; no fremitus. Liver displaced downward. Duration about 3 months No previous illness. Commenced with pain in left shoulder; disappeared but returned very severely.^ Bulging, impaired respiratory motion. Dul- ness, diminished breathing and crack- ling rales over left chest. Tumor above left clavicle. General cachexia. Duration about one year No clinical history CARCINOMA 203 AUTOPSY NOTES METASTASES MICKOSCOPE Occasion- ally bloody, neither tubercle bacilli nor tu- mor par- ticles Mucoid, no tuber- cle bacilli; no blood Bloody fluid in right pleura. Tumor nodules in mucous membrane of right main bronchus connecting with large masses surround ing trachea and extending into right chest, penetrat- ing lung and compressing it Upper cava compressed Large firm tumor at left hilus ; polypoid tumor masses obstructing left main bronchus. Tumor penetrates lung along bronchial ramifications No others Alveolar structure ; small cylin- drical cells Lymph nodes and liver Pavement epithelium with tjTjical cancer nests Mostly bloody Encapsulated empyema Carcinoma of left lung and bronchi. Carcinomatous infiltration of pleura Bloody No tubercle bacilli No details Bloody serum in right pleura. Right main bron- chus and branches infil- trated and obstructed by tu- mor. Cavities with thick capsules in upper and lower right lobes Tubercular cavity at left apex; wall of cavity pene- trated by tumor involving 1st and 2d ribs, and 6th and 7th cervical and 1st dorsal vertebrae. Compression of axillary nerves and vessels Cavity in right upper lobe, walls of which are formed by firm white tumor. Tumor extends to right main bronchus, wall of which is perforated, one of the per- forations communicating with cavity. Tumor pene- trates into upper cava Muscles of chest, liver, kidneys, capsule of spleen Posterior mediastinal lymph nodes, liver, ribs, inter- costal mus- cles, brain No others Alveolar structure; pavement epithelial cells Alveolar structure ; cancer nests Tubercular tissue with bacilli in wall of cavity be- sides typical cancer pearls. Bronchi intact No other details Alveolar structure; cy- lindrical and cuboid cells with forma- tion of mu- cus. Origin bronchial mu- cous glands Supposed origin from bronchus 204 TABLE I NO. AUTHOR SEX AGE LUNG IN- VOLVED CLINICAL SYMPTOMS 259 Loc. CIT. M 50 L No clinical history 260 LOC. CIT. F 48 L Diagnosis made during life from expectorated tumor particles 261 PiTINI & MeBCADANTE, La Reforma Med. Roma, Vol. Ill, 1902, p. 710 Carcinoma midollare primitivo del polmone F 37 R SjTjhilis admitted. On admission cyanosis of face, cedcema of right arm, forearm, and hand. For about 6 months harassing dry cough, and pain in right shoulder. Later cough be- comes moist. Increasing dyspncea, irregular dulness over greater part of right chest from above downward; diminished fremitus; bronchial respi- ration; many rales. All other organs healthy. No leucocytosis; red cells 3,500,000. Later swelling of right thorax and arm, dulness and absence of voice all over; diminished breathing. Still later all signs of effusion in pleura. Diagnosis of solid tumor of lung was made. Under observation 21 days 262 Pitt, London Path. Trans. 39, p. 54 (After Paessler) Malignant Disease of Bronchial Glands F 67 R No clinical history 263 PUECH, Montpellier Med. 2 me SSrie, XI, 1888, July, p. 6 Cancer de la Trach6e et Tuberculose pulmo- naire M 67 R No heredity. Disease commenced with severe bronchitis, general weak- ness, fever, diarrhoea. Tubercular cav- ity right apex. Duration about 9 months 264 Reinhardt, Arch, der Heilk. 19, 1878, p. 369 Primarer Lungenkrebs M 47 R CEdoema of upper half of body. Hoarseness, dyspnoea, dysphagia. Di- lated veins on posterior and anterior surface of chest. Dulness over right upper lobe; diminished breathing an- teriorly; bronchial behind. No rales. Effusion in right chest. Little cough; some fever. Erysipelas of chest. Death. Duration about 5 weeks CARCINOMA 205 SPUTUM AUTOPSY NOTES METASTASES MICBOSCOPE HEMAHKS No details Left upper lobe almost en- Regionary Alveolar tirely replaced by large nod- lymph structure ; ulated tumor protruding in- nodes and polymorph- to mediastinum. In centre wall of left ous epithelial of tumor a cavity into which ventricle ceUs; tumor bronchus of upper left lobe injection of opens. Left upper bron- lymph ves- chus infiltrated with tumor sels nodules Tumor par- Left main bronchus infil- Bronchial Carcinoma- ticles trated with tumor; lung and tra- tous struc- studded with small tumor cheal lymph ture nodules; larger tumor at nodes; both apex left lower lobe kidneys brain Abundant, Abundant serous effusion Left lung, Typical epi- Nearly all the usual mucopu- in pleurae and pericardium. axillary. thelioma. symptoms of pulmo- rulent. Left lung studded with peribron- Massive new nary carcinoma ab- Nothing larger and smaller tumor chial lymph formation of sent — no character- charac- nodules. Upper part right nodes. fibrous tissue; istic bloody sputum. teristic lung firmly adherent to Right sub- mucoid and no haemorrhagic exu- chest wall ; numerous clavian colloid degen- date in pleura; no ca- smaller nodules throughout compressed. eration with- chexia lung, but upper lobe one All other in the new large mass of tumor organs nor- mal formed tumor masses. Car- cinomatous structure in secondary lymph nodes. Lung tissue completely replaced by_ tumor. Ori- gin attrib- uted to alve- olar epithe- lium No details Carcinoma of right main bronchus considerably ob- structing lumen No details No details Profuse Left lung normal. Tu- Peribron- Alveolar Tumor evidently haemop- bercular cavities right lung. chial lymph structure ; flat gave no recognizable tysis White tumor in trachea near bifurcation, extending into right main bronchus _ and partially obstructing it nodes epithelial cells clinical symptoms None Wall of right bronchus penetrated by tumor start- ing from hilus. Infiltration of upper lobe along bron- chial ramifications. Com- pression of upper cava Lymph nodes at bi- furcation No details 206 TABLE I 265 266 267 268 269 270 271 272 273 Reinhardt, Sections Protocol! des Dresdener Stadt- krankenhauses, 1885, No. 83 Log. git. 1858, 232 Log. git. 1861, 108 Log. cit. 1872, 433 Log. cit. 1873, 260 LOC. CIT. toe. CIT. RiPLET, New York Med. Record, XVIII, 1880, 691 Primary Infiltrating Medullary Carcinoma of Lung RiSPAL, Toulouse MM. Vol II, p. 305 (1900) Cancer primitif du Pou- mon M M M M M 66 62 40 67 62 40 74 58 55 LUNG IN- VOLVED R R R CLINICAL SYMPTOMS No clinical history No clinical history No clinical history No clinical history No clinical history Increasing debility, cough, pains in left chest. Dulness and feeble breath- ing over lower left chest; tympanitic percussion note over upper portion. Duration of disease about 5 months Cough, dyspncBa, pain in back, ver- tigo, anorexia, and weakness, bulg- ing of lower right thorax with dulness and diminished voice and breathing. Above this area tympanitic percussion note and bronchial breathing. Dislo- cation of heart and liver No heredity. Always weU. Com- menced with slight cough, pain in sternal region, weakness, and dyspncsa. Dulness from left clavicle downward with loss of fremitus and distant bron- chial breathing. Exploratory punc- ture: small quantity bloody serum without relief of dyspncsa. Duration about 4 months No heredity. Bronchitis since in- fancy; cough and expectoration al- ways. For 3 months severe pain in right chest; anorexia, cachexia. Dul- ness at right base with diminished vesicular murmur. Only other symp- CARCINOMA 207 No details No details No details No details No details Mucoid Purulent and bloody, one haemop- tysis Mucous Abundant, yellowish purulent AUTOPSY NOTES Large tumor in left lower lobe, softened in centre. Ob struction of main bronchus Tumor of left hilus. Bronchiectatic cavity lower lobe; also nodule in left lower lobe Bloody fluid in right pleura. Large round tumor in middle lobe involving up- per and lower lobes. Bron- chi run freely through tu- mor; rest of lung com- pressed. Tumor extends to heart and compresses upper cava and pulmonary vein Large cavity in left lower lobe surrounded by wall of tumor with papillary excres- cences proliferating into in- terior of cavity Primary carcinoma of main bronchus of left lower lobe. Carcinomatous infil tration of the lobe. Effu- sion in left pleura Solid tumor at hilus of left lung occluding bronchus and compressing large vessels Entire right lower lobe converted into a large sac filled with pus and com- municating with main bron- chus. Walls of the sac con- sist of tumor. Walls of bronchus infiltrated with tumor and obstructed Bloody serum in left pleura. Almost entire left lung solidified. Right lung also infiltrated Large tumor in lower lobe Softened in spots. Chalky tubercles in left lung METASTASES Brain No details No details No details No details Bronchial and tracheal lymph nodes Liver, peri toneum, tra^ cheal lymph nodes Bronchial lymph nodes. Both kid- neys Pleura, heart, peri- bronchial, tracheal, and medi- astinal MICROSCOPE No details No details No details No details No details No details No details Medullary carcinoma Thick, fi , brous matrix bounding cavities filled with epithe- lioid cells. 208 TABLE I 274 Rosenthal, .. Diss. Miinchen, 1899 Uber einen Fall von primarem Lungen- carcinom 275 ROTHMAN, C. Deutsch. Med. Wo- chenschr. 1893, No. 35, p. 844 Primares Lungencar- cinom (Demonstra- tion) 276 ROTTMANN, Diss. Wiirzburg, 1898 Uber primares Lungen- carcinom 277 278 Log. git. Rowan, John, Transact. Ophthal. Soc. of United King- dom, Vol. XIX, 1899, p. 103 M M M M 52 56 35 57 55 lung in- volved R CLINICAL SYMPTOMS toms digestive disturbances, consti- pation, and polyxiria No heredity. Gradual hemiplegia of right side with aphasia, convulsions, and other cerebral symptoms. Later some dyspnoea. Nothing found on lungs. Later bronchitis with fever and cough; symptoms of vocal paralysis. Duration about 6 months. Entire clinical picture dominated by cerebral symptoms; no lung s5miptoins except cough and dyspnoea Slight haemoptysis at 17. A year before admission bloody expectoration, but nothing could be found in heart or _ lungs. Good appetite; gained weight. Later dyspnoea, cedcEma of face and right arm, dilated veins of chest. Dulness and diminished respi- ration over right apex. Haemorrhages almost without interruption for f of year. Sudden death from oedoema of glottis. Probable tumor diagnosed during life. Duration of disease a little more than a year No heredity. Pain, dulness, dimin- ished breathing and voice sounds. Exploratory puncture negative. Sud- den paralysis of both lower extremities. Fever, dyspnoea, death in collapse Cough, anorexia, emaciation. Physi- cal examination of lungs practically negative Pulmonary affection _ for 4 months before admission. Initial haemoptysis; cough. Impaired respiratory motion of right chest. Dulness behind to _6th dorsal vertebra; diminished breathing. CARCINOMA 209 SPUTUM AUTOPSY NOTES METASTASES MIGROSCOPE BEMABKS lymph mainly poly- nodes hedral; many necrotic or undergoing fatty degener- ation. Peri- pheral zone of tumor shows alveolar stroma infil- trated with small round cells; alveolar spaces con- tain polymor- phous cells Mucoid Carcinoma of left main Brain, bron- Alveolar Origin from epithe- bronchus perforating wall chial, and structure leum of bronchial and extending into left lung. tracheal well devel- mucous membrane Compression and thrombo- lymph oped stroma; sis of right pulmonary ar- nodes, wall typical cylin- tery of left ven- tricle of heart drical cells with some de- generation in centres of cell nests Bloody, no Infiltrating carcinoma of Pericardium No details tubercle right upper lobe bacilli; profuse hsemop- tysis for almost f year Occasion- A large tumor and con- Bronchial Transition Origin probably ally nected with it a smaller one lymph from cylin- from bronchial mu- bloody in left lung. Large tumor nodes and drical to cous glands contains cavity filled with bodies of pavement tumor material and pus. 7th and 8th epithelium Tumor proliferation into vertebrae. can be dem- pulmonary vein and left compressing onstrated auricle cord Purulent Emphysema and purulent bronchitis. Large tumor in left lower lobe and another between upper and lower lobes Right lung Pavement and poly- morphous epithelium and abundant elastic fibres in stroma Bloody, no Left lung normal. Pecu- Bronchial Irregular Author believes tubercle liar fibrous induration along glands and cells arranged origin to be from bacilli. bronchi of right lung extend- left eye. No somewhat in glandular or mucous Many ing through to left lower other metas- form of glan- structure of bronchi fatty lobe and adherent to peri- tases dular acini 15 210 TABLE I 279 280 281 282 283 Metastatic Carcinoma of the Choroid from a Primary Carcinoma of the Lung Rubinstein, Wratsch. 1898, No. 32. Centralbl. f. path. Anat. Vol. X, 1899, p. 240 Zur Frage iiber die Histogenese des pri- maren Lungenkrebses Sabolodnow, Gesellschaft der Aerzte an der Univer- sit. Kasan. Die Med. Woche, Berlin, 1902, p. 457 Ein Fall von primarem Lungencarcinom Sadowski, Centralbl. f. Grenz- geb. 1900, p. 781 _ Beitrage zur Casuistik der Neubildungen der Bronchien Sard, J. H. et Oulie, A. Toulouse Med. 1901, 2 s. Vol. Ill, p. 109 Un Cas de Cancer pri- mitif du Poumon SCHAPER, Vir chows Arch. Vol. .. 129, 1892, p. 61 Uber eine Metastase eines primaren Lun- genkrebses M M M M 61 63 40 51 64 LUNG IN- VOLVED R R CLINICAL SYMPTOMS DuU tympanitic sound all over right chest in front. No dyspnoea. Cervical glands enlarged over both clavicles. No pain. No history of lues. Details of examination of left eye are given. Di- agnosis of malignant disease of the lung made during life. Sudden death about 3 weeks after admission. Duration of disease about 5 months No clinical history No clinical history except statement that there was arteriosclerosis and pa- ralysis of recurrent laryngeal and that diagnosis of carcinoma of left upper lobe was made during life Attack of pleurisy with recovery. Second attack after 5 months. Aspi- ration 300 c. c. bloody serum ; later pus. Resection of rib showed tumor Admitted in semicomatose condi- tion. Slightest touch painful, hence only very superficial examination could be made. Some dyspncea. Heart feeble. Numerous enlarged glands in carotid notches and in subclavicular region. At level of right parotid a hard painless tumor; skin movable over it. Patient died next morning Admitted with apoplexy. Dulness of entire posterior left lung, also over considerable part anterior portion left chest. No other clinical data CARCINOMA 211 SPUTUM AUTOPST NOTES METASTASES MICHOSCOPE BEMARKH granular cardium. Bronchi consider- Cancer infil- cells. ably narrowed trates mucous Haemop- membrane of tysis bronchi and surrounding lung tissue No details Carcinoma of left hilus No details Alveolar structure ; cuboid, pave- inent, and cy- lindrical cells; pearls also found ' Author considers tumor of alveolar ori- gin No details Left pleura closely adher- Bronchial Very thick Author believes al- ent. Both upper and lower glands fibrous veolar epithelium to left lobes uniformly enlarged stroma sur- be origin of tumor and lung tissue replaced by rounding small soft white nodules, small cavities confluent or separated by fi- of the size of brous tissue pulmonary al- veoles. These are filled with cuboid, cy- lindrical and polygonal epithelioid ceUs. The cells are ar- ranged in a somewhat papillary form over strands of fi- brous tissue None Carcinoma of right bron- None men- Carcinoma chus with abscesses in right tioned keratodes lung None Entire upper lobe of right Parotid Simply lung converted into a block glands stated : of grayish lardaceous tissue tumor was without a trace of pulmo- epithelioma nary structure. All other of lung organs entirely normal, even those of mediastinum. The parotid tumor is only a mass of hypertrophied glands No details Large tumor starting from Bronchial Alveolar root of left lung proliferat- lymph structure; ing into lung tissue along nodes and irregular bronchial ramifications myoma of uterus polymor- phous epithe- lial cells 212 TABLE I 284 285 286 287 288 289 290 SCHLERETH, Diss. Kiel, 1888 (After Passler) Zwei Falle von prima- rem Lungenkrebs Log. cit. Schmidt, Diss. Jena, 1899 Zur Casuistik des pri- maren Lungenkrebses Log. cit. SCHNOBB, Diss. Erlangen, 1891 (After Passler) Fall von primarem Lungenkrebs SCHOTTELIXJS, Diss. Wiirzburg, 1874 Ein Fall von primarem Lungenkrebs ScHREiBER, Andreas, .. Diss. Munchen, 1906 tJber einen Fall von primarem Gallert- carcinom der Lunge mit Metastasen im Gehim M Not M M M 55 stated 61 52 42 42 44 LUNG IN- VOLVED Uncer- tain R R R CLINICAL SYMPTOMS No clinical history- No clinical history No heredity. Cough, pain, dysp- noea, cyanosis. Enlarged cervical glands. Dulness with diminished fre- mitus, impaired respiratory motion, feeble bronchial breathing. Two tap- pings bloody serum. Sudden death. Duration of disease about 16 months No heredity. Cough, dyspnoea, pain. Dulness over left chest; diminished or absent breathing. Heart dislocated to right. Cachexia. Aspiration: bloody serum containing characteristic tumor cells. Sudden death. Duration of dis- ease about 6 months No clinical history No clinical history Disease commenced with cough and pain in chest. Clinical diagnosis: pleurisy. Sick for 9 months; then purely cerebral symptoms — headache, projectile vomiting, paralysis of left side, strabismus. No fever; no cough; no signs on lungs except slight dulness over left apex. Clinical diagnosis: tuberculosis of right cerebral hemi- sphere CARCINOMA 213 SPUTUM AUTOPSY NOTES METASTASES MICEOSCOPE REMARKS No details In both lungs and pul- monary pleurae, numerous nodules of all sizes down to miliary. Bronchial walls not involved No details Alveolar structure ; mostly cylin- drical cells; somie flat No details Irregularly defined tumor in right lower lobe extending from root through lung to pulmonary pleura No details Cylindrical cells Bloody, no Nodulated tumor contain- Right lung. No details Left lung had 3 tubercle ing cavity in left middle and both pleurse. lobes bacilli lower lobe. Bronchial walls infiltrated with tumor bronchial and portal lymph nodes, gas- tro-hepatic ligament. and right kidney No details Tumor at root of lung fol- lowing ramifications of bronchi. Bronchiectases. Thrombosis of pulmonary artery Liver, kid- neys, right suprarenal No details No details Tumor along ramifications of bronchi involving almost entire right lung, also pleura and pericardium Left lung, cervical and axillary lymph nodes No details No details Clear serum in right Substernal, Lymphangi- The miliary nod- chest; bloody serum in peri- tracheal and tis carcino- ules throughout lung cardium. Entire right lung bronchial matodes and pleura are ar- firm, without air and stud- lymph ranged in an anasto- ded with numerous nodules nodes. mosing reticulum up to size of walnut Pleura, peri- cardium, beginning of aorta and pulmonary artery studded with miliary nodules corresponding to the lymphatics. Author attempts to establish origin of tumor from endothelium of lym- phatics None Tumor left lower lobe Brain, both Gelatinous Author assigns adrenals. gland-like tu- origin to alveolar left kidney, bules con- epithelivmi both ovaries taining much mucoid ma- terial. Bron- chial epithe- lium and bronchial mu- cous glands normal. Me- tastases same structure 214 TABLE I 291 292 293 294 295 296 297 298 Schroder, Hugo, Diss. Kiel, 1902 Ein Fall von primarem Krebs der Lunge SCHWALB, HeINRICH, Diss. Wiirzburg, 1894 Ein Fall von primarem Lungencarcinom Schweninger, Annalen des Stad. Krankenhauses in Miinchen, 1876-77. Vol. II, 367 Loc. CIT. Sehrt, Diss. Leipzig, 1904 Beitrage zur Kenntniss des primaren Lun gencarcinoma Loc. CIT. Loc. CIT. SlEGEL, Diss. Miinchen, 1887 (After Passler) Zur Kenntniss des Pflas terepithelkrebses der Lungen M M M 34 LUNG IN- VOLVED Both (?) 60 49 62 66 75 68 63 Probably L CLINICAL SYMPTOMS Pneumonia with incomplete absorp- tion. Thereafter occasional fever; gradual development of cedoema in ter- ritory of upper cava. Cough, cyanosis, dyspnoea. Ronchi over both lungs, but nothing characteristic. Later ascites, enlarged liver, albuminuria, and hya- line casts. Clinical diagnosis: myocar- ditis after pneumonia. Death from erysipelas and peritonitis. Duration of disease about 15 months Always well. For a few months dyspnoea, cough, sense of suffocation. On admission great emaciation; some cyanosis and fever. Pneumonia of left lower lobe; bronchitis. Death after 2 days No clinical history except that pa- tient was sick for 2 years with symp- toms of chronic pulmonary phthisis R No clinical history No clinical history Clinical diagnosis' pleuro-pneumo- nia Intense dyspnoea. Dulness over en- tire left chest with harsh respiration and rales. Death from profuse and sudden haemorrhage. Clinical diagno- sis: phthisis No clinical history CARCINOMA 215 SPUTUM AUTOPST NOTES METASTASES MICROSCOPE REMARKS Mucoid Chronic induration of None Hsemor- No clinical symp- both lungs. Pneumonic rhagic areas. toms pointing to tu- consolidation of right lower typical carci- mor; diagnosis only lobe ; pleurisy on left. Hasm- noma prob- possible with micro- orrhagic areas in both lungs ably from scope at autopsy diagnosed macroscopically bronchial epi- as infarctions, but micro- theUum and scopically proved to be typi- extending cal carcinoma along lymph channels Profuse Turbid serum in left pleura. Tumor size of an apple in left lower lobe, sur- rounded by inflamed lung tissue. Tumor is whitish gray, sharply defined against surrounding lung tissue. Firm fibrous masses inter- spersed with soft, very cellu- lar portions of tissue No details Alveolar structure No details Tumor nodules in both lungs No details Carcinom- atous struc- ture; cylindri- cal and poly- morphous cells No details Primary cancerous tumor of left upper lobe No details No details No details Carcinoma of right main Bronchial Alveolar bronchus and of cavity at and tracheal structure; hilus of right lung with ero- lymph pavement sion of pulmonary artery nodes epithelium. and acute lethal haemor- cancer pearls; rhage. Bronchiectases. Ex- patches of ne- tensive chronic ulcerative crosis tuberculosis No details Bloody fluid in pleura. Both lungs. Horny pave- Carcinoma of right lung left ventri- ment epithe- with gangrenous cavity and cle, left adre- lium chronic indurative pneu- nal, and 6th monia. Carcinomatous rib thrombosis of pulmonary artery Hsemopty- Carcinoma of left main Bronchial Pavement sis bronchus with extension to left pleura, bronchial Ijonph nodes, and large branch of pulmonary artery. Chronic ulcerative tuberculosis of left upper lobe lymph nodes and oesophagus epithelium No details Large tumor in left upper Both lungs Large polyg- and lower lobes and left pleura onal cells 216 TABLE I 299 300 301 302 303 304 305 Loc. CIT. SlEGEHT, Virchows Arch. 1893, 134 Zur Histogenese des pri- maren Lungenkrebses Singer, Prag. med. Woch. 1885, pp. 329-341 Drei Falle von intra- thoracischem Tumor Singer, Diss. Berlin, 1908 Zur Klinik der Lungen- carcinome Loc. CIT. Loc. CIT. SiROTINI, Wratsch. St. Peters- burg, 1905, Vol. 72, p. 58. Lubarsch-Oster- tag,1907,Ht. 2,p. 734 Two Cases of Primary Cancer of Lung M M M Not 53 60 41 80 77 stated LUNG IN- VOLVED R R R CLINICAL SYMPTOMS No clinical history Admitted 5 days before death suf- fering from hemiplegia of right side, aphasia and pleurisy with hsemor- rhagic effusion in left side Sudden onset with dyspnoea, cough, and increasing debility. Later dila- tation superficial veins. Dulness at right apex with bronchial respiration in front; no breathing sounds pos- teriorly. Pain; harassing cough. Du- ration about 3 months No heredity. Previous history neg- ative, but had lung trouble for some years. Cough, dyspnoea on exertion. On admission _ emaciation, intense dyspnoea, cyanosis; no fever; no glands. Greater portion of left lung in front and behind, flat; diminished voice and breathing. Nothing on right lung. Aspiration: 1200 c.c. turbid serum. Paralysis of left vocal cord. Death in 2 days No heredity ; no previous illness. Re- cently weakness, pain in chest. Dulness and bronchial respiration upper left apex. No rales. Right lung and heart normal. Gradually some fever; fine crackling in left base. Sudden death Admitted in moribund condition. Intense dyspnoea for some time, cyano- sis, hoarseness, some fever. No ca- chexia. Tumor size of small fist emerges above sternum. Death within 24 hours after admission No clinical history CARCINOMA 217 SPUTUM AUTOPSY NOTES METASTASES MICHOSCOPE REMARKS No details Tumor in right middle Bronchial Large polyg- lobe lymph nodes, pleura, liver, left suprarenal, thyroid, and both kid- neys onal cells No details Extensive infiltrating car- cinoma of left lung and bron- chi simulating pneumonic consolidation. No pro- nounced tumor or nodules. Extensive secondary carci- nosis of lymphatics None Alveolar structure; cy- lindrical cells with transi- tion to pave- ment epithe- lium Foul, Cavity with hsemorrhagic Pleura, No details Origin from bron- bloody contents in right upper lobe. Walls consist of partially necrotic and infiltrating tu- mor. Ulcerated medullary tumor in right main bron- chus and its larger branches, obstructing lumen. Ob- struction of upper cava liver, adre- nals and thy- roid chial mucous glands Glairy Carcinomatous thrombo- Pleura, peri- Pavement sis of left lower pulmonary cardium. cell carci- vein. Carcinoma of left bronchial noma main bronchus infiltrating and perito- and occupying the bronchus neal lymph of left lower lobe. Diffuse nodes, left carcinomatous infiltration of kidney, left left lower lobe. Carcinoma- adrenal, left tous infiltration of lymphat- ovary and ics of bronchi of left upper in thyroid lobe Scant, Primary carcinoma of No details No details mucopu- lower left lobe originating rulent, from bronchial mucous no tuber- membrane. Many small cle bacUli pneumonic abscesses No details Right upper lobe adher- Pericar- Pavement ent to sternum and to ribs, dium, right cell carci- infiltrated with hard carci- pleura, ster- noma noma. Small bronchi and num and bronchioles filled with detri- upper ribs, tus and carcinomatous ma- mediastinal terial; also some in upper lymph cava. Lymph channels in- nodes filtrated No details Multiple miliary carci- No details Flat epithe- Origin supposed noma of lower lobe lial cells from alveolar epithe- lium 218 TABLE I 306 307 308 309 310 311 312 313 314 Log. cit. Smith-Shand, British Med. Jour 1875, I, 844; II, 41 Stieb .. Diss. Giessen, 1900 Uber das Plattenepi- thelcarcinom der Bronchien Loc. CIT. Stilling, Virchow's Arch. Vol LXXXIII, 1881, p. .. 