DOI: 10.7925/drs1.ucdlib_280451
title: Cancerous disease of the pleura

description: Watercolour medical illustration depicting cancerous disease of the pleura. It has the alternative reference number 1974 and P2C on the front. The Richmond Hospital Museum reference is B.e.38. The entry for this in P263/1 pg. 17 reads 'Cancerous disease of the pleura'. The same is written below the illustration. The artist's name is in the bottom left corner 'E. Ribton Byrne Fecit. 1874'. The typescript note on the back begins 'Case of Haemorrhagic Sarcoma of the Pleura, combined with Extensive Pleuritic Effusion'.
description: Scope and content: The full typescript note on the back reads 'Case of Haemorrhagic Sarcoma of the Pleura, combined with Extensive Pleuritic Effusion. By Samuel Gordon MB., F.K.Q.C.P.; Physician to the House of Industry Hospitals. The following case presents many features of interest, not the least of which is, that it elucidates the difficulty of diagnosis which complication of disease causes, whereas either of the morbid conditions existing alone could have presented little or no difficulty. Margaret Clarke, aged twenty, a servant, from the suburbs of Dublin, reported herself to have been in perfect health, and able to perform her usual work, until five weeks before her admission to hospital. She then got a severe wetting, and was immediately after attacked with pain in her right side and short breathing. She was admitted into the Whitworth Hospital on the 20th of February. She is a strong, well-made girl, and has not the appearance of being affected with any constitutional disease. She has still pain in her right side on deep inspiration. The entire right side is dull on percussion, the dulness [sic] extending beyond the anterior mediastinum, and the heart is displaced downwards, and towards the left side. The right side was two inches larger than the left; the intercostal spaces obliterated, the side motionless on inspiration, and she could not lie on the left side. There was no respiratory murmur audible in the right side of the chest, except in the very upper and posterior part, where it was bronchial. The respiratory murmur over the left lung was loudly puerile. The heart's action was very rapid, 120, and feeble. The respiration was 34. The diagnosis given was pleuritis, with very extensive effusion, compressing the right lung into the cone of the pleura, displacing the anterior mediastinum and the heart. As she had still some pain on deep inspiration, a few leeches were applied to the right side, and she was ordered some mild mercurial. On the 23rd there was no improvement in any respect – on the contrary, the face was rather suffused, and her lips rather blue. I therefore, introduced a small-sized trocar and canula, between the fifth and sixth ribs, and drew off 90 ozs. of reddish serum. After this she was able to lie on her left side. The respiration came down to 28, and the pulse, without diminishing in frequency, became more full. The heart returned almost to its normal position, the bronchial breathing at the apex of the lung was less pronounced; but otherwise the stethoscope phenomena was not much altered. The secretion of urine was very scanty; contained a large amount of lithates, but no albumen. The grey powder was continued, with a diuretic mixture, containing in each dose a few grains of iodide of potass, and she was allowed a small quantity of wine. On the 7th of March the breathing had again become frequent, and the pressure on the heart so urgent as again to require thoracentesis, and 60 ozs. of the same red serum were withdrawn, with again temporary relief. Again, on the 14th, 50 ozs. were withdrawn, and on the 21st 75ozs. After each tapping there was decided relief, chiefly evidenced by the effct on the circulating system – the face became always less suffused and the lips of a brighter colour, and the heart invariably rose up to nearly its natural position, and each time that the operation was performed I was led to do so more from the evidence of pressure on the heart, than from the difficulty, or frequency, or respiration. On the occasion of the third tapping I found her almost pulseless, her face becoming livid; I rapidly introduced a trocar, and as the fluid came away she revived, and on this occasion made a very considerable rally for some days. The internal treatment adopted was quite unsuccessful in producing any of the ends sought for. It was found impossible to mercurialise her, though there was not the least disposition for the mercury to pass away by the bowels: nor did any form of diuretic increase the flow of urine. She rapidly emaciated, had slight cough, with frothy expectoration, which was sometimes tinged with a very light streak of blood. At length her hands became oedematous, her appetite failed, and she rapidly sank. She died on the 30th of March. The post-mortem examination was made by Dr Yeo, Assistant-Physician to the Hospital, and the following is his account of the recent appearances. [The morbid parts and a drawing of the recent appearances were presented to the Society.] Body emaciated and anaemic. Liver considerably displaced – lower margin extending down to the umbilicus, the right half of the diaphragm bulging into the abdominal cavity. Abdominal viscera, and left lung, and pleura, healthy. Heart displaced on the left side. Pericardium greatly thickened on its mediastinal aspect, blended above with a dense mass of tough elastic tissue, and below with the thickened pleura. It contained about 2 ozs. of clear fluid. The parietal layer of the membrane was also thickened and enlarged on the right side, where were numerous elevated nodules, about the size of a Spanish nut, some of which were extremely congested. On the anterior surface of the heart was a group of very small nodules, similar to those on the parietal portion of the membrane. The right pleura contained 80 ozs. of the same reddish serum as was drawn off during life. The parietal pleura was greatly thickened throughout, and covered with smooth round knobs, about the size of a walnut, some of which were deep plum colour, and others pale yellowish white. Its mediastinal part reached an inch in thickness, and was found to be continuous with a marge mass of tissue which occupied the entire