77 ijber primaren Krebs der Bronchien und des Lungenparen chyms Loc. CIT. Loc. CIT. Loc. CIT. Stobeh, Amer. Jour. Med Sciences XXI, 46, 1851 SEX AGE LUNG IN- VOLVED Not stated R F 36 L M 50 L M 60 R M 52 R F 27 R M 70 L M 64 R M 39 R CLINICAL SYMPTOMS Diagnosed during life Cough, pain, hoarseness, right hemi- plegia. Dulness over left chest; im- paired respiratory motion; absence of breathing sounds _ No clinical history except patient died of cirrhosis of liver Cough, pain, infiltration of right apex, increasing debility. Duration of disease 6 to 8 months No clinical history No clinical history No clinical history No clinical history Cough, dyspnoea. Dulness of lower f right chest and absence of breathing CARCINOMA 219 No details Scant, bloody No details Moderate, mucoid, no tuber- cle bacilli No details No details i No details No details Tenacious mucoid AUTOPSY NOTES METASTASES Primary carcinoma of walnut size in right lung Left main bronchus plugged by tumor. Left lung full of soft tumor ad- herent to pericardium and surrounding structures at root. Compression of left vagus and recurrent Submucous carcinoma in bronchus of left lower lobe infiltrating surrounding lung tissue Primary carcinoma at bi furcation of right main bron chus. Gray hepatization of right upper and middle lobes Large tumor of bronchus of right middle lobe extend- ing into right main bron- chus, penetrating wall and infiltrating peribronchial tis Bloody serum in right pleura. Polypoid tumor right main bronchus and in upper bronchus. Tumor nodules in both lungs and in trachea. Bronchiectases right upper lobe. Left main bronchus com- pletely destroyed by tumor mass in left upper lobe pene- trating into lower Upper and middle lobes almost entirely converted into tumor infiltrating along blood vessels and bronchi Encephaloid mass occu- pies more than J of right lung. Contains small cav ities; tumor in right pri- No details Brain Small poly- morphous epithelial cells almost Uke sarcoma cells No details Regionary lymph nodes Both lungs supra clavic- ular lymph nodes Bronchial, mediastinal lymph nodes ; also cervical nodes, peri- cardium, and liver Bronchial, cervical, and retroperito- neal lymph nodes; liver and small curvature of stomach Left bron chial lymph nodes Bronchial, cervical, and axillary lymph nodes; left lung, liver, and left su- prarenal Bronchial and tracheal lymph nodes MICROSCOPE Origin bronchial mucous membrane Although no micro- scopic examination is given, there is little doubt that this tumor is carcinoma Horny pave- ment epithe- lium Alveolar structure ; horny pave- ment epithe- lium Plexiform and alveolar cancer nests; cancerous in- jection of lymph spaces and prolifer ation along vascular and nerve sheaths Same as above No details No details No details 220 TABLE NO. ATJTHOB SEX AGE LUNG IN- VOLVED CLINICAL SYMPTOMS Carcinoma of Right Lung with Symptoms of Hydrothorax 315 Stumpf, Diss. Giessen, 1891 (After Passler) Zur Casuistik des pri- maren Lungencarci- noms Not stated R No clinical history 316 Suckling, Lancet. 1884, 1047 Case of Primary En- cephaloid Growth of Lung M 61 R No heredity; no pain. Dyspnoea, cachexia. Right chest more volumi- nous than left. Dulness over lower right lobe with impaired respiratory mobility and absence of fremitus. Later on signs of cavity. Enlarged Liver. First puncture: bloody fluid; second negative 317 SZELAG0W3KI, Thhse de Paris, 1900 Contribution a I'etude clinique du Cancer primitif pleuro-pul- monaire F 47 L No heredity; no serious illness. Commenced with loss of appetite, then some general stiffness and malaise; ver- tigo. Later attacks of suffocation. On admission intense dyspnoea, some cyan- osis, bulging of left chest ; absolute flat- ness behind to spine of scapula and in front to below clavicle ; absence of voice and breathing. Heart displaced to right of sternum. Right lung normal. Aspiration: 1000 c.c; pink fluid; slight relief. Repeated puncture only small quantity fluid and but little relief. X- rays show a lobulated mass to left of vertebral column besides shadow over aU of lower left lung. Intense pain and dyspnoea; dysphagia, fever, delirium. Duration of disease about 6 months 318 Tillman, Diss. Halle, 1889 (After Passler) Drei Falle von prima- rem Lungencarcinom M 45 R No cUnical history 319 Log. git. M 61 R No clinical history 320 Log. git. M 68 Not stated No clinical history u CARCINOMA 221 No details I Profuse, whitish ; later "currant jelly" haemop- tysis. Tubercle bacilli Scant; no tubercle bacilli No details No details No details AUTOPSY NOTES mary bronchus, gans normal Other or- Tumor of right upper lobe proliferating along bron- chial ramifications into sur- rounding tissue. At root, tumor extends into main bronchus and penetrates in to lumen. Proliferation of tumor into pleura, pericar dium, right auricle, and large vessels especially upper cava and right pulmonary artery Tubercular cavity and miliary tubercles through- out right lung. In lower right lobe a large patch of yellowish tumor Left pleura thickened. Nearly whole of left lung oc cupied by grayish white tu- mor softened and degener- ated in parts Tumor in right lower lobe close to large bronchial branch Bronchial carcinoma of lower lobe following bron- chial ramifications. Nu- merous small secondary- nodules each surrounding small bronchus Primary medullary nod- ule in lung. Numerous sec- ondary nodules in brain, cerebellum, and medulla. Nodules frequently show cystic degeneration METASTASES Regionary Ijonph nodes No details Only lymph nodes at lu- lus Alveolar tructure ; polymorphous epithelial cells No details; author sim- ply says "epi- thelial tu- None Bronchial, mesenteric, and coeliac lymph nodes and liver Brain, cere- bellum, and medulla MICKOSCOPE Cylindrical cuboid and large poly- morphous cells Carcinoma with cells re- sembling nor- mal alveolar cells Cylindrical cells with ten- dency to mu- coid degener- ation Large cylin- drical cells with mucoid degeneration 222 TABLE I 321 322 323 TURNBULL & WOETH- INGTON, Arch. Path. Inst. London Hospital, Vol II, 1908, p. 163 Two Cases of Carci- noma arising pri- marily in a Bronchus Loc. CIT. M M V. Fetzbb, Med. Correspon- denzbl. des Wiirten- bergischen arztli- chen Landes Vereins, 1905, p. 139 Ein vom rechten Bron- chus ausgehendes Carcinom der rechten Lunge LUNG IN- VOLVED 55 66 M 36 R R CLINICAL SYMPTOMS About 7 months before admission on lifting a parcel "something gave way in his back." Ever since pain in back and down legs. Sweating and wasting of legs. Tenderness over left lumbar spine and both sciatica; no impairment of sensation. Increasing nervous symptoms; fever up to 106. Later 2 pigmented spots on inner sur- face right chest and several spots on chest and abdomen. Increasing ema- ciation and weakness. Albumin in urine and occasionally a trace of al- bumose. Nothing is said about physi- cal examination of lungs Always healthy until 6 months be- fore admission, then pain in left shoul- der and back after lifting heavy weight. Disappeared for some time, then reap- peared and persisted with occasional remissions. Loss of weight, tender- ness on percussion of dorsal spine; anaesthesia of 8th left dorsal nerve; wasting of lower limbs. Remarkable absence of physical signs. X-rays show apparently deepened shadow to the left of upper descending thoracic aorta and 2 small dark shadows in lower half of right lung. Diagnosis of either aneurysm or neoplasm of lumbar spine was made. Later on symptoms pointing to lungs. Nothing said of cough, sputum, or physical signs on lungs. Symptoms mainly referableto spine — severe pains in legs, wasting of legs, bladder symptoms, inconti- nence of faeces, etc. Duration about 10 months Cough, irregular fever; good appe- tite. Dulnesa at right base; dimin- ished voice and breathing. Later dul- ness over left apex with bronchial respiration. No rales. Patient feels better and gains steadily in weight; leaves hospital having gained 5 kilos. Works at his trade for 4 months when readmitted with severe dyspnoea, cya- nosis, and dilated veins about head, neck, chest, and upper extremities. Flatness over right chest; bronchial breathing but no rales. Intercostal spaces levelled; heart dislocated^ to left. Enlarged glands above right clavicle; 2 tumors on left parietal bone. CEdoema of right arm. Right pupil dilated. Duration of disease about one year CARCINOMA 223 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE BEMARKS Once a Carcinoma of bronchus in Retroperi- Alveolar lump of left lower lobe. On outer toneal, in- structure foul- surface both lungs many guinal, cer- lined with cy- smelling hard miliary nodules. In vical and lindrical cells. material left lower lobe cavity size of bronchial some cuboid- size of walnut with ragged edges lymph al. Main walnut, and containing many white nodes, right bronchus, looking nodules; communicates with femur, both bronchioli. like "her- bronchi of 3d and 4th order; iliac bones. pulmonary ring roe" nodular thickening of mu- lumbo-sacral arteries and cous membrane. Atelecta- vertebrae, vein and sur- sis below cavity. Nodules ribs, and rounding in both costal and visceral sternum. lung tissue in- pleura; adhesions and effu- Nodules in filtrated by sion on both sides both adre- nals and in atrophied liver. Brain not exam- ined tumor No details Carcinoma of lower right 7th and 8th Acinous In both cases singu- bronchus. Carcinomatous dorsal ver- structure larly small size of lymphangitis of pleura of tebrae press- with secre- primary tumor and both lungs. Bronchitis and ing on cord; tion of mucus selection of bones as capillary bronchitis of left 7th and 8th but greater chief sites of second- lower lobe. Myocarditis, left ribs and part is at3T)i- ary growth. Absence acute endocarditis; abscess 8th right cal of physical signs in spleen; septic infarct in rib. No en- pointing to lungs in right kidney. Solid nodule largement both cases at back of right lower lobe of lymph communicating with bron- nodes in chus ■ chest Occasional No details No details No details Case is interesting haemop- on account of the tysis; no steady gain in weight tubercle during his stay in the baciUi hospital 224 TABLE I 324 325 326 327 V. SCHHOTTEH, H. Mitth. der Gesellsch. f. inn. Med. u. Kinder- hlk. in Wien, 1907, p. 145 Demonstration eines Falles von Carcinom der Bronchien V. SCHEOTTER, H. Zeitschr. f. klin. Med. Vol. 62, 1907, p. 508 Zur Preezisions Diagnose der Lungentumoren ; bronchogenes Karzi- nom mit Glykogen- bildung ; Bemerkun- gen zur Histogenese desselben M 328 WaCHSMANN & POLLAK, New York Med. Rec ord, Nov. 1904 Three Cases of Primary Malignant Tumor of the Lung Wagner, Miinch. med. Woch 1903, p. 133 Primares Bronchial- carcinom Waldmann, Anton, Diss. Miinchen, 1902 Ueber primares Carci- nom des Lungenpa- renchyma M M Not M LUNG IN- VOLVED 30 44 55 stated R R CLINICAL SYMPTOMS Most severe heemoptyses for 11 months. Perfectly healthy until first sudden haemorrhage without apparent cause. Haemorrhage repeats at inter- vals of 8 to 14 daj's. Must have ex- pectorated about 8000 c.c. of blood. Repeated and most careful examina- tion showed no cause for the bleeding. Nose, throat, trachea suspected. X- ray examination showed nothing; nothing found on lungs. Broncho- scope found a tumor at bifurcation of right main bronchus in right lower lobe No heredity. 5 weeks before ad- mission cough, pain in chest, loss of weight. Dilated veins left anterior chest and abdomen. Right chest lags in respiration; flatness over right apex in front from axillary line over left border of sternum. Absence of breath- ing upper portion right lung; dimin- ished in lower. Tumor suspected and demonstrated by bronchoscope in main bronchus just above bronchus of upper lobe. Excision of small piece in bronchoscope shows pavement epi- thelium carcinoma. Cells contain gly- cogen in small round spheres. Patient feels better for a time and gains in weight. Later oedcsma of face, intense cyanosis; death from exhaustion Cough, pain, emaciation, clubbed fingers. Dulness over right upper lobe No clinical details except that there was normal percussion note and breath- ing over whole left lung, but that vocal fremitus was markedly diminished, al- most abolished, and that at a very early stage of the disease the clinical diagnosis of tumor of the lung prob- ably starting from bronchus could be made Emphysema; bronchitis. Gradual loss of weight ; pain ; swelling in region of liver. Six months later fever and dulness over right upper lobe._ Fever disappears, but dulness remains and increases. Two months later cerebral symptoms and tumor perforating skull. Duration about 9 months. Clinical diagnosis: primary tumor of lung with cerebral metastases CARCINOMA 225 AUTOPSY NOTES METASTASES MICHOSCOPE Severe repeated hEemop- tysis No details No details Often bloody. Later hsemop- tysis. No tubercle bacilli Carcinoma of right main bronchus with carcinoma- tous degeneration of right upper lobe. Proliferation into superior cava. Indu- ration and cheesy tubercular remnants in right apex. Tu- mor of lung contained cav- ity Profuse, bloody. No hee- moptysis. Contains ceUs sug- gesting "tumor cells" No details Bloody; no tubercle bacilli ; no tumor elements Ulcerated right upper bronchus; infiltrating tu- mor following lymph chan- nels in lung, also in pleura Proliferating tumor ob- structing lumen at final di- vision of left main bronchus General carcinomatosis of left upper lobe. Cancerous pleurisy of both sides Examination of small por- tion removed by probatory incision showed carci- noma None except upper lobe Left lung, lymph nodes of neck and chest; liver, thyroid gland Left lung, anterior mediasti- num, and left lobe of liver Liver, both kidneys, dura, brain, bones of skull Pavement epithelium There was not much dyspnoea Carcinoma Cylindrical cell carci- noma Origin from bron- chial mucous mem- brane Typical pavement epithelium Author assumes al- veolar epithelium as origin of tumor 16 226 TABLE I 329 330 331 332 333 334 335 336 Walshe, W. H. A Practical Treatise on Diseases of the Lung, etc. 4th Ed. London, 1871 Waters, Lancet, XIX, 1871 Wechselmann, Diss. Milnchen, 1882 (After Passler) Ein Fall von primarem Lungencarcinom Weinbergeb, Zeitsch. f.Heilk.1901, II, 78 Beitrag zur Klinik der malignen Lungenge schwtilste Log. cit. Werner, Diss. Freiberg, 1891 (After Passler) Das primare Lungen- carcinom Log. cit. West, Trans. London Path. Soc. XXXV, 1884, 87-88 Primary Cancer of Root of Right Lung M M M M M M M Not stated Not stated 64 42 62 19 65 39 LUNG IN- VOLVED R R Both R R R R CLINICAL SYMPTOMS Exclusively psychic symptoms. Neither local nor systemic symptoms pointing to lungs. No cough. Dura- tion about 8 months Pain, dyspnoea, cough. Swelling and cyanosis of face, neck, arms, and chest. Supraclavicular glands. Dulness over right chest; bronchial breathing above, diminished or absent breathing below. Duration about 2 months No clinical history No heredity. Fever; cough. In- creasing dulness over right apex; to a less degree over left. Diminished fremitus; bronchial respiration. Pain, dysphagia, dilated veins. Enlarged axillary glands; compression of tra- chea. Dyspnoea, cedcema of larynx. CEdoema of face and arms. Cyanosis. Death after profuse haemoptysis. Du- ration of disease about one year. Diagnosis made during life. No heredity. Pain, cough, dyspnoea, emaciation. Secondary tumors in vari- ous parts of body. Dulness, dimin- ished and absent breathing over most of right chest. Spleen enlarged. Pu- rulent effusion in right pleura. Dura- tion of disease about 10 months No clinical history No clinical history Pain, dyspnoea, loss of strength, ema- ciation. Impaired respiratory motion of right chest. Dulness, faint breath- ing, no vocal fremitus. Left lung nor- mal. Puncture furnishes 8 ounces thick pus. Incision and drainage gives no relief. Cough only at end of disease. Duration about 4 3 months CARCINOMA 227 SPUTTTM AUTOPST NOTES METASTASES MICHOSCOPE BEMABKS None Infiltrating encephaloid cancer throughout right lower lobe Left lung and brain No details Frothy; later hae- moptysis Entire right lung con- verted into scirrhous tumor with cavities and beginning suppuration Mediasti- nal lymph nodes No details No details Scirrhous tumor of both lungs No details Pavement epithelium proliferating from periph- eral portions into other- wise normal pulmonary alveoles Mucoid, oc- casion- ally bloody, haemop- tysis. No tubercle bacilli. Abun- dant epi- thelial cells Carcinoma of right upper lobe beginning in a second- ary bronchus and involving main bronchus, trachea, left main bronchus, upper cava, both pleurae, 2d and 3d ribs and intercostal muscles. Bronchiectasis right middle lobe Bronchial and cervical lymph nodes Fibrous stroma; cy- lindrical epi- thelial cells Tumor particles are found Carcinoma of right main bronchus; abscess and ne- crosis of right lower lobe Liver, kid- ney, mus- cles, intes- tines, pari- etal bone, brain Alveolar structure; cu- boid epithe- lial cells No details Tumor in right upper lobe Both lungs, regionary lymph nodes, liver, spleen, kid- neys Small cuboid cells No details Tumor size of walnut in secondary bronchus and left lower lobe Bones No details None Hard mass at root of right lung following main bron- chus which it compresses. Spreads throughout lung along bronchial ramifica- tions. Two abscess cavities Left lung and liver Cancer with well-devel- oped stroma 228 TABLE I NO. 337 338 339 340 341 342 343 344 Log. git. WiEBER, Diss. Berlin, 1889 Primares Lungencarci- nom, etc. WlLLANEN, Zeitschr. f. Krebs- forsch. 1905, III, p. 618. Wratsch (Rus- sian) 1904, No. 44 Zwei Falle von prima- rem Lungencarcinom Log. cit. WiLLEHT, Diss. Wllrzburg, 1905 Beitrag zur Casuistik des primaren Lun- gencarcinoms WiTHAUEK, Therapeut. Monats- hefte, 1899, April, p. 185 Das primare Lungen- carcinom Wolf, Fortschritt. der Med. XIII, 1895 Der primare Lungen- krebs Log. cit. M M Not M M M 62 49 stated Not 48 62 54 57 LUNG IN- VOLVED R R stated R CLINICAL SYMPTOMS Brother died of cancer of liver. Cough, rapid emaciation. Physical signs like preceding case. Enlarged supraclavicular glands. Diagnosis made during life. Duration about 10 months Family history of cancer. Asthma and bronchitis. Later pain and tvunor in leg which was amputated. Tumor found to be carcinoma. Cachexia; cough. Death from exhaustion Clinically the symptoms of catarrhal pneumonia. Cough, dyspnoea, and ca- chexia Clinical symptoms those of chronic consoUdation of the lung. Cough, dyspnoea, and cachexia No heredity; always healthy. Cough, increasing debility. Dulness over left lung; diminished breathing; some bronchial respiration. No pain, dyspnoea, or fever. Later paralysis left hypoglossal and facial; complete left hemiplegia No heredity. Some dry cough, but complains mainly of stomach. In- tense hunger, but disgust for food; occasional vomiting. Flatness, in- creased resonance, and absence of re- spiratory sounds over right infracla- vicular region. Heart sounds are heard with especial loudness over this area. Dyspnoea, pain over both lungs, harass- ing cough, emaciation. Slight bulging of dull area The cUnical picture is that of chronic phthisis. Nothing to indicate tumor Clinical history that of chronic phthisis CARCINOMA 229 SPUTUM AUTOPSY NOTES METASTASES MICEOSCOPE BEMABKS Occasion- Around main bronchus a Tracheal Scirrhus ally white firm tumor penetrat- and cervical bloody ing lung following bronchi. Consolidation and ulcerated cavity at root of lung lymph nodes; liver and both kidneys No details Tumor size of walnut in Lung, liver. No details Author considers middle of right lower lobe. bronchial the lung tumor the Tumor infiltration through- lymph primary one out lower lobe surrounded nodes. Left by broncho-pneumonic con- leg sohdation No details Miliary cancer nodules originating from smaller bronchioles and alveoli No details No details No details A well-defined tumor No details No details Occasion- Bloody effusion in left Mediasti- Gland-like Author calls tumor ally pleura. Large tumor in left nal, perigas- arrangement ; carcinoma myxomat- bloody. upper lobe; somewhat small- tric and peri- principally odes. Origin prob- Repeated er one in left lower lobe. aortic lymph cyhndrical ably bronchial mu- hsemop- WaUs of bronchi and blood nodes. Liver, epithelial cous glands tyses vessels infiltrated. Mucoid brain, kid- cells chang- areas in tumor neys, right adrenal and thyroid ing to cuboid and some fiat polymor- phous forms. Distinct se- cretion of mucus No details Large tumor in right up- per lobe Both lungs, liver, and kidneys No details No details Tubercular cavity in left Right Pavement lung in which carcinomatous pleura and epithelium tumor proliferates left inter- costal muscles with typical cancer pearls No details Tubercular cavity in right upper lobe containing poly- poid cancerous excrescence near the efferent bronchus of the cavity. Walls of No details Pavement epithelium with cancer pearls 230 TABLE I LUNG IN- VOLVED 345 Log. cit. M 64 R 346 Log. git. M 56 347 Log. git M 54 R 348 Log. cit. M 44 R 349 Log. git. 48 R 350 Log. cit. M 36 No heredity. Emphysema, bronchi- tis, emaciation. Pleurisy and pneu- monia of right lung; after which dul- ness remains. Pain; increasing dysp- Signs of pulmonary phthisis. Heart pushed to left. Sudden death from hgemorrhage CLINICAL SYMPTOMS No clinical history Pain in right chest; cough. Dul- ness over upper portion right chest; feeble respiration. Increasing emacia- tion. Left lung normal. Duration about 2 months Cough, dyspnoea; dulness over right chest with diminished respiration. Re- peated aspirations: clear serum No heredity. Pleurisy and pneu- monia; then dyspnoea, night-sweats, and great cachexia. Left chest more expanded than right. Flatness with slight tympanitic note from left clavi- cle downward; bronchial respiration. Exploratory puncture negative, but needle penetrates into hard mass. Axillary and infraclavicular glands enlarged CARCINOMA 231 BPUTUM AUTOPSY NOTES METASTASES MICROSCOPE REMARKS bronchus thickened and mu- cous membrane ulcerated. Tubercular granulations all over neoplasm Mucoid; Middle and lower lobe Liver Fibrous later converted into large tumor stroma; alve- bloody. penetrating diaphragm and olar struc- No tu- continuous with secondary ture; flat epi- bercle tumor in liver thelial cells. bacilli or Epithelial tumor pearls in aci- cells nous alveoles Haemor- Tumor in left apex. In No details No details rhage left upper lobe large cavity with necrotic walls; left main bronchus almost com- pletely destroyed by tumor. Tumor surrounds necrotic walls of cavity. Miliary tu- bercles over right pleura No details Tumor in right lower lobe Bronchial Alveolar penetrating between 7th and lymph structure; 8th ribs. Cavity in centre nodes small oval of tumor surrounded by nod- epithelial ulated neoplasm. Cavity cells communicates with lower main bronchus, the walls of which are partially de- stroyed by tumor Yellow, no Prominent tumor of right Both Alveolar Histogenesis not to tubercle upper lobe perforating into lungs structure; be determined bacilli, right upper bronchus with pleura, peri- small oval or some destruction of its walls. The cardium, cylindrical blood cancer is surrounded by Fresh miliary tubercles. Both suprarenals are tuber- cular; tubercular ulcer in ileum liver cells Scant, no Small hard nodules at root Bronchial Large alveoli Histogenesis not to blood or of right lung. Polypoid ex- and tracheal filled with be determined tubercle crescences on mucous mem- lymph polymor- bacilli brane of larger bronchi. Bi- nodes. phous small furcation surrounded by Pericardium epithelial large tumors of bronchial cells. Miliary and tracheal nodes. Fresh cancer miliary tuberculosis of both throughout [ungs both lungs Slightly Irregularly defined, hard Pericar- Alveolar bloody, tumor in left lung. Cheesy dium, left structure; but con- pneumonia in left upper lobe auricle, left round and cu- tains ilso several tumor nodules. ventricle boid epithe- neither tubercle bacilli Tubercular pleuritis and lung lial cells nor tu- mor par- tides 232 TABLE I 351 352 353 364 355 356 357 358 359 Log. cit. Wolf, Loc. cit. LOC. CIT. Loc. CIT. Loo. CIT. Loc. CIT. Loc. CIT. Loc. CIT. Loc. CIT. SEX AGE LUNG IN- VOLVED M 65 R M 58 R M 42 R M 66 L M 47 R M 54 L F 54 R M 51 R M 64 R CLINICAL SYMPTOMS Clinical picture donunated by cer- ebral symptoms No heredity. Paralysis of left arm and leg. Painful swelling of nose and epistaxis. Dyspnoea and emaciation. Impaired motility of right chest. Flat- ness right apex; diilness below. Bron- chial respiration. Heart displaced to right Clinical picture dominated by brain symptoms Symptoms of cavity in right chest Pain in right_ chest, dyspnoea, dry cough, emaciation. Dulness over right chest; bronchial breathing. En- larged, painful liver; ascites. Some fever Anorexia, debility, emaciation. Flat- ness over left chest ; diminished breath- ing; absence of voice. Duration about 6 months Sudden onset with chill and pain in right chest. Dulness; friction at right base; fever. Later pericarditis. In- creasing dyspnoea; death. Duration about 5 weeks No heredity. Acute onset with pleurisy. After that emaciation and cachexia. Loss of patellar reflexes; left pupil larger than right. Friction over right lung. Duration of disease about 3 months No heredity. Commenced with ano- rexia and emaciation followed by symptoms of right pulmonary phthi- sis; death after a few months without characteristic symptoms CARCINOMA 233 No details Glairy, shortly before death bloody, no tuber- cle bacilli No details No tubercle bacilli No details Mucopuru- lent, no tubercle bacilli ; no blood Rusty No details No details AUTOPSY NOTES Ulcerated right main bronchus leading into large tumor at the root adherent to bronchial nodes. Trachea compressed ; bronchiectatic dilatations Retraction of entire right lung; dislocation of heart. Right main bronchus almost completely filled with cauli- flower-like tumor. Smaller bronchi of lower and middle lobes, same tumor. Tmnor penetrates into right pul- monary vein and prolifer- ates into left auricle. Pneu- monia left lower lobe Ulceration of right main bronchus; tumors in right upper and lower lobes; latter contains cavity perforating into pleural cavity Circular obstructing can- cer in left main bronchus ex tending to lower lobe. Cav- ity in tumor Right main bronchus filled with cancer proliferat- ing from its walls, extending into trachea. Tumor nod- ules in right lung Hard carcinoma of main bronchus completely ob- structing it; left lung re- tracted. Bloody serum in abdomen; miliary tubercles in liver Right lower lobe and part of middle lobe destroyed by medullary cancer; right low- er lobe adherent to pericar- dium Carcinoma of lower branch of right main bron- chus Carcinoma of right main bronchus; bronchiectases in both lungs METASTASES Bronchial lymph nodes; brain Left lung, dura mater, tip of nose, nasal sep- tum; right supraclavic- ular lymph nodes Tracheal and bron- chial lymph nodes, brain, spleen, kid- neys Bronchial lymph nodes and liver Right pleura, in- tercostal inuscles and ribs, verte- brae, liver, dura mater Miliary car- cinosis of peritoneum Lower cava, right auri- cle; liver Lung, spleen, liver, right pleura, muscles of back, brain Right kid- ney, liver; spleen MICROSCOPE Pavement epithelium Adeno-carci- noma Alveolar structure ; large poly- morphous and cylindri- cal cells Alveolar structure; cy- lindrical cells Alveolar structure ; polymor- phous cells Cylindrical cells No details No details No details Bronchial mucous glands normal Histogenesis not to be determined Origin from bron- chial mucous glands 234 TABLE I 360 361 Loc, CIT. Wolf, Loc. cit. 362 363 364 365 366 LUNG IN- VOLVED Loc. CTT. Log. cit. Loc. CIT. Loc. CIT. Loc. cit. 367 Log. cit. M M M M M M M 57 64 60 63 64 69 67 76 R R Both R clinical symptoms Pleuritic eflfusion in left chest. As- piration: pus. Resection of 9th left rib with removal of 2000 c.c. of thick putrid pus. Death Aspiration of clear serum from right pleura; dulness not affected. Abscess over 8th rib opened and rib resected. Death after a few weeks Cough, emaciation, bronchitis. Red- ness and swelling left side of neck; fluctuating retropharyngeal swelling No clinical history except died of suffocation on day of admission Pain, emaciation. Complete dul- ness left lung; no voice or breathing sounds A fluctuating swelling at angle of left scapula found on incision to be tumor penetrating from interior of chest. No cough Clinically characteristic of pulmo- nary phthisis No heredity. Dyspnoea, dysphagia, emaciation. Pain in left arm. Upper left chest bulging. Flatness and ab- sence of breathing over left upper lobe No heredity. Well until 3 weeks before admission; then increasing CARCINOMA 235 AUTOPSY NOTES METASTASES No details Mucopuru- lent No details No details None No details No details No details Carcinoma of left main bronchus and its ramiiica- tions. Large cavity in left lower lobe. Extensive cheesy broncho-pneumonia of right lung Right main bronchus completely filled with papil- lary growths firmly adherent to its walls. Tumor pene- trates into right lung form- ing a large tumor in upper and lower lobes. Large ves- sels compressed ; upper cava perforated and filled with tu- mor Cavity in right upper lobe communicating with bron- chi completely closed by tu mor originating from their walls Pericar- dium, Uver, left kidney, and right suprarenal Mediasti- nal lymph nodes; left auricle, kid- neys, left suprarenal MICROSCOPE Pavement epitheUum re- sembling epi- dermis Left kid- Pavement ney, 3d cer-; epithelium vical verte- bra with de- struction of bone and compression of cord; also left ventri- cle and bron- chial Ijonph nodes Papillary proliferation Both lungs, almost completely closing liver, spleen, lower portion of trachea andjand left extending into both bronchi. Also large tumor surround- ing trachea and large bron- chi and compressing upper cava Entire lower lobe con- verted into large cavity the walls of which consist of white tumor. Main lower bronchus communicates di- rectly with cavity and is obstructed by proliferating tumor Tumor proliferation in right main bronchus; bron chiectatic cavities in right lower lobe Left main bronchus al- most completely filled with tumor which proliferates from its walls and extends along ramifications into left upper lobe forming large hard, white tumor Carcinoma of left main bronchus and left lung kidney Bronchial lymph nodes and lung Bronchial lymph nodes and liver Bronchial and retro- peritoneal lymph nodes; peri- cardium No details No details REMARKS Pavement epithelium Pavement epithelium Pavement epithelium Alveolar structure; 236 TABLE I 368 369 370 371 372 373 Log. cit. M 56 Log. git. Wolf, Loc. cit. Log. cit. Loc. CIT. Loc. CIT. M M M M 55 47 63 54 59 LTJNG IN- VOLVED R R Both CLINICAL SYMPTOMS hoarseness, pain in chest, dyspnoea, dysphagia, and palpitation. Paralysis of left recurrent. No signs in heart or lungs. Treated for 6 months by electricity and felt well; then rapid failing, dyspnoea, effusion in left pleura Father died of cancer of the stomach. Well until a year ago, then dyspnoea, debility, and emaciation. Left upper chest retracted and impaired respira- tory motion. Dulness over left lung with loud bronchial breathing No clinical history Always well. Disease commenced with paralysis of right vocal cord and dysphagia. Soon thereafter dyspnoea and a sense of suffocation. Later intense tracheal stenosis. Hard nod- ules in thyroid which seem to extend up from below sternum. Dulness over sternum and on right side behind. Tracheotomy, with long canula intro- duced into right bronchus. This ia followed by putrid bronchitis, im- paired deglutition, increasing debility. Double pleuro-pneumonia; death Sudden onset with anorexia, debility, pain in lower abdomen, emaciation, icterus, cedcema of skin of abdomen and lower extremities. Liver much en- larged; no nodules can be felt. Nothing found in lungs. Duration of disease only about 3 weeks Clinical symptoms of pleurisy with effusion No heredity. Well until 6 months before admission when dyspnoea, pain in chest, cough. On admission cyano- sis, impaired respiratory motion of left chest. Dulness from middle of CARCINOMA 237 Bloody, no tubercle bacilli or tumor cells No details No details No details No details Haemopty- sis; tuber- cle bacilli AUTOPSY NOTES Left main bronchus com- pletely obstructed by carci- noma proliferating also into trachea and right bronchus. Greater part of lung con- verted into solid tumor extending along bronchial ramifications Carcinoma of right main bronchus METASTASES Just below right lobe of thyroid a large tumor which penetrates into right upper chest adherent to bones which are not affected. Lob ulated tumor from bifurca tion extending into right main bronchus, penetrating its walls, and extending into surrounding lung tissue. Tumor in upper lobe in di rect contact with large tu mor on thyroid Left main bronchus and bronchus from left upper lobe obstructed by cancer Walls of both bronchi infil- trated Obstruction of right main bronchus by cancer. Sur- face of right lung covered with net of lymphatics in- jected with white tumor ma- terial Carcinoma growing from walls of both bronchi and trachea and obstructing their lumen. Continuous with this a tumor spreading Bronchial lymph nodes, peri- cardium, heart, thy- roid, and both supra- renals Bronchial Ijonph nodes, right lung, liver, lymph nodes around por- tal vein, retroperi- toneal nodes and bodies of 7th to 10th dorsal vertebrae Bronchial lymph nodes MICROSCOPE Bronchial lymph nodes and liver Bronchial lymph nodes, right pleura, peri cardium Left auri- cle; oesopha- gus and left kidney pavement epithelium typical giant cells Scirrhus- like; small round and cuboid cells Alveolar structure ; broad con- nective tissue bands of stro- ma; large and oval epithelial cells No details No details No details No details Origin from bron- chial mucous glands Origin probably from bronchial mi cous glands 238 TABLE I NO. AUTHOB SEX AGE LUNG IN- VOLVED CLINICAL SYMPTOMS 374 Z1EM88EN, Berlin, klin. Wochen- Bchr. 1887 M 50 L scapula downwards; no fremitus. Dulness over right apex with feeble respiration and rales. _ Aspiration evacuated large quantities of clear serum. Death with symptoms of progressive tuberculosis Diagnosed first as tuberculosis; then as syphihs. Dulness over entire left anterior chest extending to lateral and posterior aspects to below spine of scapula. Over this area bronchial breathing and dry rales. Bulging of left chest; intercostal spaces obliter- ated. All symptoms and signs dis- appeared under antisjT)hilitic treat- ment; then reappeared; again shght improvement under mercury followed by rapid failure and death CARCINO^IA 239 AtTTOPST NOTES At first fi- brinous, then rusty over both lungs and into left auricle. Pulmonary veins compressed. Lesions of old and more recent phthisis Jellj'-like mass at apex of left lung: remainder of left lung diffusely infiltrated with carcinoma. Large ab- scess behind sternum; an- other behind pericardium METASTASES None MICROSCOPE Carcinom- atous struc- ture 240 TABLE II Barclay, H. C. New Zealand Med. Jour.,V, 1892, 170-172 Sarcoma of Lung Bauman & Bainbridge Lancet, 1903, I Primary Sarcoma of the Lung Bell, Monthly Jour. Med Science, London, 1846 -47 Bjornsten, Centralbl. f. Path. Anat., Vol. 15, 1904, .. p. 513 Uber Lungen und Herz geschwiilste bei Kin dern (Swedish) Blumenthal, Diss. Berlin, 1881 Zwei Falle von prima- ren malignen Lungen tumoren Bock, A. F. Weekly Med. Review, St. Louis, Vol. XIX, 1889, p. 512 Primary Sarcoma of the Lung M M M 18 3 yrs. 11 mos, 28 20 LUNG IN- VOLVED R CLINICAL SYMPTOMS No heredity. Disease commenced with pain at right base, some cough, slight temperature. Dulness over greater portion of left chest; absence of vocal fremitus, some harsh respira- tion and diminished breathing sounds. Emaciation. Temperature at times to 104. Gradually bulging over left chest; oedcema of left arm and chest. Glands above left clavicle. Two ex- ploratory punctures practically nega- tive. Pain always at right base Well until 6 weeks before admission. Illness commenced with headache and abdominal pain; later emaciation, cough, haemoptysis. Flatness, dimin- ished voice and breathing, bulging of intercostal spaces, displacement of heart to right. Fever 101. Aspira- tion recovered only a small amount of bloody fluid without anything char- acteristic. Duration 8 weeks Pain in sternum ; later severe cough, dyspncea, and vomiting. Retraction of left chest; imperfect expansion, no fremitus. Dulness over entire left lung in front and behind; absence of breathing sounds; numerous rales. CEdoema of upper and lower extremi- ties; diarrhoea. Duration of disease about 3 years No clinical history For several years pain in left arm; 7 months before admission swelling on left chest; later swelling in left axilla reaching size of a child's head. No respiratory disturbances. Dulness over left chest more in front than be- hind, with absence of breathing sounds. No cough; no sputum. _ Fluctuation in axillary tumor. Aspiration with- draws a Hght green, clear, mucoid fluid No heredity. Disease commenced with fever and severe pain in left side, the latter continuing until death. Fever yielded to quinine (probably malarial). No cough; some dyspnoea. Sweating of right half of body; left always dry. Left thorax larger than right. Impaired respiratory motion; enlarged superficial veins. Marked SARCOMA 241 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE REMABKS Scant, bloody Old and recent pleuritic adhesions in right chest. Effusion in left pleura. Greater part of left lung replaced by hard, nodular timior. Smaller bronchi occluded None "Small celled sarcoma" Hffimop- tysia Upper lobe of left lung re- placed by soft sarcomatous tumor. Pleura thickened None P Abundant, green and foetid Lower left lobe one large cavity with hard irregular walls, filled with green fluid. Numerous spherical nodules excavated in same manner scattered through remainder of left lung and in right None ex- cept nodules mentioned in right lung None given Although no micro- scopic examination is given, the age of the patient, sputum and character of the nod- ules speak for sar- coma Not given Entire right lung trans- formed into soft nodular tu- mor. Large vessels at heart surrounded by tumor Left lung, pericardium and heart muscle Round celled sarcoma None Left pleura 400 c.c. bloody fluid. Upper lobe of left lung compressed and flat- tened. Of the lower lobe only a narrow border of highly compressed lung tis- sue remains, all the rest taken up by a large tumor which has eroded several ribs, and which has pene- trated into the axilla and compressed the brachial plexus None Myxosar- coma None Entire left thorax occu- pied by white tumor mass without visible lung struc- ture. Left bronchus en- tirely obliterated. All other organs healthy None Large spin- dle celled sar- coma 17 242 TABLE I NO. AUTHOB SEX AGE LUNG in- volved CLINICAL SYMPTOMS emaciation. Flatness and absence c breathing sounds over all of left lung Heart to right of sternum. Repeate aspiration only small quantity sere purulent fluid. Sudden death dvu-in aspiration. Duration of disease months 7 Box, C. R. St. Thomas Hosp. Re- ports, 1896, p. 260 Sarcoma of Lung M 5 L No heredity; good health until months before admission, when grac ually increasing lump under angle c left scapula. Slight cough, pain, in creasing dulness over upper left ches Diminished voice, breathing an fremitus. Negative aspiration. Late dilatation of superficial veins ; enlarge ment of axillary and cervical glands Later dulness and tubular breathin over right upper lobe. Occasions fever. Extreme dyspnoea and cyanosis Duration of disease about 1 1 months 8 Bramwell, Byron, Clinical Studies, Vol. I, 1903, p. 130 Solid Intrathoracic Tumor M 57 L Illness commenced 7 months befor admission with dyspnoea on exertioB weakness, hoarseness, cough, pain i left chest. Luetic infection admittec Dulness all over left chest, more fla on upper part than base. Lou bronchial breathing at base, increase vocal fremitus; no rales. Punctur negative. Left chest i inch more thai right. Heart not displaced. _ Patien was treated with KI and improve somewhat; gained 7J pounds in weigh Physical signs remain the same. Sue den death 9 Braureuteh, Diss. Miinchen, 1881 (after PoUak) Prim^res Sarkom der Lunge und der Bron- chial driisen M 56 R No clinical history. Admitted un conscious and moribund; died afte 5 days 10 Chiari, Wien, 1878, No. 6 (quoted after Fuchs) Anzeiger der Gesell- schaft der Arzte F 14 R No clinical history except that chil died of facial erysipelas and genera oedcema 11 Coats, Joseph, Glasgow Med. Jour., New Series, Vol. VI, 1874, p. 274 Not me ntioned No data except persistent vomitin and symptoms of laryngeal obstruc tion SARCOMA 243 AUTOPSY NOTE8 Nearly the whole of left lung converted into a soften- ing tumor continuous with large external mass. Erosion of 5th to 8th ribs. Large hard tumor infiltrating upper and middle right lobes, adherent to upper dorsal vertebrae and infil- trating dura. Cord healthy All other viscera healthy Large new growth from root of lung and bronchial glands extends in large masses along bronchi into lung. Left main bronchus completely occluded, the lung collapsed and airless. Bronchiectasis in lower lobe. Arch of the aorta completely surrounded by tumor Enormous enlargement of bronchial glands of right hi- lus with abscesses. Nearly half of right lower lobe con- verted into sarcomatous tu- rnor proliferations from the hilus, mostly along bronchial ramifications Upper lobe of right lung hard and firm; middle and lower lobes compressed. In lower part right lobe pneu- monia. Section of upper lobe could be completed only with a saw, and showed a spherical tumor 10 cm. in diameter. In interior of tu- mor bronchioles could be made out Disease centred in lymph nodes at root of lung and ex- tended from there to glands of neck, many as large as METASTASES MICK08C0PE Right lung, verte- brae, spinal dura Only bronchial lymph nodes mentioned No details None Not men- tioned Not given No details given; simply stated sar- coma LjTnpho- sarcoma Spindle celled sar- coma with calcification Lympho- sarcoma 244 TABLE II 12 13 14 15 16 A Case of Lympho-sar- coma of the Bronchial Glands Cockle, Medical Times & Gaz. Oct. 29, 1881, p. 518 Cohen (S. Solis) & KiRKBRIDE, Proceedings of Path. Soc. of Philadelphia, New Series, Vol. Ill, 1900, p. 200 Tumor (Sarcoma?) of the Mediastinal and Bronchial Glands; Metastases in Liver. Rupture with Fatal Haemorrhage COLOMIATTI, Rivista Clinica di Bo' logna, 1879, Gennaio Virch. Jahrbuch for 1879, I, p. 267 CURRAN, Lancet, 1880, II, p. 258 Da VIES, Arthur, Transactions London Path. Soc, XL, 1889, p. 46 Lymphosarcoma of Left Lung M Not M M 44 30 given 10 18 LUNG IN- VOLVED R CLINICAL SYMPTOMS Dyspnoea. Absolute dulness, ab- sence of voice and breathing over en- tire left chest. Heart displaced. La- ter increasing dyspnoea and diarrhoea; then coma, convulsions, and death Pain in lower right chest. Right pupil larger than left. Nothing said about cough, sputum, temperature, etc. Enormously enlarged nodulated liver, left lobe simulating enlarged spleen. Right lung expands less than left. Irregular areas of dulness in lower chest with diminished breath- ing and absence of fremitus. Haemo- globin 60; reds 4,400,000; whites 18,000. Albumin and casts in urine. Aspiration shows serosanguinolent fluid with enlarged leucocytes. Slight dyspnoea, sudden collapse, death No data Blow on left chest; later swelling of that spot and fever. Puncture nega- tive. Signs of pneumonia over left apex. Dulness on both sides lower down. Scarcely any respiratory move- ment of left chest. Copious haemor- rhages. Rapid increase of tumor. Duration of disease about 5 months Pleurisy a year and three quarters before admission to hospital. 9 months before admission cough, gradual loss of weight, night sweats, dyspnoea, pain in left chest. Shortly before admission pain in right groin. Physi- SARCOMA 245 AUTOPSY NOTES METASTASES MICROSCOPE a hen's egg. Pericardium, both parietal and visceral involved. At auricles mus- cle had been replaced by tumor which penetrated in to cavity of auricles, both right and left. Growth ex- tended likewise into trachea bronchi, and lungs. Right vagus buried in tumor and its tissue involved Bloody serum in left pleu- Retro- ral sac. Upper part left peritoneal pleura and lung filled with IjTnph soft tumor. Tumor appar- nodes ently from hilus along bron chial ramifications. Left pulmonary vein obliterated Abdomen contains 2,000 No others c.c. of blood and large clots mentioned from two rents in Hver cap- sule, which is enormously dis- tended by layers of swollen tumor nodules. Anterior mediastinal glands much en larged; tracheal and right bronchial glands also en- larged. Heart and large vessels pushed somewhat to the left. Several small nod ules in left lung, also in left bronchial glands. Right bronchial glands enormously enlarged; right main lower bronchus almost occluded by tumor; this tumor passes along bronchial ramifica- tions and infiltrates lower lobe._ Separate timior nod- ules in right lung. Right upper lobe convert- No details ed into an amber-colored gelatinous neoplasm Left lung consisted of a None mass of what the author calls "medullary cancer," which had eroded 7th to 9th ribs and penetrated chest wall Large tumor above left Liver, ret clavicle; large mass above roperito- Poupart's ligament filling up neal lymph- hollow of ilium to median nodes; over hne; several nodular masses' spine erod- below this. Left pleural ling vertebra Round celled sarcoma Unsatis- factory Probably lympho- sarcoma, possibly from bronchial glands Spindle cells and pe- culiar form of giant cells No details Original not acces- sible. I. A. Probably sarcoma Round celled lympho-sar- coma 246 TABLE II LXJNG IN- VOLVED CLINICAL SYMPTOMS 17 18 19 20 21 Demange, Revue Med. de I'Est, IV, 119 (Quoted by Fuchs) De Renzi, Giorn. Internaz. de See. Med. Napoli, 1885 Sarcoma primario del Polmone Dick, J. A. Australian Med.Gaz., Vol. XV, 1896, p. 50 Notes in a Case of Primary Malignant Disease of the Lung Duckworth, British Med. Jour., 1885, I, 943 Malignant Disease of the Lung Elkan, Julius, .. Diss. Mlinch., 1903 Uber primare Sar- kome der Lunge im Anschluss an einen Fall von primarem Sarkom der linken Lunge M 37 M 40 40 R R M M 62 57 cal signs were those of commencing phthisis with rapid consolidation with cavity at left apex. In the course of 3 weeks cavity disappeared and complete dulness with loss of voice and breathing sounds took its place. Heart pushed to right side. Large neoplasm appeared in right groin and eventually smaller growths above left clavicle. Duration of disease at least 15 months; probably longer For 5 months increasing debility and emaciation. Pain in right chest; dulness over left chest with absence of breathing. Heart dislocated to right. Later cedcsma of left chest, enlargement of liver, dyspnoea and cough. Exploratory puncture nega- tive; sudden death Pain in right chest and hypochon- drium; headache, epistaxis; swollen glands in neck Symptoms of pleurisy with effusion of right side; 3 months later puffy swelling of face and neck; slight cyanosis; dilatation of veins over right chest; orthopnoea; impairment of respiratory motion. Absolute dul- ness over right chest in front and behind except small area over apex. Absence of voice and breathing; every- thing else normal. Death 4 months after first examination Incomplete left hemiplegia; cough; flatness below 4th rib with absence of voice and breathing. Purulent fluid in pleura; pain in right chest For some time cough and bloody sputum, then swelling of hands and feet; slight rise of temperature for weeks; some loss of strength and dyspnoea. At first examination lungs found normal except some dry rales at about 3rd left rib anteriorly. Systolic murmur at apex of heart. History of syphilis. Clinical diag- nosis at that time bronchitis with myocarditis. Temporary improve- ment. X-ray showed a dense shadow over whole of left upper lobe. Supra- clavicular glands enlarged. Diagnosis of tumor made principally by X-ray picture. Duration of disease about 10 months SARCOMA 247 AUTOPSY NOTES cavity completely obliter- ated and the whole left chest filled with hard new growth; hardly any lung substance visible. Neoplasm pene- trates diaphragm into abdo- minal cavity. Nothing on right lung 6 to 8 encapsulated timaors from the size of a pigeon's egg to that of a fist in left lung. No bronchi could be traced in them. Left main bronchus completely filled with tumor. Thrombosis of pulmonary artery Round celled sarcoma of right lung compressing right bronchus METASTASES and involv- ing pan- creas; right iliac bone and lymph nodes None MICROSCOPE No details Clear serum in right No others pleura. Neoplasm at root of right lung pressing on venae cavae and right auricle. Right lung reduced in size; neoplasm extending along bronchial ramifications throughout right lung. Growth surrounds right main bronchus and involves bronchial glands. Bron- chiectatic cavity in lung Neoplasm from root of Various right lung, proliferating parts of along bronchial ramifica- brain, liver, tions and invading right pancreas lung Bloody serum in left pleura. Large encapsu- lated greenish tumor in left upper lobe Nodules on pleura; tumor infil- tration of 2nd, 3rd and 4th ribs Fasciculated sarcoma Round celled sar- coma Mixed, round and spindle celled sarcoma Diagnosis of tumor made during life. Author believes tu- mor to have origi- nated in lung tissue itself Round celled sar- coma Medullary spindle celled aar- 248 TABLE II 22 23 Faerell, Maritime Med. News Halifax, XIII, 1901, p. 291 Lympho-sarcoma of Lung 24 Fbhband, Sarcoma primitif du Poiimon gauche (after Chauvain) FiNLET, Medical Times and Gazette, London, 1885, Vol. I, p. 145 Case of Lympho-sarco- ma of Left Lung vnth great displacement of Heart 25 26 M LUNG IN- VOLVED Not stated 32 FOOTE, A. W. Proceedings Dublin Path. Soc, Session 1871-2 Primary Encephaloid Sarcoma of Lung Fraseb, Edinburgh Med. Jour 1880 - 1881, XXVI, 677-673 M 32 56 39 CLINICAL SYMPTOMS Soldier; complained of pain in neck and shoulders for 9 to 10 months, also in left chest. Loss of flesh, short breath on exertion. On admission complete flatness over left lung in front from 4th rib down; absence of breathing and fremitus. Pos- teriorly flatness from spine of scapula down; loss of voice and breathing. Slight dullness and absence of breath- ing at right base. Heart displaced to right. Diagnosis: pleurisy. Aspi- ration: "dark fluid." Death 6 days after admission 111 for about a year before admission to hospital, but nevertheless gives birth to a normal chUd. Pain in chest; dulness to about middle of left lung; abolished breathing ; harass- ing cough; bulging of chest, respira- tory immobility ; displacement _ of heart. No fever, but emaciation. Enlarged axillary glands. Diagnosis made during life No heredity. For 3 years before admission failing strength and pain in epigastrium and lower part of sternum. Cough, emaciation, dysp- noea. Lies on back and left side and any attempt to change position brings on cough and suffocation. Tumor below clavicle extending towards axilla; similar smaller mass above clavicle, and a large irregular mass from left interspace to breast. Left chest larger than right and immobile on respiration. Nearly all of left chest in front and behind revealed absence of breathing and absolute flat- ness. Heart displaced far over to right. (Edcema of face, left arm, and chest. Duration about 3i years Sick for 3 months before going to hospital. Dyspnoea and a sensation of weight across chest. Left chest gave all the signs of pleuritic effusion, chronic and receding. Slight con- traction of that side of chest. _ Heart not displaced. Intense pericardial friction. No enlarged glands, no pain, no haemoptysis; much cachexia. Death from hemiplegia 7 weeks after admission Pain in right hip and right shoulder. Dyspnoea and cough. Effusion in left pleura. Bronchitis ; dilatation of veins over left chest. Secondary tumors around left clavicle and right humerus SARCOMA 249 AUTOPSY NOTES METASTASES MICKOSCOPE No tubercle bacilli Bloody; hae- moptysis None No details Copious, often bloody Entire left lung except small portion of apex occu- pied by large fibrous mass, involving and adhering to pericardium and heart and invading left auricle and pleura. Right lung normal except some pleurisy at base Entire left lung occupied by tumor Hard nod- ule in left ventricle and second ary growth involving nearly | of left auricle. No other metastases None, not even in pleura Simply stated : lympho- sarcoma Remarkable that the man performed his duties as a soldier until 5 or 6 days be- fore his death Spindle celled sarcoma Heart and pericardium firmly adherent. Neoplasm filling almost entire left chest. Tumor on surface of chest communicates directly with tumor of lung. Bron- chiectatic cavities and ( eluded bronchi Bronchial, mediastinal, axillary lymph nodes, liver Lympho- sarcoma Entire left lung infiltrated with neoplasm, bounded by a mass of compressed lung tissue. Only tube through mass is pulmonary artery, which is much compressed; bronchi and pulmonary veins not distinguishable Left lung entirely solid; large tumor in centre reach- ing surface at 3rd and 4th ribs posteriorly None Round celled sarcoma Bronchial and cervical lymph nodes, left shoulder, right hu- merus, right hip Small round celled sar- coma 250 TABLE II 27 28 29 30 31 32 33 34 FUCHS, Diss. Miinchen Beitrage zur Kenntniss der primaren Ge- schwulstbildungen in der Lunge Log. git. Log. git. Hagenbach, 1882 (after Roth) M M M BLlhbis, St. Bartholomew's Hosp. Reports, Vol. 28, 1892, p. 73 Intrathoracic Growths Loc. CIT. Log. git. Log. git. M M M 70 73 74 LUNG IN- VOLVED R lOJ yrs, 24 53 36 48 R CLINICAL SYMPTOMS No cUnical history Marked cachexia; senile bronchitis; some vomiting after deglutition which improves. Death without symptoms pointing to lungs Clinical symptoms mainly cerebral and psychic; with the exception of some emphysema nothing abnormal found in lungs Treated for right pleurisy for about 7 weeks; diagnosed later as encap- sulated empyema of right upper lobe increasing in extent. Increasing dyspncea; cyanosis. Absolute flat- ness over right apex in front to 3rd rib; behind to angle of scapula. No fremitus, diminished respiration, sibi- lant rales. Right cla\'icle protrudes, as also supraclavicular space, where there is absolute flatness. 3 proba- tory punctures in region of flatness draw blood but no pus. Diagnosis of tumor of right upper lobe made dur- ing life Cough, pain in right shoulder, dyspnoea. Left chest more promi- nent; deficient respiratory move- ment; diminished vocal resonance; bronchial respiration. Complete flat- ness of entire left chest extending over sternum to right. Four tap- pings without relief. Duration about 6 months Pain, weakness, cough. Dulnesa at right apex; impaired resonance over whole of right chest; diminished voice and breathing; some rales. Duration about 4 months Pain both sides of chest; cough, slight hsemoptysis. Flatness of left chest; absence of voice and breath- ing. Duration about 3 months Cough, pain in left side, swelUng of abdomen. Absolute flatness with absence of voice and breathing over entire left chest. Duration about 10 months SARCOMA 251 AUTOPSY NOTES METASTASES MICROSCOPE No details None None No details Scant Scant, muco- purulent; no blood Scant, slight hae- moptysis Scant, no hsemop- tysis Primary sarcoma with central softening in right upper lobe. Nodulated tumor size of a child's head enclosed thick fibrous capsule, in right lower lobe Nodule size of a pea in left upper lobe Medullary sarcoma of right upper lobe extending to ribs and vertebrae. Tu mor size of child's head dis places right subclavian art- ery upward, right bronchus downward Bronchial lymph nodes, liver, pancreas Nodule in left lower lobe None Pleura Not given Spindle celled sar- coma Structure in some parts Ismapho-sar- coma, in others fibro- sarcoma Round celled sarcoma Left lung infiltrated by soft neoplasm involving bronchial lymph nodes, oeso- phagus, and destrojdng and obliterating left main bron- chus Upper right lobe com pletely infiltrated with neo- plasm, white, firm and solid in upper portion; soft and decomposed in lower portion Upper lobe of left lung almost entirely occupied by new growth ; lower lobe com pletely invaded by tumor Lower lobe of left lung completely occupied by hard, white tumor. Pleura enormously thickened and honeycombed Regionary lymph nodes, lung, pericardium Small nodules in right lung, no others Right lung, bronchial and medias- tinal lymph nodes Liver, spleen, pan- creas, peri- toneum, and retro- peritoneal glands Sarcoma Small round celled fibro- sarcoma Round and spindle celled sarcoma with excessive fi- brous tissue Sarcoma 252 TABLE II 35 36 37 38 39 40 Hellendall, Zeitschr. f . Klin. Med. XXXVII, 1899, p. 435 Ein Beitrag zur Diag- nostik der Lungen- geschwiilste HiLDEBHAND, Diss. BerHn, 1887 (after PoUak) Primares rundzellen Sarkom der linken Lunge im Anschluss a n Lungentuberku- lose Hooper, Intercolonial Med. Jour, of Australasia, Vol. Ill, 1898, p. 222 Sarcoma of Lung Iscovesco, Bull, de la Soc. Anat de Paris, 1888, p 182 Sarcome pulmonaire simulant la Phthisie JAN38EN, Diss. Berlin, 1879 Ein Fall von Lungen- sarkom mit grass- griinem Auswurf KOBYLINSKI, .. Diss. Greifswald, 1904 Uber primare Sar- kome in der Lunge M M M M 47 46 24 Not stated 30 20 LUNG IN- VOLVED R R R Both CLINICAL SYMPTOMS No heredity; dry cough, dyspnoea; pain in chest. Increasing dulness from right apex downward. Varying physical signs. Later cedcEma of legs and right arm. Dyspncsa dysphagia, ascites. Dilated superficial veins. Large hard liver. Bloody effusion in right chest. CHnical diagnosis at first tuberculosis, but examination of white particles in bloody effusion showed heaps of round cells from which the diagnosis of sarcoma of lung was made. Duration of disease about 6 years Acute onset with pneumonic symp- toms; since then emaciation, dizzi- ness, cough; severe dyspnoea. Dura- tion of disease about 1 year No heredity; always well; disease commences with area of dry pleurisy. Fever to 102, persistent dry cough; great debility, dyspnoea. 2700 c.c. clear serum removed by aspiration from right chest. Area of dulness anteriorly over middle of right lung with normal breathing and voice sounds. Tumor was diagnosed from sweating, cough, emaciation. CEdcema of right face, chest, and arm. Death from asphyxia. Duration about 6 weeks No heredity. Pain in right chest; much cough. Signs of consolidation of left apex and patient went through all the clinical stages of phthisis — night sweats, haemoptysis, some cedcema of face; slight albuminuria No heredity. History of lues. Pain in right chest, dyspnoea, cachexia Later painful enlargement of inguinal glands. Attack of pneumonia with crisis. After this progressive dulness with friction sounds, some of which also appeared on left chest. Antisyphi- litic treatment shows apparent im- provement; nevertheless dulness in- creases and cachexia progresses. Duration a little over 1 year No heredity. 8 weeks ago attack of scarlet fever. 2 weeks ago sud- denly cough, pain in chest. Slight paralysis first of foot, then ascending. 6 days before admission last volun- SARCOMA 253 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE EEMABKS Occasion- Large tumor in right lung Only in Typical ally covered with thickened liver, no round celled bloody, pleura. Lung compressed, others sarcoma contains in parts cystic no tuber- cle bacilli, several abundant hsemop- tysea Mucoid, Pulmonary phthisis. Ex- Absolutely Small numerous tensive sarcomatous prolif- none round celled tubercle eration in left main bron- sarcoma in- bacilli chus with ulceration of bron- chial wall. Large nodular, hard tumor at left hilus compressing right and left main bronchus vading a previously tubercular lung. Origin not to be de- termined Bloody; no Right pleural cavity oblit- None No details The rapidity of de- tumor ele- erated. Whole right lung given velopment in this ments; no infiltrated with new growth. case is remarkable. tubercle soft and whitish — "evi- Hooper had known bacilli dently a rapidly growing round celled sarcoma" the patient well for 10 years. Death en- sued in 6 weeks from time of onset Scant, hae- Two large tubercular cav- Right Not given Some doubt as to moptysis, ities in right lung; sarcoma- kidney and primary site of tu- nothing tous nodules in right pleura. cEBophagus mor. Possibly pri- said Right lower lobe sarcoma- mary in kidney about tous infiltration. Tubercles tubercle in left lung bacilU Grass green Right lung filled with con- Mediastinal Round color necting tumor nodules. Tu- and bron- celled sar- mor in middle of otherwise chial lymph coma normal left lung. Abscess nodes. anterior mediastinum over spleen, pan- trachea creas, hilus of both kid- neys, retro- peritoneal, axillary and inguinal lymph nodes Mucopuru- Left lung adherent; clear Spinal cord Spindle lent, no serum in pericardium. celled sar- tubercle Large solid tumor size of a coma bacilli. man's head in left lower lobe no blood almost entirely replacing 254 TABLE II 41 42 43 44 Krienitz, Walter Diss. HaUe, 1903 Adenoma der Lunge Keoniq, Berlin klin. Wochen- schr., 1887, p. 964 Ein Fall von primarem Sarkom der rechten Lunge Lanqe, J. C. Penna. Med. Jour., Pittsburg, 1903-4, Vol. XXXIII, p. 202 Four Cases of Malig- nant Disease of the Lunga Loo. CIT. M M M 18 26 72 12 LUNG IN- VOLVED R CLINICAL SYMPTOMS tary urination; 5 days before, last fascal movement; within last few days paralysis up to horizontal mammillary line. No sensation in paralyzed parts; no oedcBma; no glands. Dulnesa with absent breathing over greater part of left chest behind. Some pleuritic friction; bronchial respiration anteri- orly. Heart displaced to right. Pro- batory aspiration some turbid bloody fluid. Haematuria. Fluid in chest present only in thin layers; most of the dulness due to solid mass in lung. Duration a little more than 1 month Pain in chest, increasing dyspnoea, palpitation. Flatness over whole of left chest. Heart displaced to right Pain in right chest. Dulness below right clavicle; diminished voice and almost absent breathing sounds. Clini- cal diagnosis of lympho-sarcoma made from particle of tissue withdrawn by needle at time of puncture. Later fever, increasing dulness and disloca- tion of heart, enlargement of liver; dyspnoea; swelling of cervical and mediastinal glands; tremendous sweat- ing, especially on right side. Duration of disease about 10 weeks Progressive loss of strength and gen- eral malaise without definite symptoms for some months; then pleuritic pain in left chest, some fever; violent cough. Flatness over left lower lobe. Aspira- tion negative. No glandular enlarge- ment ; no cedcema. Death from exhaus- tion 3 months after first clinical signs No clinical history. Came to hos- pital with incision in 7th left inter- costal space in front. Left face, arm, neck, and chest oedoematous. Dilated veins; enlarged glands. Flatness over left chest. Much pain. When flap including 2 ribs was lifted up a large sarcoma was revealed SARCOMA 255 No details lung tissue. Involves cos- tal pleura and penetrates in- tercostal muscles; involves also lower part upper lobe. Tumor penetrates through vertebral column and fills canal from 4th to 6th verte- bra. Does not penetrate dura, but compresses cord. Above and below compres- sion extensive softening of medulla spinalis Large tumor weighing 20 kilos filling whole of left chest and extending to right, pushing heart to axillary line. Left lung compressed to small strip between tumor and chest wall. On section soft white tumor tissue con- taining numerous cystic _ cavities and areas of ossify- ing and ossified tissue No blood, no tuber cle bacilli, no elastic fibres Scant, mucoid No details AUTOPSY NOTES METASTASES Large tumor in anterior mediastinum continuous with tumor of right lung. Tumor affects several large bronchi. In upper right lobe a fresh pnevunonia "Encapsulated fibro-sar- coma in left lower lobe" as large as a small cocoanut. Small abscess around tumor No details Enormous masses of fi- brous tissue in some pla- ces having the charac ter of soft medullary sarcoma. Areas of hy- aline carti- lage. The small cysts have a glan- dular char- acter, lined with cylin- drical cells Right ax illary lymph nodes, liver, cervical, su- pra- and in- fraclavicu- lar glands with pres- sure on vag' us and sym^ pathetic None MICBOSCOPE Fibro-chon- dro-adenoma with sarcoma- tous degener- ation Sarcoma-car- cinomatodes No details No details No details 256 TABLE II 45 46 47 48 49 Lehndohff, Wiener med.Wochen. 1909, No. 31 & 32 Primares Lungensar- kom in Kiudesalter Lenhahtz, Miinch. Med. Woch. 1896 Primary Sarcoma of Lung with Metas- tases in Left Motor Region Levit, Diss. Erlangen, 1901 (after Pollak) Primares Rundzellen sarkom der linken Lunge mit Obtura- tion von grossen Bronchien und Bron- chiectasen Log. cit. Mac Donnell, New York Jour, of Med.. Sept., 1850, 153-157 Extensive Encephaloid Disease of Left Lung M Not 46 Not stated (adult) stated 17 LTJNQS IN- VOLVED R CLINICAL STMPTONS No heredity. Sudden cough and high fever for about 8 weeks. Bron- choscopy and pumping out of left lung; child worse after it. Pain, dyspnoea, high fever, harassing cough. Puncture in left axilla, much blood; 2nd puncture in front near sternum, same result. Some temporary im- provement. On admission to hos- pital cyanosis, no fever, left thorax more voluminous than right, lags in respiration; flatness over all of left chest in front and behind to about 7th rib with sharp boundary. Right lung normal. Notwithstanding the absolute flatness, respiration much diminished and some vocal fremitus is heard all over the flat portion. No glands; other organs normal. Increas- ing signs of compression — intense dysp- noea, cough, cedcema, dilated veins. No dysphagia. Haemoglobin 65-70; reds 4,820,000; whites 16,000. Poly- nuclears 70.4%. X-ray shows tumor convex boundary at base and erosion of 6th rib. Another punc- ture of tumor brings out blood and a piece of tissue from which the diag- nosis of round cell sarcoma was made. Death after about 5 months of sick- ness Cerebral symptoms prominent. Flatness right middle and lower lobes. Hoemorrhagic fluid in right chest No clinical history No clinical history For 2 years pain in left side and left shoulder; dyspnoea. Later small tumor above left clavicle; ptosis of left eyelid and contraction left pupil. Dry cough, emaciation, paralysis of left arm, oedcema left arm and chest, SARCOMA 257 AUTOPSY NOTES Left lung entirely com pressed and pushed down- ward and backward. Sar- coma originating from tip of left lower lobe, compressing lung and displacing heart and mediastinum to right. Tumor is encapsulated and centre degenerated and ne- crotic. Erosion of 6th rib No details At hilus of left lower lobe an irregular grayish red nod- ulated mass. Pleura over 2 c.c. thick, containing nu- merous abscesses. The tu- mor is found loosely adher- ent to the walls of many smaller and larger bronchi and bronchiectases Large soft sarcoma of left hilus. Numerous nodules throughout lung. Prolifer- ation into pulmonary veins, obstructing them. Tumor fills and obstructs numerous bronchi Nothing left of lung ex- cept thin layer of lung tissue at diaphragmatic portion of tumor 18 METASTASES None, not even re- gional glands No details No details No details Nodules in right lung, other organs healthy MICROSCOPE Small round celled sarcoma, probably congenital No details Small round celled sarcoma Round celled sarcoma Not given Origin not to be determined 258 TABLE II 60 61 62 53 attended by Unusual Symptoms Mac Donnbll, The Canada Medical Record. XVI,. No. 1, 1887, p. 3 Gaillards Med. Jour., Vol. XLVI, Dec. to June, 1888, p. 540- 543 Malignant Disease of the Lung Maeini, Giorn. Internaz. della Scien. Med. Napoli, 1891, XII, 1890. p. 98 Sarcoma primitive del Polmone McCall Anderson, Glasgow Med. Jour. 1893, XXXIX, p. 243 Cilinical Memoranda. Left Hemiplegia Com plicating Tumor at Root of the Lung Meter, Diss. Milnchen, 1900 Beitrag zur Casuistik der primaren Lun- gensarcome M M M M 40 48 54 LUNG IN- VOLVED R R CLINICAL SYMPTOMS obliteration intercostal spaces, respi- ratory immobility. Dulness over en- tire left chest in front and behind with bronchial respiration. Apex of heart in right axilla. Dilated veins, paralysis of right arm; bulging of intercostal spaces Shortness of breath for some weeks; no other symptoms. At first visit whole right chest flat on percussion, presenting the physical signs of pleu- risy with effusion. Repeated punc- ture negative, except small quantity of blood at one time containing the usual number of leucocytes. Gradu- ally increasing dyspncsa and signs of thoracic pressure — distension of tho- racic veins, bulging of right chest, oedcema of right side of face. Death after an illness of 6 weeks Family history of cancer. After a disease of chest diagnosed as bron- chitis patient had persistent harassing cough. After a fall pain in right chest with cough and fever. Pneumonia is diagnosed. Since that time not well. Pain in shoulder and anterior portion of right chest radiating from above angle of right scapula. At that time there was very slight dulness and slightly diminished breathing. All other organs normal. Later oedcema of right hand and arm, increasing dulness under clavicle and slight prominence above; entire absence of voice and breathing over greater part upper lobe. Gradual bulging of right chest in region of 3 upper ribs anteri- orly; no fever; no glands. Increas- ing dyspnoea; increasing pain. Clini- cal diagnosis : tumor in chest probably in lungs. Duration 22 months No heredity; always in good health. 2 months before admission inflammation of lungs. Later complete left hemiplegia. Clinical diagnosis: cerebral haemorrhage. Sudden death No heredity. Emaciation, cough; symptoms principally brain symptoms. Dulness over all left lung, bronchial respiration, diminished motion; fine rales at both apices. Liver much enlarged and tender. Icterus. Clini- cal diagnosis: pneumonia, phthisis pulmonalis, brain tumor, possibly old apoplexy. Duration of disease at least 8 months SARCOMA 259 SPUTUM AUTOPSY NOTES METASTASES MICEOSCOPE REMARKS No details Right lung adherent to chest wall and seat of exten- sive new growth. No other organs involved None Alveolar structure. Small round celled sarcoma with numer- ous lymph elements. Lympho- sarcoma Mucopuru - Firm, whitish-gray tumor None Fibrous lent, often occupying right upper lobe. stroma; cells bloody partly broken down and eroding clavicle and ribs. No glands of varying size and shape; where tumor is hard stroma pre- dominates, where it is soft and med- ullary, almost entirely cel- lular. Author calls it sar- coma No details Bulky tumor at root of left lung extending into lung and centred around main bronchus, the walls of which are incorporated in the tu- mor. Large hsemorrhagic cavity in right corona radiata No details Small round celled sarcoma Bloody Large, diffuse, nodulated Liver, Alveolar Origin probably in tumor left lower lobe desig- brain, peri- structure Ijmiph nodes nated at autopsy as primary bronchial with thick carcinoma lymph nodes bands of fi- brous tissue arranged in meshes; ex- tremely fine reticuli in meshes, which 260 TABLE II NO. AUTHOE SEX AGE LUNG IN- VOLVED CLINICAL SYMPTOMS 54 MlLIAN ET BeENABD, Biill. de la Soc. Anat. de Paris, 1898, p. 336 Sarcome aigu du Pou- mon; Generalization, Bacteries dans les tu- meurs F 27 L No heredity; no syphilis. _ 4 months before admission while in perfect health, sudden pain and paresis of both legs. Later an attack of pneu- monia. Since then cough, dyspnoea, some congestion and rales at both bases; cyanosis; high fever; para- lytic and spine symptoms. Clinical diagnosis varied; last tuberculosis. Duration about 4 months 65 MiiiiAN ET Mante, Soc. Anat. de Paris, Vol. 76, 1901, p. 82 Sarcome primitif du Poxunon M 31 R History of syphilis. Admitted for brain symptoms. One year previ- ously had severe bronchitis; since then some cough, dyspnoea, emaciation, fine rales over both bases. Clinical diagnosis: syphilitic hemiplegia. Sub- comatose state; apoplectic attack, increasing fever. Death about 1 week after admission 66 MiRINBSCU ET BaHON- CEA, Revue mens, des Malad. de I'enfance, Paris, 1894, XII, 82- 86 Sarcome primitif du Poumon F 14 R Uncle died of cancer. 3 months before admission acute disease, prob- ably pneumonia. Acute symptoms improved, but general condition re- mained bad. On admission flatness in lower posterior portion of right chest above and below to spine of scapula and in right subclavicular region. Some pleuritic friction at right base. Spasmodic cough like whooping cough. Exploratory punc- ture of thorax negative. All other organs apparently healthy. Dulness extends, involving nearly whole of right lung. Breathing rough and diminished with amphoric note. Soon signs of thoracic pressure — cyanosis of face, cedcema, dilatation of super- ficial veins of chest, hoarseness, in- tense attacks of dyspnoea. Death from suffocation more than a month after admission to the hospital 67 Mora, M Not Both Toper and formerly mine worker. Ann. univ. de Med. e stated Admitted in moribund condition; no SARCOMA 261 AUTOPSY NOTES METASTASES MICROSCOPE Green, pro- fuse hae- moptysis No details Mucus, bloody at first. Nothing charac- teristic Left lung almost entirely transformed into large cav- ity, the walls of which are lined with whitish-gray neo- plasm; cavity contains white liquid. Also tumor sur- rounding 5th and 6th ribs Irregular tumor near hilus of left lung; showed some fluctuation and on incision seemed composed of a num- ber of cavities with soft walls filled with thick, creamy greenish fluid. In right lower lobe a solid tumor size of a large orange, sur- rounded by a series of cavi- ties containing a purulent, viscid, greenish or chocolate colored fluid, which can in some places be lifted by the fingers in strings the size of a penholder. Atelectatic lung tissue around the tumor traversed by whitish bands Right pleura almost ob- literated ; slight yellow effu- sion in left. Right visceral pleura everywhere studded with nodules, whitish yellow. Nearly whole of right lung occupied by soft pulpy tu- mors; in the centre a large cavity formed by degener- ated tumor and filled with puriform material. All other organs healthy No details Both lungs from root to base and more anteriorly Medias- tinal and hilus lymph nodes; bodies of 2nd and 3rd vertebrae invaded by tumor ex- tending into canal and compressing cord Anterior mediasti- num, spleen In brain a multitude of small cavi- ties filled with green- ish or choco- late colored pus. All other organs healthy Medias- tinal and bronchial glands are filled with small round cells. Alveolar round celled sarcoma Small round celled sarcoma in part resem- bling lympho- sarcoma ; large round cells also. Sarcomatous lymphangitis Sarcoma Round and spindle celled sarcoma originating from conneC' tive tissue of septa and alveoles Bronchial glands Small round and 262 TABLE II 58 59 60 61 Chir., Milan, 1875, Vol. 231, p. 11-17 Moore, Lancet, 1890, II. p. 876 Pal, J. Jahrbuch der Wiener K.K. Krankenanstalt, III, 1894. Vienna, 1896, p. 545 Lymphosarkom der Lunge Pater et Rivet, Arch, de med. experi- mentale et d'anato- mie path. Vol. XVIII 1906, p. 85 Sur un Cas de Sarcome primitif du Poumon Pfrttz Diss.' Berlin, 1896 M M M M 10 21 26 38 LUNG IN- VOLVED R Both CLINICAL STMPTONS history obtainable; could not be examined. Death from suffocation Duration 4 months. Signs of pres- sure on recurrent laryngeal and sym- pathetic; left pulse absent; some fever. Constriction of left subclavian Well until 5 months ago. Suddenly severe pain in stomach, headaches, weakness, dizziness, constipation last- ing 3 or 4 days at a time, but ending in spontaneous evacuation. Pain in left chest, legs, and feet; some jaun- dice; pain all over abdomen. Later vomiting after almost every meal; then pain in right chest and about heart; some dyspnoea. No vomiting for 3 months, but all other complaints worse. On admission jaundice, some cyanosis; dulness from 3rd rib down- wards, merging into heart dulness; flatness posteriorly. Diminished frem- itus and breathing. Dilated veins over abdomen; Uver enlarged and tender. Increasing dulness over both lungs. Systolic murmur; accentua- ted 2nd sound. Apex beat to left of mammUlary line. Aspiration of both pleurEe withdrew bloody serum. Death 2 days after admission. Noth- ing said about cough or sputum Illness commenced with cough and loss of weight. Gradual swelling of numerous peripheral Ij'mph nodes. On admission harassing cough with dyspncea and cyanosis; hoarseness; enlarged lymph nodes everywhere. Paralysis of right vocal cord. Dulness at left base with rales. Some diar- rhoea. Rapid decline. Fever. Red cells 3,174,000; whites 8,370; poly- nuclears 71%; eosinophiles 0; lym- phocytes 9; transitionals 17. Clinical diagnosis: tuberculosis. Duration about 1 year Sudden onset with cough, pain in chest, dyspnoea, night sweats. Ca- chexia; slight fever. Swelling of neck, dislocation of larjmx; paralysis left vocal cord. CEdoema left chest; dilated veins. Dulness and diminished respiration over left chest. Aspira- tion clear serum. Needle enters hard tumor. Enlarged axillary glands. Duration of disease about 3 months S.IRCOMA 263 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE EEMAEK8 than posteriorly trans- enlarged; in spindle celled formed into soft pinkish tu- part cheesy sarcoma. mor adherent to pleura and and calcare- Pigment and diaphragm. Upper portion ous connective of both lungs interstitial tissue indu- fibrosis ration of rest of lung No details Nearly entire upper por- Pleura, Round and tion of left lung replaced by right lung, spindle celled whitish tumor mediastinal and inguinal lymph nodes sarcoma No details Right lower and middle lobes replaced by tumor lar- ger than child s head with only a trace of compressed lung tissue remaining at its peripherj\ The greater part of the tumor is hard; some places soft on section with round pigmented areas corresponding to bronchial glands, also here and there the lumen of a bronchus can be seen Both auri- cles, pericar- dium; head of pancreas, retroperito- neal lymph nodes; com- pression of lower cava by tumor No details No details Numerous tumor nodules _ Medias- Large Author claims origin at both bases; more in left tinal mesen- round celled from intra-alveolar teric. sarcoma tissue at left base. peripheral Numerous nodules in lymph liver shown to be nodes; tubercular, contain- nodes at ing bacilli hilus of liver Occasion- Lympho-sarcoma of left Bronchial, Lympho- ally bloody lung, bronchi, pleura, and mediastinum. Bronchiec- tases, purulent bronchitis, indurative pneumonia of left iung; (xdoema of right lung. Degeneration of left recur- rent ; myo- and endocarditis cervical, axillary lymph nodes; left auricle sarcoma 264 TABLE II 62 63 64 65 Log. cit. PiTOT, Arch, de Med. et de Pharm. MU., Vol.. 34, Paris, 1899, p. 306 Sarcome primitif du Poumon a Marche rapide Poison et Robin, Gaz. mfed. de Paris, 1856, No. 9 Quoted (from Fuchs) Tumor Fibroplastique du Poumon PoLACci E La Franca, Arch. Ital. de Med. Intern., Palermo, 1901, Vol. IV, fasc. 1-2, p. 408 Enorme Sarcoma primi- tive del Polmone con sintomi di pseudo mixedema M M M 53 20 30 55 LUNG IN- VOLVED R R CLINICAL SYMPTOMS No heredity. After some gastric disturbance anorexia, cough, pain in chest, night sweats, dyspnoea. Dimin- ished respiratory motion over right chest; posteriorly, flatness and dimin- ished voice and breathing. Aspira- tion: bloody serum. Tumor appears over right clavicle. Right chest be- comes retracted; stridorous respira- tion; club fingers. Aspirating needle now enters hard, firm tissue. Dura- tion about 1 year Tubercular family history. Always well. Cough since a month before admission. Looks well. On both lungs sonorous and sibilant _ rales. No dulness anywhere. No lesions in other organs. Diagnosis: bronchitis and grippe, which was then epidemic. No fever. Some weeks later dyspnoea; slight dulness middle of left lung behind. Dulness increases towards apex. Severe pain at left base. Later pleural effusion, heart displaced to right; fever. 800 c.c. of bloody serum aspirated. Patient feels better but physical signs persist. Diagnosis: tuberculosis. Repeated aspirations. Diilness increases in front and behind. Left chest measures 2 cm more than right. 900 c.c. greenish fluid aspirated. Left jugular thrombosed; cedoema of that side of face, neck, and shoulder. 2 more aspirations without result. Thrombosis popliteal vein. Death with intense dyspnoea and suffocation about 2 1 months after admission Cough, night sweats, dyspnoea, pain in left chest, emaciation. Later pleu- risy and signs of consolidation of left lung; cyanosis; intense asphjrxia. Duration about 6 months or over Disease began with swelling of right carotid, which gradually invaded right side of neck and upper part right chest; later left side also involved. Increas- ing difficulty in breathing and swallow- ing, dilated veins in chest and neck. Cough, pain in chest, nocturnal attacks of dyspnoea, cedoema of lower extrem- ities. Dulness over right chest below 3rd interspace; diminished voice and breathing ; from spine of scapula down- wards bronchial respiration ; absence of breathing at base. Left lung normal. Duration about 9 months SARCOMA 265 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE REMARKS Mucoid, no Tumor degeneration of Bronchial, Small round Origin probably tubercle right main bronchus, some- retrobron-_ celled sar- from small lymph bacilli, what in left bronchus and chial, cervi- coma retain- nodes within the lung later in trachea; at bifurcation cal, axillary ing alveolar straw- penetrates right upper lobe lymph structure of berry col- from hilus along bronchi. nodes, skin, lung due to ored con- Large bronchiectatic cavi- liver, and persistence of taining ties in lower lobe kidneys septa bronchial casts and great numbers of large round epithelial cells At first mu- Left lung almost entirely Tumor Round celled coid, replaced by large tumor size of sarcoma later everywhere adherent to cos- orange in bloody, tal pleura. Tumor softened liver with finally in some places and resem- cavity in typical bles brain substance; in centre con- "currant- other places grayish masses taining col- jelly," no traversed by bands of fibrous loid mate- tubercle tissue. No enlarged glands rial. All bacilli at hDus. Veins in left neck thrombosed and merged into nodulated tumor at base other organs healthy Repeated In the lumen of bronchi. No details Spindle celled hsemop- on surf ace of lung and in fibroplastic tyses lung tissue itself soft whitish encephaloid masses sarcoma No details Fluid in right pleura. Bronchial Round celled Heart dislocated to left. All lymph sarcoma of right lung except tip oc- nodes cupied by large nodulated tumor. Enlargement of right lobe of thyroid 266 TABLE II 66 67 68 69 70 71 POLLAK, Dis. Wiirzbtirg, 1897 Ein Fall von primarem Lungensarkom M 71 POOHB, The Lancet, London, 1895, I, p. 870 A Case of Tumor of the Lung Porter, British Med. Jour., 1885, II, 448 Powell, Brit. Med. Jour. 1879, p. 115 Sarcomatous Disease in- vading the Lung and Occluding its Bronchi Ranglahbt, Bull. Soc. Anat. de Paris, 1893, Vol. VII, p. 591 Sarcome primitif du Poumon Gauche Reymond, E. Bull, de la Soc. Anat. M M M M 20 LUNG IN- VOLVED R 39 Not stated 34 23 R CLINICAL SYMPTOMS Various tropical diseases. Death with symptoms of icterus gravis Quite healthy untU one morning on getting up sudden shortness of breath. Remained in bed for some weeks. Later, while walking, severe pain in back. Went to bed and then to hospital. SHght dyspnoea on exer- tion, slight cough. Left side impaired respiratory motion. Below 3rd rib absolute dulness. Absence of voice and breathing over this area; some bronchial breathing; similar condi- tions below. Heart dislocated to right. Aspiration negative. Left chest increased in size; swelling in left mammary region ; slight fever. Later oedoema of left chest; dilated veins. Small tumor over head of right humerus. Dulness extended over to right chest. No pain at any time. Duration about 4 months Dyspnoea, palpitation, cough. Pain, dysphagia. CEdcema feet and left forearm. Flatness upper left lung; dulness at base; feeble voice and breathing Haemoptysis of 2 weeks duration. Cough and haemoptysis recurred few months later. Jaundice. Dulness at base to spine of scapula and nipple with diminished voice and breathing, later extending over upper lobe. Pain in chest; intense dyspnoea No heredity. Pain in left chest. Pregnancy; normal labor. Continued pain; negative puncture. Later ex- pansion of left chest. Flatness and ab- sence of breathing sounds all over chest. Harassing cough. Dislocation of heart to right. Debility and emaciation. Dilatation of superficial veins. Qildce- ma of lower extremities. Bloody fluid in left pleura. Diagnosis made during life. Duration about 16 months Sudden onset after "cold" with dyspnoea, severe pains in left shoulder SARCOMA 267 AUTOPSY NOTES METASTASES MICROSCOPE No details Scant, once or twice bloody Bloody Mostly bloody Mucoid and bloody, haemop- tysis Bloody, no tubercle From root of right lung and extending along bron- chial ramifications, medul- lary infiltration, particu- larly of the alveolar septa; compression of bronchi and blood vessels Whole of left chest filled with soft growth covered by thickened pleura firmly ad- herent to chest wall. Upper anterior portion of tumor covered by shell of collapsed lung Liver and lymph nodes of lig. hepatoduo denale Large tumor occupying entire left upper lobe, and enveloping root, transverse aorta, left carotid and sub- clavian. Pneumonia in lower lobe Large lymphomatous growth in posterior medias- tinum occupying bifurcation and extending into lung, in- volving two lower bronchi and completely occluding the lower one. Middle lobe entirely occupied by tumor. Bronchiectases in lower lobe Left lung totally replaced by soft encephaloid tumor with cavities containing bloody and greenish con- tents. Right lung normal Nearly whole of left lung converted into large tumor Right lung, mediastinal lymph nodes, liver and over humerus and scapula No details Liver, left kidney and peritoneal lymph glands Absolutely none any- where Glands at hilus only Round celled sarcoma pro liferating mainly in the fibrous tissue of the intra- lobular and intra-alveolar septa of the smaller bronchi Round celled sarcoma Round celled sarcoma Lympho-sar- coma Spindle celled sarcoma Spindle celled sarcoma; no 268 TABLE II de Paris, 1893, VIII, p. 256 Sarcome primitif Poumon Gauche Vol du 72 ROLLESTON, H. D. Transact. Path. Soc of London, 1891, p. 54 Myxo-sarcoma of Lung 73 74 75 RoLLESTON & Trevor, British Med. Jour., Feb. 14, 1903 Primary Sarcoma of the Lung Roth, Ludwig, .. Diss. Miinchen, 1904 Uber primares Lun- gensarkom, etc. Rttetimeyer, Corresp.-blatt fiir Schweizer Arzte, 1886, XVI, 169-199 M LUNG IN- VOLVED 33 M 13 45 28 R CLINICAL SYMPTOMS radiating into arm and fingers. Im- proved for a time, but symptoms re-ap- peared with loss of flesh and haemopty- sis. Examination then showed nothing but slight pericardial friction. Clinical diagnosis at that time: rheumatism with dry pericarditis. Later increas- ing pain, slight fever. Bulging of left chest; heart dislocated to right. Flat- ness from left clavicle downwards; diminution of breathing sounds. Re- peated cultures negative. Heart sounds heard clearly all over left chest. Blood normal. Fever up to 104. Duration about 5 months No clinical history except that paracentesis of thorax gave mucous fluid Recurrent pains in right chest and all symptoms of empyema. Aspira- tion at first negative; later small amount of bloody fluid. Resection of rib showed solid growth Always well. December, 1902, pain in chest and cough. Got better, but had renewed attack in Jan., 1903. Never quite well since then. In beginning of May, 1903, severe pain in chest and back; impossible to walk upright. While walking sudden feel- ing as if something burst in his ab- domen. Signs of paralysis after that. On admission 10th to 12th thoracic vertebrse very tender; to the left of their spines a fluctuating tumor presents size of the palm of the hand. Flatness over entire right apex. Rales over both lungs. Clinical diagnosis: tuberculosis of lungs and spine. Later puncture of abscess. Rapid decline, intense dyspnoea. Pains in both legs; emaciation; death No heredity. Sudden onset with pain in side and moderate fever. Pain disappears; some dyspncsa remains; dry cough. Chills and fever; dulness over left base. Exploratory puncture SARCOMA 269 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE EEMARK8 bacilli filling greater part of chest. Some remnants of lung tis- sue under pleura. Cavity in centre of tumor contains large amount of fresh blood remnants of pulmonary structure No details Left lower lobe completely Bronchial Small celled occupied by a mass of new glands; 8th, myxosarcoma growth almost completely 9th and 10th replacing lung tissue. Upper left ribs lobe compressed and infil- trated with new growth in its lower parts. Parts of the tumor calcified; honey- combed in parts with cysts containing gum-like fluid consisting chemically of al- bumin and mucin. The tumor projects into pericar- dial- cavity No details Whole right lung except apex converted into soft gruel-like growth with hsem- orrhagic areas None Spindle celled sarcoma Bloody sev- Right lung adherent. Ne- Peribron- Alveolar Author designates eral oplasm size of a fist in right chial glands structure ; the tumor as a small weeks upper lobe. Pneumonic in- stroma of fi- round celled sarcoma before filtration of lower lobe. brous_ strands probably originating death Bronchi infiltrated with tumor. Tumor almost com- pletely replaces lung tissue containing dilated and congested blood vessels. Tumor con- sists of small round cells with large nuclei and small proto- plasmatic bodies. Walls of alveoles lined with similar cells. Large areas of tumor ne- crotic in lung itself Green, later Whole left lower lobe None any- Small round Origin from lung severe practically one large tumor where and spindle tissue itself haemop- surrounded by thin layer of celled sar- tysis compressed lung tissue. Bronchi normal coma 270 TABLE II NO. AUTHOR SEX AGE LUNG IN- VOLVED CLINICAL SYMPTOMS negative. Later flatness with absence of voice and breathing over left base. CUnical diagnosis: encapsulated em- pyema. Rib resection showed soft, reddish tumor masses in lung. Dura- tion about 2 years 76 Sangalli, Gaz. med. Lombarde, 1897, p. 226 Osservazione sul Sar- coma della Pleure e dei Polmoni M 49 Both Increasing dyspnoea 77 Loc. CIT. M 61 R Clinical diagnosis: right pleurisy with effusion. Aspiration negative. Increasing cough, dyspnoea, dysphagia. Bougie in oesophagus showed nothing 78 SCHECH, Virch. Arch. f. klin. Med., Vol. 47, 1891, p. 411 Das primare Lungen- sarkom M 57 R Acute onset with profuse haemop- tysis. Nothing found on lungs. Repeated severe hsemoptyses. Year and half later slight dulness, dimin- ished fremitus and absence of breath- ing over right base. Some rales. Embolism was suspected. No dysp- noea, fever, pain, or emaciation. Repeated hgemorrhages. Year later dyspnoea, intense pain, cough. Grad- ually complete paralysis up to mam- miUary line. Increase of dulness over entire right chest. Duration of dis- ease at least 3 years 79 SCHNICK, Diss. Greifswald, 1899 Ein Fall von primarem Spindelzellensarkom der Lungen gepaart mit Tuberkulose M 36 R 3 weeks before admission bloody sputum and pain in right chest. In- creasing dyspnoea and weakness. Phys- ical signs of tuberculosis in both apices. Hectic fever. Dulness over upper portion right chest; loud vesic- ular breathing; rales 80 Shewen, Austral, med. Gaz., 1885, Vol. IV, p. 81 Case of Sarcoma of Left Lung involving the Diaphragm and the Spleen M 31 L Chill and congestion of lung; never quite well after. Gradually dyspnoea, enlargement of left chest. Dilated veins; heart displaced to right. Dul- ness with absence of voice and breath- ing over left chest. No cough, _ no fever, no pain. Aspiration negative. Tumor diagnosed during life. Dura- tion of disease between 2 and 3 years 81 SiLVA, Gaz. degli Ospidali e M 63 L No heredity; no lues. Illness be- gan 7 months ago with difficulty in SARCOMA 271 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE EEMAHKS No details Numerous nodules in both lungs, more in right, often confluent and merging into large masses No details Round celled sarcoma with calcification No details Old tuberculosis of left Bronchial Round celled apex; numerous larger and and medias- fibro-sarcoma smaller nodules throughout tinal lymph right lung, also strips of in- nodes and filtration of white tumor oesophagus throughout lung. Tumor proliferates into wall of oesophagus. Tumor masses surround and compress de- scending aorta, oesophagus, both bronchi, and right auricle Purulent, Bloody fluid in right Spleen; Round celled green pleura. Almost entire right lung converted into firm white tumor mass enclosing cavities filled with necrotic material. Left lung normal pleura. Brain and cord not examined fibro-sarcoma Profuse, Fresh endocarditis. Tu- None Typical muco- berculosis of both lungs. In spindle celled purulent, right middle lobe a large sarcoma occasion- tumor, encapsulated and ally containing a cavity filled bloody ; with degenerated tumor ma- contains terial ; in part chalky degen- tubercle eration; numerous tubercle bacilli bacflli No details Left chest entirely occu- Diaphragm Small round Origin from bron- pied by tumor of left lung and spleen celled sar- chial glands displacing heart and com- coma pressing right lung Tenacious, Bloody fluid in left pleura. No details No details bloody, Nearly whole of left lung 272 TABLE II 82 83 84 della cliniche Milana, XXIII, 1902, seria 11, p. 1236 Sul Sarcoma primario del Pulmone Smith, W. G. Dublin Jour. Science, 1881, 72, p. 452 Med. Vol, SPILLMAJm AND HaUS- HALTER, Gaz. Hebd., 1891, p. 587 Du Diagnostic des Tu- meurs malignes du Poumon Steell, Geaham, Lancet, 1894, I. p. 388, Clinical Lecture on Case of Tumor of Lung M M M 'LUNG IN- I VOLVED Not stated 42 45 85 Sutton, Lancet, 1869, I, p. 459 11 R R CLINICAL SYMPTOMS swallowing. For 1 month icterus and mUk diet. For 5 months severe cough; no fever. Some nausea, but rarely vomiting. Severe pain in epigastrium and behind sternum radi- ating to left chest and shoulder. On admission much emaciation. Im- paired respiratory motion of left chest; flatness over whole left chest except shght space at base. All over flat area absence of breathing and frem- itus. Oesophageal sound finds resist- ance 32 cm. from teeth. Puncture jaelds only a few drops of blood; needle enters hard, firm tumor mass. Gradual decline; intensest dyspncsa, cyanosis. Slight fever. Clinical diag- nosis: primary sarcoma of lung Pleurisy of right side 2 1 years before. Since then never quite himself ; breath- ing always short. Later principally cerebral sjonptoms, paralysis,_ etc., due to haemorrhage and softening in pons. 4 or 5 weeks before death haemoptysis, cough. Dulness below _ht clavicle extending downwards; complete absence of breathing sounds. Later temperature to 102. Later complete dulness of entire right chest. Excessive sweating; foetid breath. Duration of illness from development of paralysis, 3 months Occasional pain in left chest; biil- gmg of entire left chest. Irregular areas of dulness increasing to flatness; absence of voice and breathing. Emaciation and sweating. Various symptoms referable to the heart. No dyspnoea; no cough. Duration of disease about 2 years Good health until haemoptysis, followed by failure of health. No cough, no expectoration, and no physical signs on lungs for months. Later much pain in right chest and large quantities of putrid expectora- tion as from ca\dties. Upper right chest fuller than left; impaired res- piratory motion. Absolute flatness o f upper right lobe with later de- velopment of tympanitic sounds and other signs of cavity. Dilatation of veins of upper right arm and right chest. Slight temperature shortly be- fore death Cyanosis, dyspncea. Absolute flat- ness and absence of breathing sounds throughout left chest. Heart dis- SARCOMA 273 no tuber- cle bacilli transformed into hard, dark, greenish tumor mass Repeated haemop- tysis None AUTOPSY NOTES Right lung adherent. En capsulated empyema with putrid pus. Upper | of lung converted into lobulated tumor separated by highly pigmented septa. Lower third completely gangrenous None at first, later abun- dant, ex- tremely foetid. No micro- scopic ex- amina- tion No details Large tumor filling nearly all of left chest dislocating heart to right and pushing diaphragm downward. Ori gin of tumor right upper lobe. Peripheral areas of tumor surround a cyst-like central mass; entire central mass surrounded by com pressed lung tissue Both pleurae adherent. Right pleura practically ob- literated; no effusion. Large cavity in right upper lobe with irregular soft walls of grayish-white tumor. Tu mor size of a small orange projects into cavity. Only slight traces of lung tissue remain in upper lobe Medullary cancer occupy- ing entire left chest. " Left lung collapsed, pushed back- METASTASES Mediastinal lymph nodes None None; not even in mid- dle and low- er right lobe MICROSCOPE Small round celled sar- coma Cystic fibro-sarcoma Simply said to be lympho- sarcoma None No details 19 274 TABLE II 86 87 A Case of Medullary Cancer of Lung simu lating Pleuritic Effu- sion Vandervelde, Paul, Jour, de Med. Chir. et Pharm. Bruxelles, Vol. 94, 1892, p. 193 Un Cas de Sarcome en- cephaloide primitif du Poumon, etc. Walch, Bull, de la Soc. Anat. 1893, p. 90 Cancer du Poumon gauche; generaliza- tion; Pleuresie puru- lente h pneumoco- ques Weiss, Miinch. med. "Woch., 1895, p. 790 Zwei gleichzeitig beo bachtete Falle von bosartiger Neubil- dung in den Lungen resp. Mediastinum anticum White, W. Hale, Transact. London M M 23 30 65 37 LUNG IN- VOLVED R Both CLINICAL SYMPTOMS located to right. Right chest smaller in circumference than left. First puncture, a little dark blood; second "something hke pus." Tubercular family history. About 2 years before admission pleuro- pneumonia; in bed 5 weeks; never entirely well since then. Attacks of profound dyspnoea at short intervals; pain in right chest. 6 months before admission a tumor was noticed in right chest, growing rapidly and causing much pain. On admission loss of appetite; no cough; no expectora- tion. Pain in chest; much oppres- sion. Soft fluctuating tumor of 6th to 8th ribs covered by healthy skin. Probatory puncture recovers a few drops of thick, grayish-yellow fluid containing numerous sarcoma cells. Most of the lung had undergone mucoid degeneration; no tubercle bacilli. Tumor was removed by operation and pedicle was found pro- jecting into pleural cavity. Both leaves of the pleura were adherent to tumor, allowing it to be removed without opening the pleural cav- ity. Uneventful recovery. Patient re-enters hospital about 6 months later with emaciation, anorexia, night sweats, intense dyspnoea, haras- sing cough. Almost no respiratory movement of right chest; flatness; rales Disease commenced with pleurisy; never well since then. Intense dysp- noea; pain in left chest. Spells of coughing, loss of flesh; dulness over left chest; loss of breathing and frem- itus. Other organs normal. Tem- perature up to] 104. Profuse night sweats. Aspiration yields pus. Oper- ation :_ very slight quantity pus, which contains pneumococci in pure cul- ture. Fever remains after operation. Entire clinical picture dominated by empyema Always healthy. Much cough; mu- cous rales over both lungs, but no dulness. Rapid loss of weight and strength. Continuous high fever. Small tumor above left clavicle, others in left axilla, right inguinal fold and below clavicle. Spleen much enlarged and hard. Death in coma. Clinical diagnosis: acute miliary tuberculosis. Duration not quite 2 months Loss of appetite, flesh, and strength. Pain, dyspnoea, dysphagia. Aspira- SARCOMA 275 AUTOPSY NOTES METASTASES MICROSCOPE Purulent, often bloody, no tuber- cle bacilli wards and spread out over cancerous mass " Scar infiltrated with tu- mor and adherent to right lung. Whole right lung re- placed almost entirely by soft yellowish tumor. Lung tissue compressed and stud- ded with tumor nodules. In centre a cavity containing blood and detritus Bronchial glands and resected ribs Operated tumor shows: alveolar structure ; small round celled sar- coma with mucoid de- generation; no epithelial or giant cells After careful search and study of all other organs, tumor was pronounced primary in lung No details Entire left lung trans- formed into firm tumor ad- herent to chest wall Bronchial IjTnph nodes, peri- cardium, right lung, liver Medullary sarcoma Repeated haemop- tyses, no tubercle bacilli Both lungs studded with sarcoma nodules, especially left upper lobe, surrounding bronchi and proliferating into their lumen Various lymph nodes, liver Several hse- moptyses Left bronchus completely surrounded and obstructed Left recur- rent laryn- Round celled sarcoma Doubtful if primary in lung 276 TABLE II NO. AUTHOR SEX AGE LTJNQ IN- VOLVED CLINICAL SYMPTOMS Path. See, Vol. 44, tion: bloody fluid from left pleura. 1893, p. 14 Dilated veins over left chest. Heart dulness extended to right. Difference in pupils. Duration of disease about 9 months 90 WiLKS, Trans. London Path. Soc, Vol. IX, 1857, p. 31 Fibrocelliilar Growth of the Lung M 46 L Dyspnoea, dulness over left chest. Dropsy SARCOMA 277 No details AUTOPSY NOTES by tumor; infiltration of left upper lobe; portion of lung gangrenous. Tximor com- municates with small growth behind left sternocleido muscle. Compression of pul- monary artery, veins, and aorta by tumor. Aorta and oesophagus ulcerated and perforated by gangrene Tumor occupied nearly whole of left chest, destroy- ing lower part, compressing upper of lung. Root not affected but adherent to chest wall METASTASES geal nerve Posterior mediastinal glands MICEOSCOPE Fibro-sar- coma, long nucleated fibres with nucleated ceUs inter- spersed, in some parts very rich ii round cells Author remarks that in appearance and behavior it re- sembles more the non-malignant than the malignant type 278 TABLE III Adam, G. R. Glasgow Med. Jour. 1879, pp. 31-37 Log. cit. Adams, London Path. Soc, 1848-50, II, pp. 174- 177 Ad AMI, Montreal Med. Jour., Vol. XXIV, 1895, p. 510 A Case of Malignant Intrabronchial Growth Associated with a Misleading Train of Symptoms AVIOLAT, Th^se de Paris, 1861 Du Cancer du Poumon. Bennett, J. Risdon, Intrathoracic Growths London, 1872 Bernard et Vermorel Bull, de la Soc. Anat. de Paris, 1894, pp. 251-253 Cancer du Poumon avec ^panchement pleural sero-sanguinolent M M M 25 20 LUNG IN- VOLVED 25 60 30 36 44 Both R Both R CLINICAL SYMPTOMS Pain in chest and dyspnoea for 15 months. Dulness from right apex to nipple; absence of breathing sounds Cough, dyspoena, pain in left chest; deficient respiration; no vocal frem- itus. Dulness from clavicle to 5th rib. Left chest half inch more in circumfer- ence than right. Later aphonia and dysphagia No symptoms until 2 weeks before admission, then dyspncBa and slight cough; later cyanosis. Small tumor below right clavicle Died 4 hours after admission. One year before beheved to have incipient tuberculosis of right apex. Whole right side dull; cavernous breathing above; feeble breathing below. Clubbed fingers; cyanosis No heredity. Some pain, dyspnoea, increasing weakness. Brain symp- toms (strabismus, headache, formica- tion of arms, vomiting) at an early stage. Right lung normal. Dulness over left anterior chest with bronchial respiration. Later flatness with ab- sence of voice and breathing Cough, pain in left side; increasing emaciation and debility. Consider- able scoliosis No ascertainable heredity. For 6 years cough each winter with abund- ant expectoration. Dates sickness 4 months before admission, when increas- ing weakness and dyspnoea on slight exertion. On admission no marked loss of flesh; night sweats. No lesions anywhere except on lungs. Left lung DOUBTFUL 279 No expecto- ration, ^ ounce of blood at late stage White, never bloody Scant Yellowish, mucopu- rulent Not men- tioned None; no haemop- tysis Scant, mu- copuru- lent; at times pink. No tubercle bacilli AUTOPSY NOTES Cancer nodules through- out entire right lung Upper part of left lung occupied by nodular mass extending up to thyroid, enclosing aorta and roots of cervical vessels. Heart dis- placed to middle line Both lungs studded with spherical, well demarcated tumors of all sizes. Upper cava compressed. No effu Lobular consolidation at left base; purulent bronchi- tis. Right lung adherent; interstitial pneumonia of up per lobes and bronchiectasis. No signs of tuberculosis Right lower lobe completely collapsed and adherent to diaphragm. Saccular dila- tation of left main bronchus which is obstructed by large soft tumor proliferating up ward into the bronchus and obstructing it Several cystic tumors in the brain. Clear serum in left pleura. Upper left lobe and its bronchi a mass of nodulated tumor Both pleurae adherent. Right lung large; left small and misshapen on account of scoliosis. Both lungs studded with grayish white tumors. Both lungs dis- tinct and diffuse cancerous infiltration. Lung tissue between infiltrated portions normal METASTASES Glands of thorax Sanguinolent effusion in right pleura. Lung com- pressed upward. Large tu- mor in upper mediastinum, white and hard, extending slightly to left, but main bulk in right chest; tumor has replaced greater part of Lymph nodes of neck and mediasti- num ; both kidneys and right supra- renal Bronchial and cervical lymph nodes and liver Peribron- chial lymph nodes MICROSCOPE Not given Not given Author calls it "Fungus haematodes" Alveolar structure that resem- bles carci- noma; many cells like sar- coma None Liver Bronchial lymph nodes. No other metas- tases any- where Not given No details Adami is inclined to call it sarcoma Possibly sarcoma Author simply states that the tumor Not recorded Probably carci- noma 280 TABLE III NO. AUTHOR SEX AGE LUNG IN- VOLVED CLINICAL SYMPTOMS healthy except some moist rales. Right chest immobile on respiration and all signs of pleural effusion. Aspiration, 1800 c.c. yellow serum. Dyspnoea im- proved but dulness remained all over upper right lung. Tumor of lung ia suspected in spite of good appetite. lack of cachexia and non-characteristic sputum. Sudden attack of intense dyspnoea; probatory puncture in upper lobe seems to enter solid tumor. OEdoema of lungs. Death 8 BiBBBATTM, Preusa. Vereinszeit., N. F., V, 31, 1862 (after Reinhard) M 25 L Pain in left hypochondrium ; harass- ing dyspnoea; no cough. Left chest dilated; some dulness; normal auscul- tation, ffidoema of feet and hands 9 BOUILLAXTD, Jour. comp. du Die. des Sciences Med., 1826, Vol. 25, p. 289 Observations sur le Cancer des Poumons F 29 L Over 3 months in hospital but chest not examined as patient was in sur- gical ward. Dry cough, rapid maras- mus, hectic fever. Swelling, supposed to be cancerous, of right lachrymal gland 10 Bricheteau, Gaz. des Hopit. de Paris, 1833, VII, p. 281 D6gen6rescence squir- rheuse de la presque totality d'un Poumon etc. M 35 L When admitted to hospital was so weak he could not be examined. Ex- treme emaciation; high fever; en- larged left axillary glands. Hard tumor over left clavicle. Dulness over left chest. Clinical diagnosis: acute phthisis 11 BUDD, London Medico-Chir. Trans., 1859, Vol. XLII, p. 215 On Some of the Effects of Primary Cancerous Tumors within the Chest M 31 R Good health until attack of pneu- monia in right lower lobe; since then short breathing; later pain in lower, right chest. Gradual loss of strength, cough, dulness and inaudible respira- tory murmur over lower right chest. Later cedcema of right chest and face; enlargement of superficial veins; fric- tion over precordial region; intense dyspnoea; purpuric spots. Enormous enlargement of veins over right chest and belly. Duration of disease about 2 years 12 Loc. CIT. M 20 R Always well. After a cold, pain in right chest posteriorly, later anteriorly. After a week well, then cedcematous. Dilatation of veins of chest and epi- gastrium. Dyspnoea, hoarseness, cough ; later vomiting. Fever, intense dyspnoea; death. Duration about 6 months DOUBTFUL 281 Frothy mu cus tinged with blood. Later greenish pus AUTOPSY NOTES right upper lobe and envel- ops origin of anterior me- diastinum, trachea, arch of aorta, and both pneumogas- trics, proliferating slightly into trachea at bifurcation. Left lung healthy Entire left lung converted into medullary tumor except small portion at apex. Pleura adherent. Right lung displaced Upper left lobe almost completely converted into whitish tumor. No ulcera- tion; no cavity. "Cancer- ous polypi" in posterior nares Right lung normal. En- tire left lung transformed into a hard, bluish, marbled tumor showing no remnants of pulmonary structure; no softening, no suppuration, no ulceration. Tumor ad- herent to pleura in upper portion. Yellow serum in pleura. All other organs normal Lower part of right chest occupied by a white can- cerous mass; extending to mediastinum; tip on level with clavicle. Penetrates upper cava, projects into right auricle enclosing root of lung. Large bronchi pen- etrated by tumor and nar- rowed but not closed. Large bronchiectatic cavity filled with pus in upper lobe Pericarditis Firm, nodular, yellowish white tumor in mediastinum, penetrating into right lung. Upper cava, right innom- inate vein and part of left involved in tumor, which also projects into pericar- dium. Tumor penetrates trachea ^ inch above bifur- cation and down right main bronchus. Small nodule in left bronchus METASTASES Right lung and liver No others None No others mentioned Bronchial and tracheal glands MICROSCOPE Not men- tioned Not given Not given No details None given Probably sarcoma Probably sarcoma Doubtful whether bronchial carcinoma or sarcoma Probably primary in mediastinum and sarcoma 282 TABLE III 13 14 15 16 17 Bttdd, Loc. cit. BUREAIT, Bull, de la Soc. Anat. de Paris, V, Serie 10, 1896, p. 26 Tumeur de hile du Pou- mon droit. Pleuresie droit BlTRROWS, Med. Chirurg. Trans., 1844 Cannstatt, Hannover. Annalen fiir die gesammte Heilkunde, Vol. V, .. 1840, p. 433 Ahren-lese au3 der Praxis Chahteris, M. Lancet, 1874, I, p. 126 On Intrathoracic Cancer M M M 63 68 20 22 44 LUNG IN- VOLVED R R R Both CLINICAL SYMPTOMS Always well. Illness commenced with cough, shortness of breath. 3 weeks before admission swelling of face; no pain. Dulness and diminished voice and breathing over greater part right chest in front. Heart sounds are heard loud over the dull area of right chest. Dilated veins over chest on both sides. Increasing oedcema of chest, face, and arms. Intense dyspnoea. Death from asphyxia. Duration about 7 months For some years always aware of some trouble in chest. Frequent attacks of bronchitis and strong op- pression on climbing or walking briskly. No palpitation, but violent pains behind sternum. Diagnosis of angina pectoris was made, for which she was treated in hospital. Improved and for some years the attacks of pain and oppression disappeared entirely. A few days before admission to the hospital while on train to Paris, sudden chill and violent pain in right chest. On admission flatness at the right base, loss of fremitus, faint distant breath- ing. All other organs normal. No cyanosis, no oedcema ; no cardiac symp- toms. Later slight rise of temperature. Aspiration dark yellow serum. Rapid refilling of chest. Three punctures with increasing amount of serum. Notwith- standing punctures dyspnoea increases to most intense orthopnoea. Suddenly hsemopytsis and death. Duration of the acute stage only a few months First symptoms 6 months before ad- mission, then pain under sternum, cough and loss of appetite. Better for a time, then dyspnoea, emaciation, and sweat- ing. Dulness on upper right chest, in- creasing to flatness. Feeble bronchial respiration. CEdcema of face, right hand, and arm. Duration of disease a little more than 6 months Profuse hsemoptyses. No pain. Dulness over left chest; pectoriloquy For 3 months hoarseness, vomiting of food and blood ; loss of weight, increas- ing weakness. On admission cough, dyspnoea, dysphagia, persistent vomit- ing. Rales all over chest. Posteriorly dulness at angle of right scapula. Par- alysis of left vocal cord. Death after increasing dyspnoea and weakness DOUBTFUL 283 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE BEMABKS Bloody; profuse hajmor- rhage Serous fluid in right pleura. Whole of right upper lobe converted into solid white tumor included in enormous- ly thickened pleura. Below right main bronchus a scir- rhous mass, size of a small apple invading but not con- stricting bronchus, com- pressing upper cava. Few nodules in left upper lobe Left lung bronchial glands None Origin probably in bronchial glands. Possibly sarcoma, but probably bronchial carcinoma Haemopty- sis Abundant fluid in right chest. White, very hard tumor at root of right lung adherent to pericardium. The lung is of the size of 2 fists, and the tumor starting from the hilus penetrates deeply into the lung tissue. Right main bronchus com- pletely obstructed Tracheal and bron- chial lymph nodes None given Difficult to say whether we have to deal here with sar- coma or carcinoma. It is probably carci- noma Haemopty- sis and currant jell5' ex- pectora- tion Right chest larger than left. 2000 c.c. brown fluid in right pleura._ White, lob- ulated tumor in lower and middle lobes. Bronchiec- tatic abscesses. Compression of right pulmonary veins, right carotid, and internal carotid Cervical, axillary, and mediastinal lymph nodes None given Author calls the growth cancer. It is probably sarcoma Profuse, foul, pu- trid. Profuse haemop- tysea In left lung cavity larger than man's fist, the walls of which are thickened and made up of scirrhous mate- rial Bronchial glands Not men- tioned Foamy, abundant Tumor at bifurcation branching into bronchi of both lungs, especially right. Involvement and compres- sion of oesophagus. Left re- current laryngeal also in- volved Not men- tioned Numerous round cells surrounded by vascular connective tissue Probably Barcoma. LA. 284 TABLE III 18 19 20 21 22 Clark, A. Lancet, 1856 Cockle, Association Med. Jour., London, 1854, p. 990 De Boter, H. Le Progres. Med., Ill, 1875, p. 87 Adenopathie bron- chique Cancereuse De Renzi, La Riforma Med Napoli, XIV, 1898, Vol. I, p. 747 Un Caso di Carcinome del Polmone De Valcourt, Revue Med., Ill, XVIII, 1874, 723 Press. Med. Beige, Bruxelles, 1874, Ann. 26, p. 406 Cancer pulmonaire, compression, etc. M M M M 22 64 25 55 25 LTJNG IN- VOLVED R Both Both R CLINICAL SYMPTOMS Clinical signs of pulmonary phthisis. Night sweats; diarrhoea Laryngeal cough, hoarseness, dysp- noea, dysphagia, fever. Follicular affection of throat. No signs on lungs Testicle removed for suppuration two years before admission; thereafter legs became swollen and painful; dysp- noea on walking; chronic bronchitis. Loss of weight and strength, hoarseness, night sweats. Examination on admis- sion revealed a hard gland, size of a hazel nut, in left supraclavicular region. Dul- ness over sternum and posteriorly be- tween scapulae. On right side anteriorly, distinct murmur-like sounds simulating aneurysm, also faint rales. Over area corresponding to tracheal bifurcation bronchial breathing. Cough character- ized by whoop. Dysphagia, aphonia, slight albuminuria. Death during an at- tack of dyspnoea 13 days after admis- sion, glands having rapidly increased in size. Diagnosis: tuberculosis of bron- chial glands For 2 years cough; 8 months pain in left shoiilder (patient was accustomed to carrying heavy loads on left shoulder and continued to do it notwithstanding the pain). For 3 months hoarseness, loss of strength and weight, harassing cough. On admission left supra- and infra-clavicular fossse are abolished and bulging so that left clavicle is hardly visible. Bulging occupies nearly all of left shoulder and supraspinous region, extending down to interscapular space to left of vertebral column. Over all the swollen region dilated superficial veins, impaired respiratory motion. Dulness and diminished respiration and fremitus over all this region. Left supraclavicular, axillary, and inguinal glands enlarged. No fever. Paralysis of left recurrent laryngeal. Intense pain from left shoulder through arm. Blood examination showed very moderate secondary anaemia; no leu- cocytosis. All other organs healthy Dyspnoea, cachexia, complete apho- nia, cyanosis, dysphagia. Left thorax depressed, right increased in volume; dulness throughout; diminished breath- ing. Tracheotomy to relieve dyspnoea DOUBTFUL 285 Haemopty- sis Purulent, blood- stained Foamy, mucous, streaked with blood AUTOPSY NOTES Scant, mu- copuru- lent, con- tains no tubercle bacilli Mucoid Tumor in upper part right lung extending into lung from periphery. Bronchi filled with cancer cells Both lungs studded with nodules. Softening and cav' ity in upper left lobe. Su- perficial ulcer in larynx Both lungs medullary nodules; at base of both lungs small subpleural nod- ules. Bronchial glands en- larged and fill entire medi- astinum, compressing aorta, thoracic duct, vena cava METASTASES No details given. Stated 'Diagnosis confirmed" Enormous right lung that had dislocated heart to- ward left. Right lung lar- daceous, semi-transparent, and hard. Compression right bronchus Not men- tioned Mediasti- nal lymph nodes Liver, ret roperitoneal glands; bal ance men- tioned under autopsy MICBOSCOPE No details Liver, tra- cheal and bronchial lymph nodes Not men- tioned No details Not given Possibly sarcoma (?) Tumor is called en- cephaloid cancer No details Not given Possibly sarcoma 286 TABLE III NO. ATJTHOB S£X AGE LUNG IN- VOLVED CLINICAL SYMPTOMS 23 DOMBROWSKI, Jahresbericht der Schles. Gesellsch. fiir Vaterl. Cult., 1901. Breslau, 1902, p. 115 Ein Fall von Tximor der linken Lunge F 50 L Always weU until one month before admission, then pain in left chest, cough, dyspncsa. Impaired respiration left upper chest; bulging left supra- clavicular region. Left breast larger than right; small hard glands in both axillae. Dulness descends from above left clavicle, merges into heart dulness, extends into axilla and posteriorly to 4th thoracic vertebra. Absence of breathing over dull area; later faint vesicular breathing. X-ray showed deep shadow over left upper lobe. Clinical diagnosis: tumor of left lung 24 Elliot, British Med. Jour., April, 1874 F 28 R Pain in right chest; complete flat- ness; absence of breathing, dyspnoea, harassing cough. Duration 7 months 25 Fagqe, Trans. London Path. Soc, 1867, XVIII, pp. 29-31 Disseminated Primary Cancer of Lungs M 50 Both Orthopnoea, cough, debiHty. Dul- ness, slight bronchophony and sibilant rgiles at base of each lung posteriorly, especially left. CEdoema of legs. Sud- den death 26 FUCHS, Diss. Miinchen, Beitrage zur Kennt- niss der primaren Geschwtilstbildungen in der Lunge F 83 L No clinical history 27 LOC. GIT. F 56 R Diagnosed during life as pleurisy and later as empyema 28 Gat, Boston Med. & Surg. Jour. Vol. 94, p. 6 Encephaloid Cancer of Lungs M 57 L Difficulty in respiration, cough, in- creasing dyspnoea. Loss of strength. Pain in region of liver. Cough sub- sides; dyspnoea increases. Dulness over left base increasing to flatness all over left chest except at apex. Aspiration, at first clear yellow fluid; later bloody. Duration of disease about one year 29 Gordon, Dublin Hospital Gaz. 1854-5, I, 94 Malignant Tumor in Apex of Right Lung M 32 R Cough, pain in right chest, cyanosis, dyspnoea. Dulness and feeble breath- ing over right apex. Later swollen glands above clavicle. Paralysis and oedcema of right hand. Right side of face swollen. Purpuric spots fol- lowed by gangrene in cEdoematoua portion. Duration about 4 years DOUBTFUL 287 AUTOPSY NOTE3 METASTASES MICROSCOPE Bloody, raspberry jelly; no tubercle bacilli None No details Not given Fluid in right pleura. Al- most entire right lung con- verted into "cancer" Small node in right au- ricle and aorta Clear brown fluid in both Pericar pleurae. Both lungs studded jdium, right with cancerous deposits re- auricle, left sembUng tubercles Clear serum in left pleura. In left upper lobe a softened, difl'usely infiltrated area filled with greenish matter Fibrinous exudate in right pleura. Greater part of up- per right lobe converted into a soft lardaceous tumor Both lungs and pleura bronchial lymph nodes, and liver Sanguinolent fluid in left Bronchial chest. Lung compressed up- lymph ward and backward. Entire nodes, both pleural surface infiltrated lungs, kid- with encephaloid cancer, neys Left lung filled vsdth nod- ules; nodules also in right lung. Cancerous infiltra- tion of pleural lymphatics _ Small primary tumor in Subclavian right apex. Obliteration of Ij^mphatic subclavian vein; compres- nodes, liver sion of axillary artery and brachial plexus ventricle, Hver None No details No details Author says soft area is a cancerous in- filtration, consisting of spindle cells and large round epithe- lioid cells Not given No data given. Sim- ply called en- cephaloid can cer No data given Doubtful whether carcinoma or sarcoma Probably sarcoma Possibly sarcoma Primary seat of neoplasm probably in pleura 288 TABLE III ^u. AUTHOR SEX AGE VOLVED CLINICAL SYMPTOMS 30 Graves, London New Syden- ham Soc, 2d Edition, Vol. 2, p. 70 Clinical Lectures on the Practice of Medicine M 36 R Pain in right chest, cough, dyspncea, hoarseness. Later oedoema of face and neck; dilated veins. Dulness and tracheal respiration. Impaired mo- bility over all of right chest; no rales. Left chest normal. Heart sounds heard very distinctly over posterior aspect of right chest. Enlarged liver, jaundice; dysphagia, increasing dysp- noea and CEdcema. Secondary tumors on lower jaw, forehead, and near lum- bar spine 31 Green, Lancet, 1898, II, p. 1705 F 14 L Debility, dyspnoea, signs of consoli- dation of left lung and effusion into pleura. Enlarged glands above right clavicle 32 Greenwood, British Med. Jour., 1897, II, p. 1337 A Case of Pulmonary Carcinoma F 49 R For several weeks cough, dyspncea, swelling of face and neck. Hardly any air in right apex; tubular breath- ing left base in front. Improved for a short time, then increasing dyspncea and cough, pain down spine. Shortly before death tubular breathing right base; cedcema both legs. Duration a little over 6 months 33 Griffiths, Brit. Med. Jour., 1888, I, p. 647 Sarcoma of the Lung M 58 L Cough, emaciation, cyanosis, oedoe- ma of eyehds, dyspnoea. Absolute dul- ness, feeble motion and respiration over left chest. Aspiration negative. Diag- nosis of malignant tumor of lung made during Hfe. Duration about one year 34 Hafner, Med. Centralblatt, 38, 1852 M 20 R Cachexia, tumor of right clavicle; paralysis of right arm; radial pulse smaller on right than on left side. Dyspnoea, pain, dry cough, hoarseness, dulness over upper portion of right chest; dilated veins of neck and arm 35 Hanot, Arch. gen. de Med., 1877, Vol. I, Ser. 6, p. 29 Cancer primitif du Pou- mon et du Mediastin chez une femme de 78 ana F 78 L Always well. Dry cough for long time, worse for last few months; dyspnoea, pain in right chest. Alter- nating diarrhoea and constipation. On admission cachexia, weakness, dulness over whole of left chest. In upper portion distant breathing sounds; in- creased vocal fremitus; subcrepitant rales. At base of right lung rales and some friction with slight dulness. Heart pushed to the right. Later, oedcema of feet, dysphagia, delirium. Death from exhaustion about 3 weeks after admission DOUBTFUL 289 Scant, mU' coid, later bloody- Not given Purulent, blood- stained Mucopuru lent. No bacilli No details No details AUTOPSY NOTES Left lung normal; right lung a solid tumor with thin shell of lung tissue outside Tumor contains some cysts Entire left lung trans- formed into tumor, prob- ably starting from hilus. Entire mediastinum filled with tumor; imbedded aor- tic arch and large vessels Tumor size of cocoanut occupying middle and pos- terior mediastinum and ex- tending along root into right lung. All other organs healthy Tumor at root of left lung extending along bronchi and larger vessels, surrounds and compresses aorta, pulmon- ary vessels, and oesophagus. Compression of left main bronchus Effusion in right pleura; hard lobular tumor in upper part right lung. Compres- sion of trachea and superior cava Left pleural cavity filled with yellow serous fluid; lungs compressed; pleura red, thickened. Posterior mediastinum filled with large, hard, white tumor containing several soft, al- most fluctuating foci. Nod- ules as large as a pigeon's egg on trachea, directly un- der aorta; another mass under root of lung. (Esoph- agus compressed and adher- ent to tumor. Root of left lung surrounded by tumor; bronchus not compressed. Tumor in left lung consist- ing of 6 nodules extending downward and outward to METASTASES Mediasti- nal and mesenteric lymph nodes, lower jaw, cranial bones, and some verte- brae Not given Not given None Pleura, bronchial glands. No others MICEOSCOPE No data given No data given Not given Not given Alveolar structure with polyg- onal cells As no microscopic data are given it is difficult to tell whether sarcoma or carcinoma Probably sarcoma Possibly carcinoma 20 290 TABLE III 36 37 38 Harbitz, Norsk Mag. f. Lae- gevidenskaben, etc., 1903, Bd. 1, p. 727 Harris, Intrathoracic Growths. St. Bar- tholomew's Hosp. He ports. Vol. 28, 1892, p. 73 Heschl, Wiener Med. Wo- chenschr., 1877, No .. 17, p. 385 Uber ein Cylindrom der Lunge 39 M M Hetpelder, Arch. gen. de Med. 14, 2d S6rie, 1837, p. 345 DuCancer des Poumons LUNG IN- VOLVED 45 68 72 M R 24 CLINICAL SYMPTOMS Sick since childhood; more or less cough. Gradual increase of cough and dyspnoea. Pain in right chest. Lymphatic glands of neck swollen. Sonorous percussion sounds over both lungs. Prolonged expiration in front and behind Pain in left chest; dry cough, in- creasing dyspnoea and emaciation. Bulging of left chest ; absence of fremi- tus; displacement of heart to right. Aspiration 24 ounces. Pleura opened; foul discharge for a month. Death No clinical history Always well. Attack of pleurisy that yielded to treatment. Later inflammatory symptoms in chest — pain, dry cough. Left chest immov- able on respiration and dilated. Dul- ness; no voice or breathing; no heart sounds, right chest normal. Later large, hard, nodulated tumor on anterior surface of left chest. Cyano- sis; dyspnoea. Still later nodulated tumors on left clavicle, swelling of axillary glands; general dropsy DOUBTFUL 291 AUTOPSY NOTES smaller nodules. Left lower lobe catarrhal, colloid pneu- monia. Right lung soft and congested Bloody fluid in pericardial cavity with beginning mu- copurulent inflammation of pericardium. In posterior mediastinum enlarged lym- phatic glands, also hard, grayish, degenerating tu- mor. Bronchial glands and glands at root of lung en- larged. Tumor formation bronchial mucous mem- brane. Lungs emphysemat- ous but otherwise normal No autopsy 2000 CO. clear serum in right chest. Tumor occu pying almost entire right lower lobe; only small border of compressed lung tissue on upper periphery of tumor Tumor made up of soft and very hard and cartilaginous nodules Numerous tumors on wall of left chest. Left lung en- tirely transformed into one large tumor in which neither vessels nor bronchi can be recognized. Left main bronchus obliterated. Pul- monary artery and vein ob- literated, also left pleura. Superficial tumors commun- icate with internal tumors through intercostal spaces METASTASES Mediasti- nal and bronchial None Besides the axillarj' glands and superficial tumors on chest, no other metas- tases MICBOSCOPB Lympho- sarcoma with alveoli clothed with polygonal and polsonor- phous epithe- lial cells Superior and anterior nod- ules consist of round and spindle cells with abun- dant hyper- trophic elastic fibres. Pos- teriorly nod ules contain several con- cretions and some plate- lets of genu- ine bone, masses of elastic tissue between round and spindle cells and many pe- culiar colloid forms of vari- ous shapes No details Probably carci- noma of left lung and pleura Should be classed under sarcoma group Probably sarcoma 292 TABLE III 40 41 42 43 44 HODENPTL, Proceedings N. Y Path. Soc, 1895, p. 19 New Growths of the Lung, Mediastinal and Mesenteric -Glands, Liver and Stomach Hope, J. London, 1834, p. 45 Principles and Illustra- tions of Morbid Anat omy . Janewat, Medical Record, 1883, p. 215 Primary Sarcoma of Lung Jakobsohn, Deutsch. Med. Zeit- schr., 1897, p. 487 Sarkom der Lungen Jennings, Proceedings Path. Soc. of Dublin, 1867- 68, p. 291 M M M M M 43 25 56 46 42 LUNG IN- VOLVED R R Both clinical symptoms Fell on left shoulder; soon there- after lancinating pain in left chest. Pleuritic effusion of bloody serum; numerous tappings. Dulness over left chest in front and behind with absolute flatness and abolished voice and breathing in lower portion. Aspi- ration does not afford relief. Dyspnoea and suffocation, csdcema of left arm; anasarca and ascites. Duration about 7 months 10 years before admission strain at cricket; ever since tenderness on right chest. On admission tumor of right chest extending from 4th to 11th rib; imperfect expansion of right chest; absolute flatness and absence of breathing sounds below 5th rib. Death 10 days after admission. External tumor noticed 18 months before admission Progressive debility, dyspnoea, slight fever, pain in right side, dyspnoea. Flatness over half of right lung; diminished fremitus. Small quantity bloody fluid in pleura Syphilis admitted. While carrying a heavy load of zinc plates on shoulder up a ladder, suddenly severe cough and dyspnoea, with much rattling and wheezing. Was carried home and since that time intense dyspnoea, im- paired respiratory motion left chest; dulness over left chest and bronchial respiration. Within next week dul- ness becomes more intense and exten- sive. Some improvement after 10 mercurial inunctions ; respiration more normal and patient in every way much better. Probatory puncture made and needle penetrates deeply into hard mass. (Not stated where puncture was made.) A few drops of milky, easily coagulating fluid withdrawn in syringe. This under the microscope shows numerous small round and spindle cells. Since then patient feels fairly well, but has attacks of suffoca- tion from time to time Well until close of year, then intense dyspnoea, cough, slight expectoration. Pain in right chest; stridulous respi- ration. Dulness over right chest; absence of voice and breathing, except coarse tubular breathing in scapular DOUBTFUL 293 Bloody AUTOPSY NOTES Scant, grayish Not bloody No details Thin and scanty. No haem- optysis Left lung almost entirely converted into a mass of new growth. Enormously enlarged mediastinal glands compressing trachea and oesophagus. Large mass above heart, encircling large vessels. Fracture of a rib with much callus Tumor fills entire right pleural cavity except | of upper lobe. Lower lobe flattened and "inextricably confused with the tumor." Heart dislocated to left. 8th and 9th ribs destroyed by tumor, and through this space tumor emerges from chest Neoplasm in middle and lower lobe of right lung METASTASES Anterior mediastinum and anterior superior sur- face of lungs occupied by tu- mor which absorbed part of thoracic wall and formed part of tumor visible during Liver, lymph nodes, and cardiac end of stomach; ulcerated nodule in stomach Upper right lobe and left lung MICROSCOPE Tracheal, bronchial and medias- tinal lymph nodes; liver Mediasti- nal and ab- dominal glands; liver Typical car- cinoma in lung with well-marked alveolar struc ture and epi- thelial cells. In IjTnph nodes and liver alveolar structure but spindle cells No details Probably carci- noma of lung Insufficient No details Probably primary sarcoma of right lung In extract neo- plasm is called "in- filtrating cancer," and description tal- lies with usual forms of infiltrating carci- noma. In title the tumor is called sar- coma Author diagnoses sarcoma and thinks it sarcoma of pleura 294 TABLE III 45 46 47 48 49 Kempeh, Trans. Indiana Med. Soc, 1882, 172-178 Primary Cancer of Lung KOEYLINSKI, Diss. Greifswald, 1904 Uber primare Sar- kome in der Lunge KUHN, .. Diss. Zurich, 1904 Uber maligne Lungen- geschwulste Langb, J. C. Penna. Med. Jour. Pittsburg, 1903-4, Vol. XXXIII, p. 202 Four Cases of Malig nant Disease of the Lungs Langstaff, Medico-Chir. Trans., Vol. IX, 1818, p. 295ff Cases of Fungus Hae- matodes, Cancer, and Tuberculated Sar- coma with Observa- tions 60 Lataste, Bull, de la Soc. Anat 3 S., X, p. 767 (after Szelowski) Cancer primitif du Pou mon, etc. M M M LUNG IN- VOLVED M 46 75 50 31 30 47 R R L(?) CLINICAL SYMPTOMS region. Left side normal. Heart much more audible on right than on left side. Impaired mobility of right chest. Right intercostal spaces oblit- erated. Under right clavicle _ semi- globular tumor, tense and elastic. 14 days after admission enlarged gland above clavicle. Admitted August 28; died October 5 ChiUs, fever, facial paralysis. Pain right chest. Extensive dulness from below upward on right side. Bulging of intercostal spaces; cedcema of right hand; enlarged axillary glands No heredity. Patient was received into surgical clinic for phlegmon of penis and scrotum. There were no lung symptoms; death resulted from the surgical affection No heredity. Emaciation, vomit- ing, absence of free HCl in stomach; pain in stomach and Liver; dyspnoea; enlarged liver with palpable tumor After "cold," cough, pain in chest, loss of weight for 4 months; then oedoema of right face, neck, chest, immensely distended veins. Indurated glands in neck, axilla and under pec- torals. Tumor as large as orange protruded from chest, eroding 3d and 4th ribs. On physical examination many secondary nodviles in both lungs Cough, difficult breathing for 2 years. Pain in right chest, intense dyspncEa, hoarseness, dysphagia. Clini- cal diagnosis : asthma or phthisis Always in good health. Month before admission dizziness and palpi- tation. Soon after pleuritic effusion, dyspnoea. Flatness over all of left chest; dulness over right phest. Loss of fremitus on left side; increased on right. Heart dislocated to right. Congestion of lungs is diagnosed. No puncture is made, but venesection. Death in asphyxia DOUBTFUL 295 Profuse; not bloody AUTOPSY NOTES life. Both pleural layers ad- herent to diaphragm and thorax. Substance of right lung studded with miliary granules and traversed by fibrous bands. Left lung also involved in cancer. Posterior mediastinum filled with morbid deposit and glands Right lung solidified, some parts being "cartilag- inous and greasy," others "like liver." Bronchial tubes completely occluded Tumor size of a small fist in left lower lobe adherent at its free surface to the upper lobe. On section seen to be composed of 4 smaller nod- ules Primary nodule in lung None made Almost entire right lung converted into firm, pulpy tumor especially at root. Right main bronchus ulcer- ated and almost obliterated by tumor Serous effusion in left pleura. Both lungs studded with nodules size of a cherry. No tumor anywhere else METASTASES Axillary glands None Pericar- dium, liver, both pleurae, bronchial Ijonph nodes Bronchial glands None MICROSCOPE It is simply stated that tumor is "cancer" Microscopic examination seems to show fibromyoma. In epicrisis author calls the tumor ' ' fibrosar- Not given No details No details Encepha- loid cancer No secondary symptoms, no metas- tases; nothing speaks for malignant growth Probably sarcoma Probably primary carcinoma of right main bronchus Probably sarcoma 296 TABLE III LUNG IN- VOLVED CLINICAL SYMPTOMS 61 62 Lehlbach, Trans. Med. Soc. of N. J., 1870, p. 150 Case of Primary En- cephaloid Cancer of Right Lung LiNDSET, Proceedings of Arkan- sas Med. Soc, 1899, p. 131 An Obscure Case of Pulmonary Cyst M 64 R M 30 63 64 McAldowie, Lancet, 1876, II, 570 Cancer of lung in Child 5* Months Old McPhedran, Canadian Practi- tioner and Review, Toronto, XXV, 1900, p. 17 Carcinoma of Lung and Pleura with Occlusion of Superior Vena Cava M 5^ mos. Both 61 Both 65 66 Meissner, Schmidts Jahrbiicher, 1873, Vol. 158, p. 285 Olmeh, Marseille Med., 1901, p. 279 M 16 39 Both Cough, dulness upper portion right chest in front, bronchial respiration. Pain, increasing emaciation and debility; night sweats; intermittent fever. Left lung normal. Later hard painful swelling in pectoral muscle over dull area. Duration about one year In prison convicted of murder. Nov. 1898 oblong fluctuating tumor over 9th-llth ribs to left of spine. Flat- ness of left chest anteriorly and pos- teriorly to 3d rib; also absence of breathing. Several probatory punc- tures withdraw nothing but blood. No fluid in pleura. Exploratory in- cision made in tumor. Arterial blood flowed from incision and thoracic aneurysm was diagnosed. Patient's appetite good; no loss of flesh or strength, but rather gain. History of syphilis, and K I given. Tumor continued to grow and an enormous flow of blood followed the introduc- tion of the smallest needle. Opera- tive interference followed by enormous haemorrhage. Death March 1899 No heredity. Normal at birth; other children healthy. Failed al- most at once after birth. Short dry cough; emaciation; feeble breathing; few fine rales. No dyspnoea. Per- cussion clear over both lungs No heredity. Chronic bronchitis for 16 years. About year before admission pain in right scapula, arm, and face. Incipient tuberculosis of right apex suspected. Severe _ noc- turnal cough and sweats. Pain in right chest, weakness, haemoptysis. Effusion in right pleura; heart dis- placed. Several aspirations of clear serum, but no change in dulness. Increasing dyspnoea and weakness; cyanosis of face, arms, chest, and hands; cyanosis to costal margin, but not below. No respiratory motion right chest; no fremitus^ below right 2d rib; flatness and diminished respira- tion. Duration about 2 years Pain for 3 months with increasing debility, cough, swelling of limbs; intense dyspnoea; rapid enlargement of liver. Duration about 5 months Admitted moribund; died within a few hours. No history. Flatness and amphoric breathing at left apex. DOUBTFUL 297 SPUTUM AUTOPSY NOTES METASTASES MICBOSCOPE EEMARKS Streaked Almost entire right lung No details No details Nothing said about with except small area at base other organs blood. and apex converted into en- Later cephaloid mass. 3d, 4th, purely and 5th ribs entirely de- mucoid stroyed No details Large tumor filling whole left chest and pushing dia- phragm downward, heart to right and whole left lung above 3d rib. Erosion of 3 ribs where tumor had pressed out. Cystic portion of tumor had been cut off by Hgatures. On section tumor showed two kinds of tissue: the outer, pinkish, glisten- ing; inner, medullary; about 1 of bulk of tumor compact fibrous substance, resem- bling decomposing brain tis- sue No details No details Probably sarcoma No details Both lungs studded with hard white nodules; hard mass at root of left lung extending through entire thickness of lung. Pulmon- ary tissue around nodules quite normal. Pleurae thickened and adherent Bronchial glands None Bloody; no Nodules in both lungs, No metas- Epithelial Probably primary tubercle right pleura, and diaphragm tases in ab- cells, prob- in pleura. I. A. bacilli dominal or- gans ably from en- dothelium of lymph ves- sels; colum- nar cells and basement membrane, polymor- phous cells No details Both lungs studded with miliary nodules. In right lung tumor size of cherry, soft, yellowish white with hffimorrhagic centre Liver, spleen, kid- neys No details No details Cheesy masses in right Lymph Dense, fi- Author is in doubt lung. Miliary tubercles nodes of left brous, very whether it is carci- throughout both lungs. bilus vascular noma or sarcoma or 298 TABLE III 67 68 69 60 61 Tuberculose et Cancer primitif du Poumon OSBOHNE, O. T. Yale Med. Jour., Vol IX, 1902, p. 50 A Case of Primary Car- cinoma of the Lung Peacock, London Path. Soc, XIV, p. 40. Carcinoma of Left Lung with Secondary Deposits in Heart, Kidneys, Suprarenals, etc. Peacock, Trans. London Path. Soc, IX, 1859 Pepphb, Trans. College of Physicians, Penna. 1850-53 POKIER ET NeUVILLE, Jour, des Coimais- sances Med. prat. T. I. 1833-34, p. 104 D6g6nerescence squir- rheuse de la totality du Poumon droit, Phthysie consecutive. M M M 68 31 58 27 24 LUNG IN- VOLVED Both R R clinical symptoms Rales throughout both lungs, fever No _ Always healthy. Recently palpita- tion and breathlessness. 2 months before admission some trouble with left lung had been found. On admis- sion absolute flatness of entire chest with absence of voice and breathing and loss of fremitus except at very apex. At probatory puncture needle enters hard mass. Clinical diagnosis: tumor. Dry harassing cough, but never pain. Nodule in abdomen. Later paralysis of left recurrent. Dysphagia. Asthmatic attacks with profuse bronchial secretion from right lung. Centre of tumor begins to break down. Died about a month after first visit Cough, dulness over all of left chest. Almost entire absence of breath- ing sounds; feeble vocal vibration. Heart displaced to right. Swelling of lower costal cartilages; enlarge- ment submaxillary glands. Death from exhaustion. No bronzing, but dingy complexion. Duration about 8 months Disease commenced with hgemoptysis. Later larger and smaller masses were ejected with cough. Dulness, bron- chial respiration; deficient breathing; crepitation over varying areas in both lungs. Later increasing dyspnoea. Diarrhoea. Pain in chest, especially left side. General anasarca with normal urine; later anasarca disappeared ex- cept in face. Duration about 4 months Pain, swelling of right arm, chest, and mamma. Feeble pulse. Flatness over entire right chest; bronchial breathing; no rales. Right chest distended; dyspnoea, slight dysphagia. No cough Grandfather died of cancer. Dry cough for several years. When lifting a heavy weight felt sharp pain in right side. Some weeks later tumor in right side, where pain had been. On examination dry cough, tumor size of filbert adhering to 6th rib. Dulness over right chest. No fever. 8 months DOUBTFUL 299 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE REMARKS spleen, and liver. Left up- stroma en- a combination of per lobe transformed into closing alve- both dense grayish tumor con- oli filled with taining small cavities partially nec- rotic epithe- lial cells Occasion- Whole of left lung shrunk- Both kid- No micro- ally en into cancerous mass with neys and scopic exami- bloody, greatest consolidation at skin nation made no tuber- root. Base of heart at- cle bacilli. tached to tumor, also chest Numer- walls; broken down in cen- ous flat tre. Right lung healthy epithelial cells thought to be al- veolar cells Bloody, Tumor infiltration of al- Various No details Probably sarcoma large most all of left lung; bron- lymph masses of chiectatic cavities nodes. pus heart, peri- and endo- cardium. Complete tumor de- generation of both su- prarenals Bloody and Tumor masses in both None in Both tu- Probably sarcoma purulent. lungs with numerous cavi- other organs mors and the masses ties containing pus and nec- coughed-up ejected rotic material rnaterial con- sist of spindle and round cells None Tumor masses through- Bronchial Not stated Some doubt out right lung. In medi- and mesen- whether primary in astinum a large tumor sur- teric lymph lung rounding aorta and com- nodes, head pressing lower cava, pul- of pancreas. monary artery, trachea, and and ovaries oesophagus No details Tumor occupied whole of right chest and part of left, adherent to pericardium, loft costal cartilages, ster- num, right ribs, and verte- bral column ; around 6th to 8th ribs it penetrates to Probably in abdomen. Statements not very clear Not given subcutis, forming there a 300 TABLE III LUNG IN- NO. AUTHOR SEX AGE VOLVED CLINICAL SYMPTOMS Mort aprls dix-neuf later diagnosis of empyema was made, mois de Maladie; N6- but no trace of liquid was found on cropsie operation. After 19 months of sick- ness: extreme emaciation, chest more distended on right than on left, hard nodulated tumor under right breast. Dulness over right chest with absence of respiration. Tumor in abdomen attributed to liver. CEdcema of lower limbs; intense dyspnoea 62 Powell, Middlesex Hospital Reports, 1892. Lon- don, 1894, p. 87 Malignant Disease In- vading Right Lung. Gastric Ulcer M 58 R Sick for about a year with gastric symptoms. Cough for about 3 years; lately worse. _ In bed for 19 weeks before admission with dyspnoea and wasting. On admission oedoema of right arm, dilated veins of right chest. Impaired respiratory motion. Dul- ness and flatness over most of right chest. Feeble or bronchial breathing. Heart beyond nipple line. No change in physical symptoms until death. Duration probably several years 63 Powell, London Med. Gaz., 1850,XI, pp. 1029,31 F 74 R Severe pain in right chest. Right lung completely dull; feeble breathing sounds. Slight cough 64 Pbevost, Compt. rend. Soc. de Biol., 1875-76, II, 175 -180 M 44 R Cachexia. Indefinite dyspeptic symptoms. Frequent tappings for hsemorrhagic pleural effusion. Dysp- noea 65 Phtjdhomme, Union Med. du Nord- Est, Reims, 1903, p. 213 Cancer lobaire primitif du Poumon Gauche M 62 L No heredity. For 5 months rapid decline of strength. Slight attacks of cough. Flatness on left anterior chest from top to below left mammilla; behind about 2 fingers below spine of scapula. Over all this area absence of voice and breathing. _ No rales. Dyspnoea on slight exertion; some hoarseness. Later oedcema of left arm. Heart displaced to right. Increasing dyspnoea and emaciation. CEdcema of left lung. Aspiration 1000 c.c. yellow serum. CEdoema improved, but no change in physical signs. Cough with pain in shoulder. Death about 2 mouths after admission 66 QUAIN, Trans. London Path. Soc, 1857, VII F 34 L Symptoms of tuberculosis — cough, night sweats, cachexia, dyspnoea, hoarseness, dysphagia, pain in left chest. Dulness over left apex, dimin- ished breathing; rales 67 Robertson, Glasgow Med. Jour., M 37 R No heredity; no syphilis. Cough, pain across chest; cyanosis, dyspnoea, DOUBTFUL 301 No details large, white, nodulated lar daceous mass. Tumor had 3 cavities containing serum and pus. At upper and po& terior part of tumor a thin layer of lung tissue; remain- der all scirrhous. Upper lobe right lung compressed by tumor. Heart displaced to left. Albuminous mass in abdomen It is simply stated malig- nant growth invading right lung; old gastric ulcer. No other details given Scant, haem- optysis Yellow, al- bumin- ous Scanty showed nothing charac- teristic Scant, mucoid. Hffimop- tysis Mucopuru- lent, oc- AUTOPST NOTES Slight effusion in pleura Right lung almost complete- ly transformed into solid cartilaginous tumor Tumor with cavity at base of right lung Entire upper left lobe in vaded by cancerous mass broken down and forming cavities containing creamy matter Large tumor between apex of left lung and arch of aorta. Compression of oesophagus and left bron chus. Mass between tra- chea and oesophagus pressing on recurrent laryngeal. Left lower lobe infiltrated with soft tumor Simply stated that "tu- mor was found to be a lym- MBTA8TA8E3 No details No details Right lung and pleura Cancerous nodules in mediasti- num ex- tending to pericardium compressing aorta and pulmonary artery. No other metas tases Bronchial and medias- tinal lymph nodes No details MICROSCOPE No details None made No details No details No details No details Possibly sarcoma 302 TABLE III 70 71 72 73 1889, Vol. XXXI, p. 454 A Case of Tumor of the Lung Rob, Lancet, 1866, II, 723 ROTTMANN, Diss. Wiirzburg, 1898 Uber primares Lun- gencarcinom Russell, London Med. Times and Gaz., 1864, II, p. 278 Rttssell, Lancet, 1869, I, 814 See Germain, Revue Med., 1881, XXXI, 121-127 L'Union Med. Diagnostic de Cancer pulmonaire SiLVA, Gaz. degli Ospidali e delle cliniche Milano, XXII, 1902, Serie II, p. 1236 Sarcoma primario del Polmone M M M 23 47 38 30 46 52 LTJNG IN- VOLVED R CLINICAL SYMPTOMS hoarseness. Dulness over upper por- tion right lung; increased vocal fremi- tus; prolonged expiration; all kinds of rales. No fever. Enlarged and tortuous veins of abdomen and chest. Apex beat dislocated to left. Heart sounds heard distinctly over dull area. Rapid increase of dulness and some bulging of right chest wall. (Edcema of hands; sHght exophthahnus of right eye. Duration about 4 months Cough, dyspnoea, pain in chest. Flatness and harsh respiration. Right lung normal. Symptoms of peri- carditis and pneumonia, then small- pox and death Syphilis. Complained of lungs for 2 years. Emaciation and debility. Spontaneous fracture of right thigh. Flatness at right base posteriorly, slight bulging of chest, diminished voice and breathing. Cough Extreme dyspnoea. Flatness over left chest. Respiratory immobUity; intercostal spaces retracted. Explo- ratory puncture, some blood. Lower lobe cleared up before death Distress after eating, frequent vomit- ing, cough, dyspnoea, palpitation. Pain in left shoulder, chest, and arm. Impaired respiratory motion. Dul- ness at apex with absent breathing and voice. Effusion in left chest Pain, dyspnoea. Flatness and ab- sence of voice and breathing over left chest. Small hard lymph nodes above clavicle No heredity. 7 years ago acute pul- monary disease with cough. For one month dry cough, and severe pain radiating to both lower limbs and left shoulder; also behind sternum. No fever. Obstinate constipation; ano- rexia. Impaired expansion of left chest; loss of voice and breathing. Complete flatness. Emphysema of right lung. Two punctures withdraw small amount of bloody serum, but needle enters into hard tumor mass. Slight fever and much intestinal dis- turbance. Death after 3 months in hospital DOUBTFUL 303 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE REMARKS casion- phadenoma probably origi- ally nating in mediastinum, tinged some portions of it having with caseated and broken down" blood One hfiem- At base of left lung hard Right lung No details Possibly sarcoma optysis cartilaginous tumor, com- pressing bronchus and oesophagus and extending to left auricle. Bronchiectatic cavities throughout left lung Abundant Large tumor in right Bronchial Partly car- lower lobe, partially necrotic lymph cinoma, part- and purulent. Lower and nodes and ly sarcoma middle lobes diffusely infil- right femur. trated. Left lung normal No others No details Hilus of left lung sur- rounded by tumor envelop- ing bronchus and large ves- sels. Infiltration of upper lobe Left bron- chial lymph nodes only No details Bloody Cancerous nodules around Bronchial No details root involving posterior up- lymph per left lobe, extending into nodes left auricle. Tumor prolif- erates along bronchial tract. Left bronchus and pulmo- nary veins compressed Pus and No autopsy Axillary No details There was no au- blood and supra- clavicular lymph nodes topsy, but the physi- cal signs and sputum as well as absence of fever and rapid ag- gravation, all point to tumor of lung No details Left lung shrunken and Liver, su- No details Probably carci- adherent, containing tumor prarenals. noma size of melon, hard and fi- ribs, verte- brous and adherent to peri- brae cardium. Pulmonary artery compressed. In interior of tumor numerous bronchi- ectatic cavities filled with purulent secretion. Lung tissue surrounding tumor atelectatic and cedcematous 304 TABLE ni NO. AUTHOR SEX AGE LTTNG IN- VOLVED CLINICAL SYMPTOMS 74 Sims, Medico-Chirurg. Trans., Vol. XVIII, London, 1833, p. 281 On Malignant Tumors connected with the Heart and Lungs M 43 R For about a year before admission various haemoptyses, sometimes pro- fuse ; dyspnoea and severe oppression. Later harassing cough. Dulness on right chest anteriorly; absent breath- ing. Dilated jugular veins; sweUing of head and neck. Diagnosis made during life 75 Log. cit. M 64 L Hemiplegia for about 12 months. Cough and other pulmonary symptoms for several years. Brain sjrmptoms predominated and no attention was paid to lungs 76 Spabks, Lancet, 1871, II, 13 Primary Cancer of the Lungs F 22 L Diagnosis of pleuro-pneumonia. No other clinical data 77 Steell, Lancet, 1894, 1, p. 388 A Case of Tumor of the Lung M 49 L No previous illness. No symptoms pointing to lungs. Routine examina- tion showed dulness over whole left chest with loss of fremitus and absence of breathing over lower part chest. Slight cough. Later high fever and pericardial friction. Clinical diag- nosis: fibroid phthisis 78 Stokes, New Syd. Soc. Ed., 1882, p. 386 Diseases of the Chest M 36 R Some pains in right side; cough, hoarseness, dyspnoea; cedoema of face and neck. Dulness over entire right chest; gradually loss of voice and breathing sounds. Heart sounds heard all over right chest. Later en- larged liver and jaundice. Tumors appear on forehead, lower jaw, and lumbar spine. Diagnosis of tumor made during life 79 Log. cit. M 45 L Pain in left side, dyspnoea, dysphagia. Later left hemiplegia and epileptiform attacks. Left radial smaller than right. Flatness over entire upper left chest; feeble breathing. Dia- stolic pulsation and bellows murmur in upper sternal and subclavicular regions; nevertheless tumor and not aneurysm was diagnosed 80 Stokes, Loc. cit F 34 R After a cold, cough and pain in right side. Cachexia; right side tender to touch. Tympanitic percussion note; cavernous breathing; tympanitic note later replaced by flatness. Night sweats, diarrhoea, dyspnoea; oedcemaof face and left hand. Duration 5 to 6 months. Diagnosis made during life DOUBTFUL 305 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE BEMAEKS Mucoid, Solid tumor probably Bronchial No details Possibly carcinoma haemop- starting from hilus of right lymph of bronchial origin tysis lung, involving greater part of right chest and compress- ing large vessels, trachea, and right main bronchus. Bronchiectatic cavities in tumor. Upper cava in- volved nodes and heart No details Upper lobe of left lung contains tumor size of a small orange of medullary character. Traces of chronic pneumonia and solid gray hepatization, also a few patches resembling gangrene None men- tioned No details No details Large nodulated "en- cephaloid" tumor in lower left lobe infiltrating dia- phragm and pleura. Heart displaced to right Right lung, both pleurae No details Scant, Effusion in left chest. Left No details Insufficient; Possibly carcinoma slightly lung compressed ; upper lobe tumor is bloody infiltrated with soft, white called lym- early in new growth. Bronchus of pho-sarcoma disease lower lobe almost entirely obstructed by tumor. Sup- purative pneumonia lower left lobe Scant, occa- Very large tumor in place Mesenteric No details Probably sarcoma sionally of right lung of which a com- and retro- bloody pressed portion is found over posterior surface of tumor. Tumor contains cysts and envelops trachea, large ves- sels, and pericardium. Right main bronchus compressed and obstructed peritoneal glands com- pressing common bile duct Bloody Large tumor from root to No details No details Possibly bronchial apex in left lung; gangre- carcinoma nous cavity in lower lobe Copious, Entire lung converted in- No details No details Probably bronchial frequent- to tumor containing bron- carcinoma ly bloody chiectatic cavities 21 306 TABLE III NO. AUTHOR SEX AGE LUNG IN- VOLVED CLINICAL SYMPTOMS 81 Loc. CIT. M 44 R Cough, dyspnoea, pain. Increasing dulness over right lung. Dilatation of veins. Feeble respiration. Increas- ing volume of chest. CEdcsma of face and chest. A month later some im- provement; retraction of right chest. Clinical diagnosis: empyema and ma- lignant tumor 82 Stone, Clinical Cases Med. & Surg., New York, 1878. p. 55 Tumors in the Lungs, etc. M 4 Both Always thin and feeble. Some weeks before death difficult breathing, which became "asthmatic." Extreme dysp- noea. Right lung solid on percussion ; bronchial respiration. Flatness oyer left lung; mostly bronchial respira- tion; some cough. Clinical diagnosis: thymus asthma or pneumonia, but as there was no fever the latter was doubted 83 Strbhlin, Diss. Miinchen, 1904 Primares Endotheliom eines Hauptbronchus uad der Lunge M 70 R Practically moribund on admission. Intense dyspnoea, cough. Suffering more or less for a long time, but more in the last 2 months. Owing to pa- tient's condition examination was very imperfect. Emphysema of both lungs; loud tracheal rattle, diffuse rales over both lungs. Clinical diagnosis: myo- degeneration of heart, bronchitis, arteriosclerosis, emphysema 84 Suzanne, Journ. de Med. de Bordeaux, 1883-4, XIII, p. 573 M 35 R Cachexia, palpitation. CEdcema of right face, arm, and trunk. Dilated veins. Tumor in left axilla and over clavicle. Right chest flatness; cavern- ous breathing; imperfect respiratory motion 85 TiNNISWOOD, London & Edinburgh Monthly Journal of Med. Science, 1844, p. 550 Lardaceous Schirrhoma of the Lung Involving the First Rib, Clavi- cle, etc. M 41 R For over a year cough, dyspnoea, and occasional hsemoptysis. _Large_ hard tumor arising frorn 1st right rib and clavicle. Emaciation. Dulness over right chest; diminished voice and breathing. Dilatation of veins of neck and chest. CEdoema of right arm with pain and numbness. Fracture of clavicle. Duration of disease about a year and a half 86 Trotter, British Med. Jour., 1871, II, p. 583 M 30 R Dulness below right clavicle with fine rales. Later signs of cavity. Still later abdominal pain, fullness and tym- panites DOUBTFUL 307 BPUTUM AUTOPST NOTES METASTASES MICROSCOPE EEMABKS Bloody and Pus in right pleura; right No details No details "black lung converted into large tu- currant mor; bronchiectases jelly" No details Thjonua pormal. Tumors in both lungs which com- press lung tissue ; most of the tumor subpleural, al- though some imbedded in lung. Tumor resembles Malaga grapes in shape and size; white, not fatty No details No details Autopsy incom- plete, but neverthe- less likely that tumor is primary in lungs. Probably sarcoma Bloody Large quantity of turbid Both kid- Fine fibrous May be classed as serum in left pleura; right neys stroma con- carcinoma or endo- pleura obliterated. Pri- taining nu- thelioma. The mary endothelioma of right merous branching and com- bronchus with extension in- branching municating alveoli, to lung. Purulent bronchi- and commu- probably lymphatics, tis. Bronchiectatic dilata- nicating alve- point to endothelioma tion. Purulent degenera- oli filled with tion of peribronchial lymph small, closely nodes Pericesophageal ab- packed cells scess. Upper and middle like endothe- right lobes matted together. lial cells ; here Bronchiectatic cavity, size and there of hen's egg with numerous concentric small gray nodules in its wall , layers of cells. communicates with dilated Much necro- bronchus. Bronchi filled and sis obstructed by tumor masses Some haem- Fluid in left chest. Heart Liver, mes- No details optysis displaced to left. Large vessels compressed. Tumor in upper cava. Greater part of lung converted into tu- mor connected with tumor in mediastinum enteric glands Mucous, Right upper lobe com- No details No details Probably primary often pletely transformed into tu- sarcoma of right up- tinged mor which extends into mid- per lobe with dle lobe. Tumor came up blood from lung into superior tho- racic opening and involved clavicle and ribs. Autopsy not complete Haemopty- Right upper lobe almost Right lung, No details sis entirely destroyed by soft tumor, degenerated and forming a cavity left lung, kidneys, right 5th rib, 4th left rib 308 TABLE III 87 88 89 Von Pflug, H., .. Diss. Munchen, 1904 ijber primare Lungen- geschwiilste Van Gieson, Medical Record, 1879, XVI, p. 495 Cancer of Lung WaCHSMANN & POLLAK, New York Med. Rec- ord, Nov., 1904 Three Cases of Primary Malignant Tumor of the Lung 90 Log. cit. M M liUNG IN- VOLVED 70 30 60 91 Wacqttez, Journ. des Sciences Med. de Lille, Xlle Ann6e (Tome 1, 1889) p. 393 Cancer primitif du Pou- M 38 46 CLINICAL SYMPTOMS For several years cough; later pain in left chest, increasing cough and some fever. Dulness over whole of left chest; at base posteriorly flatness. Over dull area loud bronchial respira- tion, fine mucous rales. Probatory puncture: negative. Tumor suspect- ed. Slight dysphagia. Sudden death through profuse haemoptysis No heredity. Severe pain in left chest; dry cough. Left arm cedcematous. Cyanosis; dulness below left clavicle. Left chest 1 2 inches larger in circumfer- ence. Absence of respiratory sounds over all of left chest. Exploratory puncture negative. Exophthalmus left eye; pupils dilated. Severe dyspncea Commenced with pain in left shoul- der and cough; hoarseness. Flatness over left upper lobe and at base; dimin- ished breathing sounds. Bulging of left thorax. Clubbed fingers. Peri- osteal tumor over left temporal bone Cough, pain in left chest, impaired respiratory motion and flatness from 1st rib to base. No respiratory sounds in left axillary line or in back. Paraly- sis of left vocal cord No heredity; no previous illness. Sudden expectoration of clotted blood without apparent cause. Recurrence shortly with considerable haemoptysis. Some sweating and fever. Later se- vere pain along spinal column and at base of thorax ; excessively sensitive to touch. Cough very painful. _ Increas- ing dyspnoea. On examination right lung normal. Left lung: dulness an- teriorly with absence of breathing and diminished voice. Puncture: bloody effusion containing many epithelial cells with granular fatty degeneration. No relief after puncture. Death after about 6 days in hospital. Duration from first haemorrhage about 7 months DOUBTFUL 309 SPUTUM AUTOPSY NOTES METASTASES MICHOSCOPE EEMAHKS At first In place of lymph nodes Bronchial Fibrous Author himself scant, at bifurcation, a large encap- lymph stroma con- considers it not abso- later sulated tumor, perforating nodes taining nu- lutely certain whether more into oesophagus and extend- merous com- cells should be abun- ing into left main bronchus municating classed as epithelial dant. and causing extensive ulcer- cavities lined or endothelial or the Shortly ation. Erosion of large or completely tumor as endotheli- before branch of left pulmonary ar- filled with flat oma or carcinoma death, no tery. Chronic inflamma- endothelial- sputum. tion of left lung; numerous like cells Occasion- bronchiectases tending to ally slight necrosis and mixture often ar- of blood. ranged in No tuber- successive cle bacilli, layers no tumor cells None Bloody serum in left pleura. Hard white neo- plasm involves nearly whole of left lung which is adher- ent to chest wall and peri- cardium. Tumor in apex of right lung _ Pericar- dium, right lung, liver, sternocla- vicular ar- ticulation No details Possibly sarcoma No blood, Incomplete details Heart, liver. No details Probably carci- no tuber- ribs, kid- noma cle ba- neys, clavi- cilli. CeUs cles, skull. which re- suprarenals. semble mesenteric, cancer retroperi- cells toneal, and regionary lymph nodes Profuse, Entire left lung taken up Lymph No details Probably epitheli- greenish, by soft white neoplasm; nodes, liver. oma occasion- compression of oesophagus pericardium, ally and trachea; hsemorrhagic pleura bloody effusion in pericardium. Broncho-pneumonia right upper lobe Bloody, Bloody effusion left Right lung No details Probably carci- frequent- pleura. Upper left lobe solid and left su- noma ly cur- grayish mass of encephaloid prarenal rant jelly tumor; softening in central portion. Bronchi permea- ble to centre of neoplasm where they become replaced with neoplasm 310 TABLE III 92 93 94 95 96 97 98 Waldenstrom, J. A. Deutsche Klinik, 1874 No. 22, p. 169 Cancer Pulmonum Waters, British Med. 1886, I, 335 Jour., Weichselbattm, Virchows Archiv., LXXXV, 1881,p.559 Papillares Adeno-sar- kom der Lunge White, Dublin Quarterly Journ. of Medical Science, 1865, XXXIX, 219-222 Williams, Lancet, 1878, II, 732 Cancer of Lung and Pleuro-pneumonia Wilson, Edin. Med. Jour., 1857 Woodman, Bathurst, Med. Times & Gaz., London, 1876, I, p. 411 Case of Encephaloid Cancer of Bronchial Glands and Left Lung M M 31 44 67 56 40 Not stated 45 lung in- volved Not stated R R R CLINICAL symptoms Anjemia, dyspnoea ; dulness and harsh respiration over left base ; sibilant rales. No other signs on lungs or other organs. CUnical explanation of the dyspnoea: emphysema, although no signs of this. Rapid increase of dyspnoea; general bronchitis with abundant secretion. Broncho-pneumonia ; death Dyspnoea; dulness over whole right chest; impaired respiratory motion, faint breathing and fremitus. 22 ounces dark fluid removed by aspira- tion; physical signs remain unchanged Clinical diagnosis: bronchiectases and effusion into right pleura Pain; slight dulness below left clavicle; in some parts right lung total absence of breathing; dulness over en- tire lower posterior portion right lung. Dysphagia, hectic fever. Effusion in right chest Pain in left chest, increasing dyspnoea and emaciation ; cough. Dulness at base of left lung. Diminished respiration, but increased vocal fremitus; subse- quently complete absence of breathing soimds. Dysphagia. Liver enlarged Symptoms of pleurisy. Dyspnoea, cachexia. Duration 6 months For 10 months bronchitis and loss of wei'ght. On admission pain in left side and left arm. Dulness over left chest, bronchial breathing, absence of fremitus. Two months later a hard nodule appeared under upper border of left trapezius. Two months later enlargement of left axillary glands on mass on left side of neck DOUBTFUL 311 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE REMARKS No details Simply said to be primary cancer of the lung No details No details Scant, rust Malignant disease of right Pericar- No details Doubtful whether colored pleura involving right lung along septa dium, dia- phragm, large and small omen- tum primary in lung No details Small spherical tumor No details Multitudeof Author calls the tu- near hilus of right lower lobe yiUi, the bod- ies of which are made up of round and spindle- shaped cells covered with cylindrical epithelium. Glandular structures lined with cylindrical, sometimes with ciliated epithelium also found mor a papillary ade- no-sarcoma Bloody, ex- At root of right lung a No details No details pectora- large tumor extending into tion of lower lobe; posterior medi- "fleshy- astinum filled; large en- looking cephaloid mass projecting masses" into pericardium. (Esopha- gus compressed Rusty Large nodular tumor at root of left lung, penetrating and nearly obliterating left bronchus and invading lower portion of lung None No details Haemopty- Fluid in left pleura. Sev- No details No details sis eral nodules in upper part left lung, especially along bronchi Elastic fi- Tumor involving upper | Right No details bres and of left lung and connecting lung, heart, pus cells. with mass in neck. Infil- iver No tumor tration extended to mucous elements membrane of left main bron- chus almost completely ob- structing it. Bronchiec- tatic cavities base of left lung 312 TABLE III NO. AUTHOB SEX AGE LUNG IN- VOLVED CLINICAL SYMPTOMS 99 Yeo, J. Burnet, British Med. Jour., March 13, 1874, p. 342 A Case of Mediastinal Cancerous Tumor Leading to Occlusion of the Right Bron- chus, etc. M 53 R Cancer and tuberculosis in family history. Had lues 20 years ago. Six months previous to admission bron- chitis, chills, pain in right side. Pleu- ritic exudate which was entirely ab- sorbed within a few weeks. On ad- mission cachexia, heart pushed to right. Dulness all over right chest and feeble breathing DOUBTFUL 313 AUTOPSY NOTES METASTASES MICBOSCOPB No details Tiunor size of an orange in anterior and posterior mediastinum, hard, whitish extending into right bron- chus almost entirely occlud ing it Nodules in right up- per lobe Medullary cancer with much con- nective tissue and charac- teristic cells with large nuclei Probably primary in right bronchus, and the tumor in anterior and posterior medi- astinum a secondary inflammation of the lymph nodes. I. A. 314 TABLE IV BOEHIS, Arbeiten aus dem Path Anat. Institut zu Tu- bingen (Baumgarten) ..Vol. VI, Ht. 2, p. 539 (jber primares Cho- rionepitheliom der Lunge Briese, Beitrage zur wisseu' schaft. Med. Festschr etc. Braunschweig, 1897, p. 191 Ein Fall von metastasi- renden Lungenendo theliom Bbunet, Bull. Soc. d'anat. et de Physiol, de Bordeaux, Vol. XII 1891, p. 115 Cancer du Poumon Charteris, M. Lancet, 1874, 1, p. 126 On Intrathoracic Can- cer M M M 28 40 20 29 LUNG IN- VOLVED E R R CLINICAL SYMPTOMS Married at 22; 4 children. Last childbirth 14 months before admission to the hospital. A few weeks before admission cough, expectoration, night sweats, pain in right chest. On ad- mission dulness at apex of right lung; flatness over remainder of lung, bron- chial breathing, numerous friction rales. Left lung normal. Later signs of effusion in right pleura. Tappings withdraw clear yellow serum. Later several abundant hsemoptyses. Death 2§ months after admission No heredity. Pleurisy on right side 18 years ago. Since then cough, ex- pectoration occasionally very abund- ant; once haemoptysis. For 2 years, after attack of influenza, more cough, pain in chest, progressive loss of weight. Later severe intercostal neuralgia on right side. Dulness and diminished respiration, loss of fremitus over all of left upper lobe. A few weeks before death nodules from the size of a hazel nut to that of a hen's egg in skin of abdomen and leg, which when incised show a viscid fluid. Death in extreme marasmus Four years before admission ampu- tation of right leg at thigh for tumor. One month before admission violent chiUs, harassing dry cough, intense dyspnoea. Right chest bulging. Flat- ness from angle of scapula to base; in front from infraclavicular fossa to base. Intercostal muscles do not contract. Respiration feeble, distant. Marked segophony. Nothing on left chest. Puncture, 600 c.c. bloody serum; flat- ness not diminished. Gradually all symptoms increase; cedoema. Several punctures made and after the last de- cided improvement, dyspncEa better, cough not so harassing; respiration on right chest almost normal; some pleuritic friction. After a few days return of all symptoms; intense dysp- noea, sibilant rales, failing appetite and fever. Severe pain in back of chest. Repeated punctures, always bloody serum. Death about 2 months after admission Pleurisy 5 years previously. 11 weeks before admission caught cold, followed by anorexia, cough, night sweats; hsemoptysis 3 days before ad- mission, when became hoarse and tu- mor appeared on right side of neck. On admission dyspnoea, pain in epigas- trium, and vomiting. Dulness over lower half of right chest in front and MISCELLANEOUS 315 SPUTUM AUTOPSY NOTES METASTASES MICROSCOPE REMARKS Greenish, Bloody, turbid fluid in Both lungs. Typical Clinical diagnosis mucoid, left pleura. Nearly whole None in chorion epi- was uncertain though no tuber- of right lung occupied by lymph thelioma inclined to tuberculo- cle bacilli. large tumor besides a num- nodes. sis. At the autopsy Haem- ber of smaller nodules. The Haemor- no definite diagnosis optysis large tumor contains hsem- rhagic focus could be made. Mi- orrhagic and necrotic areas. in right croscope alone gave Tumor penetrates into up- broad liga- the proper diagnosis per cava and extends up- ment ward into vein Tenacious, Cavity size of fist in lower Skin, liver, Endothe- Author gives many contains part of left upper lobe, filled kidneys. lioma. Mu- reasons in detail why elastic fi- with cheesy masses and hav- left psoas. coid degener- he has classed this bres. No ing hard, irregularly pro- lumbar, and ation of cells. tumor as epithelioma tubercle truding waUs 11th and Metastases and not carcinoma bacilli. 12th tho- are all cystic Haemop- racic verte- and contain tysis brae viscid, tena- cious, clear mucus Abundant, Whole of right lung trans- Large sec- Not given Probably sarcoma. green formed into an encephaloid ondary tu- Remarkable for irregular mass without any mor in liver length of time, 4 trace of lung tissue, adher- years between pri- ent in its entire extent to mary and secondary chest wall. Left lung nor- growth, and for its mal recurrence as a mas- sive tumor involving whole of right lung Scant, Large cancer at tracheal No details Not given Course of disease rusty, bifurcation extending into remarkably rapid later pu- right lung, adherent to pos- rulent, terior wall of pericardium abun- and extending through into dant. both auricles. Right vagus often imbedded in tumor bloody 316 TABLE IV CotrVELAIBB, Annales de gynec. et d'obst., LX, 1903 DegSnerescence Ky- stique congSnitale du Poumon, etc. De Gueldre, Annal. de la Soc. de Med. d'Anvers, LXII, 1900, 83-89 Cancer generalise du deux Poximons M M 6 days 39 LUNG IN- VOLVED R Both CLINICAL SYMPTOMS behind. Some dulness on left side anteriorly. On right side anteriorly below: diminished expiration, distant bronchial breathing. Increasing dysp- noea and aphonia; swelling over right vocal cord. Death on 23d day after admission Parents normal health; good family history, uneventful normal pregnancy, normal birth. After birth, child cried, breathed, and behaved like normal child. On 5th day respiration became short and rapid; cyanosis set in; child refused breast and 6 days after birth died. No precise diagnosis was pos- sible Always in robust health. Several months before admission marked ema- ciation. Cavity at right apex; slight temperature ; intelligence slightly clouded. Tympanitic note right apex below clavicle; diminished respiration and amphoric breathing corresponding to tympanitic note. Tympanitic note at both bases. Short cough. Clinical MISCELLANEOUS 317 SPUTUM AUTOPSY NOTES METASTASES MICEOSCOPE BEMABKB None Middle lobe of right lung connected with an enormous cystic mass causing com- pression and atelectasis of upper and lower right lobes. Hypertrophy of right ven- tricle of heart. Cysts irreg- ular in dimension No details Cyst-ade- nomatous structure. Cuboid and cylindrical epithelium with base- ment mem- brane with irregular nuclei near base. Where normal lob- ules of pul- monary tis- sue exist they are complete- ly atelectatic. The bron- chial ramifi- cations are represented by irregular canals of varying cali- bre and ex- tremely simple struc- ture out of which de- velop the adenomatous tubules. The only sugges- tion of intra- lobular bron- chial differen- tiation are patches of _ cartilage im- bedded in connective tissue in the vicinity of the pulmo- nary vessels Abundant, Retroperitoneal tumor Mentioned No details Author goes into mucopu- size of child's head from under details as to how all rulent lumbar lymph nodes. Nut- meg liver, numerous nod- ules, larger and smaller; nodules of spleen; 2 nodules replace left testicle. Both autopsy the symptoms point- ing to tumor of the lung were wanting — the slight cough, no characteristic spu- lungs completely filled with turn, no dyspnoea, no nodules. Diaphragm per- pain, no dilatation of 318 TABLE IV DiONISI, Arch, di biol., Firenze LVII, 1903, p. 716 SuUe degenerazione po- licistica dei polmoni Ehlich, Primares Carcinom an der Bifurcation der Trachea Monatschr. f. Ohrenhlk., 1896, No. 3, p. 121 (Klinik v. Schrotter) Kraus, Joseph, Diss. Bonn, 1893 Ein Fall von ausgedehn- tern links-seitigen Pleuratumor M M M 19 65 39 LUNG IN- VOLVED Both CLINICAL SYMPTOMS diagnosis: tuberculosis. Enormous liver also taken as phthisical symptom. No fever. Emaciation continues not- withstanding improved appetite. Mili- ary tuberculosis is thought of, but lack of fever speaks against it. Two days before death tumor as large as a fist and painless, is recognized in left flank. Death one month after admission For some time cough, dyspnoea, slight cyanosis, occasional night sweats. End of December, 1902, fever, dyspnoea, pain about right breast. Dulness be- low right spine of scapula; harsh breathing and crepitant rales. Tem- perature up to 39.1. This state con- tinued until January 5 with rapid de- crease of temperature and signs of heart failure. Death No heredity; no serious illness. For 2 years cough and hoarseness at times. General health good. Later slight dyspnoea on exertion, dysphagia, dul- ness at right apex. Laryngoscope shows tumor obstructing both right and left bronchus. Intense dyspnoea; pneu- monia of left lower lobe. Attempt at suicide by stabbing in chest; death No heredity. Three years previ- ous to admission, left pleurisy; well after 2 months. Since then occasional pain in left chest, though working. For some months constant pain in left lower chest, cough, increasing dysp- noea, trigeminal neuralgia. Dulness left upper lobe; absence of fremitus and breathing. Some areas of bron- chial breathing posteriorly. Heart displaced towards right; loud systolic murmur at base. No pulsation in jugular notch. Left jugular more full than right. Probatory puncture yields only a few drops of bloody serum. Increasing pain in left axilla. CEdcema of upper left arm. Paralysis of left vocal cord. Percussion of chest becomes very painful. Right pupil larger than left. Clinical diagnosis: MISCELLANEOUS 319 Rusty Mucoid, at times bloody. No tuber- cle bacilli no tumor elements Mucoid, more or less abun- dant, never bloody AUTOPSY NOTES f orated both sides by tumor From history taken only after death of the patient it appears that primary tu mor of the testicle was oper- ated some years previous Fibrinous pleurisy on right side ; acute bronchitis. Left pleura thickened. On section of right lung a sys tem of numerous cavities of varying size and alveolar as- pect decreasing in size and number from above down- ward. In lower lobe very firm alveolar appearance, resembling thyroid gland. In apex of left lung similar system of cavities. Genuine lung tissue was firm with increased consistency like brown induration Scirrhus at trachea at bifurcation extending di- rectly into both bronchi. Cancerous infiltration of oesophagus Bulging of left chest :_ stomach enormously dis- tended, reaching almost to symphysis. Heart beyond right mammillary line. Clear serum in pericardium. Grayish red tumor masses fill whole of left pleural cav- ity. Right lung displaced downward. Tumor masses between spine and pericar- dium. The tumor fluctu- ates at apex ; lower portion grayish atheromatous mas- ses with numerous hairs, cartilage, and bone. (Der- moid cyst of mediastinum) METASTASES No details None. Not even in adjoining lymph nodes Right pleura MICKOSCOPE Areas of emphysema- tous lung tis- sue ; also areas where the lung tis- sue is re- placed by tubular structure, the tubules lined with epithe- lium mostly in single lay- ers and cylin- drical ; other tubules sug gest acinous structure ; others filled with exudate and leuco- cytes Not given Grajdsh red tumor is spindle cell sarcoma veins, no bloody ef- fusion in pleura, no lymph nodes According to the author this is not a true neoplasm, but a congenital cystic process depending upon the arrest or dis- turbance of the proc- ess of development 320 TABLE IV 10 11 12 Klemm, ..Diss. Munchen, 1905 tjber ein primares En- dotheliom der Lunge Labb:6, Gaz.des Mai. infantile etc., et d'obstet. Paris, 1909. No, 15, p. 113 Kyste hydatique pulmonaire chez une fillette de 8 ans. Vomique, Guerison Las^qtje, Arch. Gen. de Med., 1874,_ Vol. I, p. 486 Pleuresie droite deve- lopp6e sous I'influence d'un Lymphosar- come en voie de generalisation M M 30 49 LUNG IN- VOLVED Both Both CLINICAL SYMPTOMS tumor in chest probably not carcinoma on account of scanty and not bloody sputum. Bulging of left chest; left jugular vein becomes hard. CEdcemaof left leg. Increasing dyspnoea. Much albumin in urine. Admitted Aug. 23, 1892; died November 11 Extreme dyspnoea. No lesions could be detected in lungs or heart to ex- plain dyspnoea. Repeated examina- tions with bronchoscope negative. Patient died of suffocation on day of admission to hospital Cough and bronchitis for a long time. First seen February, 1907. Since August, 1906, intermittent cough with febrile attacks and sweat- ing. Some scant hcemoptyses. Dif- fuse bronchitis and gastro-intestinal symptoms. Diagnosis of intestinal grippe is made. Beginning of May, breath becomes foetid. X-ray shows shadow of upper | of left lung with sharp border. Dulness below clavicle; bronchial respiration; mucous rales; absence of fremitus. Pleuro-pneumonia is diagnosed and puncture is made posteriorly (!), but only a few drops of clear serum withdrawn. 32 hours thereafter violent pain in left chest; no fever. Suddenly vomited large quan- tities of pus, white, thick, and foetid, containing particles that look Uke membrane. Some purulent and bloody mucus is expectorated. After this gradual diminution of aU symp- toms. Physical signs in left chest gradually disappear and improvement is followed step by step by radiograph. September, 1907, the healing is com- plete except some signs of cavity below left clavicle Six weeks before admission pain in right chest with slight chill, fever and dyspnoea gradually increasing. Dul- ness from angle of scapula downward. Bronchial breathing above, dimin- ished breathing over middle \ and absence of breathing at base. Dul- js from mammilla downward an- teriorly, also with absence of breath- ing. Liver enlarged. Later renewed chill and next day exudate filled entire right chest. Profuse sweats, anorexia. MISCELLANEOUS 321 AT7TOPST NOTES METASTASES MICROSCOPE Sanguinolent serum in both pleurse. Almost entire left lobe consists of very firm and dense tissue containing no air except a thin periph- eral layer. Fibrous prolif- eration along bronchi. Everywhere conglomera- tions of miliary nodules. Lower lobe of right lung in same condition as left. Up- per lobe numerous, often confluent miliary nodules Bronchial, tracheal, and medias- tinal lymph nodes Yellowish, purulent fluid in right chest; right lung completely filled with puru lent serum. Right bron- chus compressed by en- larged bronchial glands, hard, yellow, and cheesy on section. Nodules in left lung. Numerous nodules in liver up to size of small apple. In both lungs along the larger and smaller bron- Gastro- hepatic lymph nodes; nu- merous nod- ules in duo- denum Firm, fi- brous tissue mostly in a state of hya- line degenera- tion. Nod ules consist of very small fusiform cells surrounded by giant cells No tubercle bacilli Examination of vomitus: portion of membrane, non-charac- teristic bac- teria and one unmistakable hook Nodules composed of leucocytes, well devel- oped embryo nal cells, and less numerous spindle cells Probably sarcoma Primary focus not to be determined; possibly in lung 22 322 TABLE IV 13 Lesieue et Rome, Lvons Med., CXIII, July, 1909, p. 74 Cancer massif du Pou-: mon, secondaire a un Cancer latent du Hec turn M 14 15 LShleix, Verhand. der Deutsch, Path. Gesellschaft, 1908, p. Ill Cystisch papillarer Lungentumor Ogle, Ctril, Trans. London Path. Soc. Vol. XL VIII., 1897, p. 37 16 RrniscH & Sch??vahtz Mt. Sinai Hosp. Re- ports, 1903, p. 26 Primary Sarcoma of the Lung and Pleura M U 54 69 28 33 Lns'G IN- VOLVED CLINICAL SYMPTOMS cfidoema'of abdominal waU, some ascites. Puncture vdthdrew bloody serum and patient felt better, but physical signs remained the same. Liver becomes larger. Increasing dyspnoea; icterus. Death 4 weeks after admission. Du- ration about 2 months Cough for years; for IJ years loss of flesh and strength. 3 months before entering hospital ceases work. On ex- amination nothing found except dulness left base, diminished breathing, some mucous rales. Continued loss of weight, but nothing found to explain condition except the few signs on lungs. Noth- ing could be felt in rectum. Died 4 months after admission. During all this time the only lung sjTnptoms were pain in left chest, dyspnoea, and persistent cough. Vocal fremitus preserved. X-raj' showed extensive shadow at left base and immobility of left diaphragm Died of tubercular pericarditis Cough and occasional haemoptysis for 5 years intermittently. Physical signs suggest empyema ; hectic tj-pe of fever. Death from profuse haemop- tysia Xo heredity. Sj-philis. Pain, loss of weight, hoarseness. Bulging of left chest. Dilated veins of upper ex- tremities and chest. Flatness and absence of voice and breathing. As- piration negative. Enlargement of IjTnph nodes, liver and spleen. CEdcema of face, left arm and chest. Increas- ing dyspnoea, fever up to 104, emacia- tion MISCELLANEOUS 323 SPTTTtrU AUTOPSY NOTES METASTASES MICROSCOPE REMAEKS chi and scattered under pleura similar nodular foci At times Massive tumor occupying In liver and Tumor of Only example of sanguin- nearly all of left lower lobe, under dia- lung consists large massive second- olent, no only a very small strip of phragm. All of typical cy- ary lung tumor. Au- tubercle lung tissue persisting at other organs lindrical thor justly says that bacilli. base. Tumor broken down healthy celled carci- if autopsy had not Mostly in places gives impression of noma exactly been so carefully muco- primary tumor in lung. In hke that of done, this case would purulent rectal ampulla 6 cm from recttoiQ undoubtedly have and anus a carcinomatous ulcer been classified as scant. evidently primary primary lung tumor. Haemop- It is also remarkable tysis at that there were prac- various tically no symptoms times of the rectal carci- noma No details _ Besides the tubercular le- No details PapUlary Origin possibly sions there was found a tu- and cystic from bronchial mu- mor the size of an apple in adenoma cous glands lower lobe containing cav- ities filled with mucus; strands and ramifying tracts of spongy tissue between them Profuse Cavity in lower lobe sur- No details The tongue- Origin probably in haemop- rounded mainly by lung tis- like projec- mediastinum com- tysis. sue communicates with left tions have pressing bronchus. Offensive main bronchus — evidently stratified epi- causing bronchiecta- sputum a bronchiectatic cavity — thelium cov- tic cavity, and pene- suggested offensive dark red contents. ering fatty trating and growing bronchi- Pear-shaped flat masses of and fibrous in this ectatic tissue roughly resembling tissue and dilata- skin and covered _with hair having many tion protrude into this cavity. Several stalks are joined in- to one mass which can be traced beyond the ca'V'ity in- to the mediastinum to right of pericardial sac. Sac con- tains sebaceous matter, hairs 1 J inches long, and one large tooth sebaceous glands No details Entire left chest and medi- Retro- Simply astinum filled with tumor. peritoneal stated that Heart dislocated to right. lymph tumor is en- Large abscess in tumor con- nodes dothelioma taining putrid pus 324 TABLE IV 17 18 SOMMERS, N. Y. Med. Record, LX, 1901, p. 475 Dermoid Tumor of the Lung SORMANI, Gazz. d. Osp., Milano, 1890, XI, p. 314-322 Di un Caso di Cisti Der- moids del Polmone sinistro M 27 26 LUNG IN- VOLVED REMARKS Died of chronic pulmonary phthisis. Both lungs tubercular and cavernous No heredity. Was first child; preg- nancy and birth normal. As baby during first 4 months very susceptible to cold and exposure to open air. After lengthy nursing had to be held in upright position, as she was seized with strong attack of coughing and dyspnoea. Cough increased as she grew older; also dyspnoea; cyanosis of lips. In her 16th year hairs were no- ticed in her usually mucoid sputum; they were supposed to have been in food eaten and no further attention was paid to them. Some time later a whorl of black hair was expectorated. Phthisical habitus. Harassing cough and dyspnoea increased. Last two years of Uf e in bed ; the slightest move- ment, even turning, caused severe pain in chest and excessive dyspnoea. Could not eat for dyspnoea. Would not seek medical aid, saying there was no cure for a poor consumptive. Admitted to hospital July 17, 1887. Exact exami- nation could not be made on account of moribund condition of the patient. Death several hours after admission MISCELLANEOUS 325 No details Mucoid, hairs AUTOPSY NOTES Besides the tubercular condition a cystic body was found at apex of right lung containing large masses of hair and some "dentoid bodies" Left pleura adherent. On section of left lung yellowish gray creamy atheromatous material of nauseating odor and containing small brown hairs. Nearly the entire upper lobe and f of lower converted into a large pouch the size of a new-born child's head, containing the ather- omatous material. The wall of the cavity is firm and hard and does not communi- cate with a bronchus. There are many places covered with longer or shorter brown hair. In some places it re- sembles cutis covered with hair; there are also small spots resembhng cartilage. There is a small cyst size of a nut above hUus, also a large one having the same structiu'e and characteris- tics except that the hair is black. Right lung normal. Turbid serum in right pleura and pericardium METASTASES No details MICEOSCOPE No details Wall of sac resembles cutis in structure with typical papillEe, hairs, epi- thelium, sebaceous glands, etc. PLATES Plate ■ 0^ *T-*': ■ Plate f Plate III Plate IV Plate V Plate VI Plate Vil Plate VIII Plate IX ^S^ "'=^' ''^ Plate XI Plate XII Plate XII w Plate XIV Plate XV Plate XVI »iaRBP.sfi»,(. -77,' . -»■ ^ COLUMBIA UNIVERSITY LIBRARY This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED,, u °^m^ DATE BORROWED DATE DUE