mediastinum. This was found to form an irregular tumour, continuous with the neighbouring serous membranes, and completely enveloped the arch of the aorta and its branches, as well as the cava and innominate veins, and lay around the front and sides of the trachea. The vessels were all quite pervious, and their calibre seemed unaltered. On section this tumour was found to be composed of rounded masses of a soft elastic structure, bound together by a certain amount of ordinary connective tissue. The nodules in the pleura and pericardium were found to have the same properties on section. The right lung was quite compressed, resembling the tissue of the spleen, quite airless, and covered by a thick, tough layer of structure, similar to the degenerated coastal pleura, but more even on the surface. There were not any adhesions at any part of the pleural cavity, and the surface was glistening, and appeared to be covered by a normal serous coat. Brain not examined. Microscopic examination showed the greater part of the tumour to be made up of small, spherical, granular cells, of uniform size, connected together by a very small quantity of slender, structureless, intercellular substance – in short, to be a strikingly characteristic example of s small, round-celled sarcoma. The dark parts were found to be extremely vascular, and in many places studded with small extravasations of blood, which gave these portions of the tumour the appearance of a haemorrhagic sarcoma. I do not think that it was possible in this case to have diagnosed the existence of the malignant disease up to the time of the first tapping, for the dulness [sic] and absence of respiration caused by the pleuritic effusion, joined on so intimately to that caused by the pressure of the tumour, as to leave no intervening space, by which the boundaries of a tumour could be defined. There was no venous congestion, nor enlargement of superficial veins, the malignant growth (as the post-mortem examination showed) being of that soft yielding nature which allowed veins and arteries to pass through it uncompressed; and, thirdly, on account of the diminished size of the heart and the intervening fluid, there was no intensification of the heart's sounds through the malignant mass. It becomes another question, whether, after the first tapping, a more correct diagnosis should not have been made. I did, in fact, pronounce that the case was most probably one of secondary pleuritic, for the following reasons: - 1st The colour of the fluid drawn off – it was not serum, tinged with blood, but serum, with which blood was intimately and permanently blended; 2ndly Because the relief afforded, although considerable, was not in proportion to the amount of fluid drawn off; and 3rdly Because there was no corresponding change in the physical signs after the removal of large quantities (on one occasion 60 ozs.) of fluid from the chest. The diagnosis so far was frequently repeated after subsequent tappings, and this additional reason assigned that the system refused to respond to any line of treatment adopted. No medicine which was administered seemed to have any legitimate effect on the system, and at last further paracentesis was declined, on the ground that it was not the amount of fluid in the chest which was causing the patient's death, but some organic disease from which the constitution was suffering. But the question remains, whether the diagnosis of malignant disease ought not to have been made. The only certain point upon which this diagnosis could have been founded was the nature of the pleuritic fluid. To this point Trousseau has paid most particular attention, and the summary of his observations is that, although the existence of sero-sanguineous fluid is highly diagnostic of the serous membrane being affected with cancer, it does not afford absolute proof of such, and, accordingly, he begins by saying:- "I need not tell you that we possess no positive sign by which to recognise cancer of the pleura, yet if in a woman affected with cancer we find pleural effusion slowly supervening, we may conclude that the bronchial glands and the pleura are themselves the seat of cancerous degeneration, and the nature of the fluid drawn off will have an especial signification". It will be observed, that in the case before us the two first indications were altogether wanting. There was no cancerous development in any other part and the accumulation of the fluid was very rapid. We had, therefore, only the nature of the fluid to guide us. Influenced by this alone, however, Trousseau pronounced a case operated on by Dr Barth to be cancer of the pleura, and did so from the recollection of one under his own care several years before. This latter case is so similar to that of Margaret Clarke (except in the existence of an external cancer), that I have ventured to transcribe it for the information of the Society. On the 9th of November, 1844, a woman, aged fifty-four, suffering from cancerous atrophy of the right breast, became my patient in the Necker Hospital. She had been several months in the St Louis Hospital for rheumatic pains of the limbs, unaccompanied by any general disturbance of the system. She was having some vapour baths, when, on the 20th of November, returning from the hot room, she felt a chill, and was attacked with acute pleurisy on the right side, which presenting nothing special in its symptoms, was treated by bleeding, blistering, digitalis, and calomel. About the 20th of December the effusion, far from diminishing, had increased much, and continued increasing until, at the end of December, it had reached the clavicle and supra-spinous fossa of the scapula. By the beginning of January enlargement of the chest was visible. The dulness [sic] anteriorly had transgressed the median line, and the heart was displaced a little to the left side. On the 20th of January the dullness had passed four centimetres beyond the median line, and the heart was still more displaced, and the liver could be felt below the false ribs. Notwithstanding this condition, the patient had no dyspnoea; sometimes in the evening slight orthopnoea. There was well-marked fever, puffiness of the face, and oedema of the chest. On the 24th, paracentesis seemed to be absolutely necessary, and was then performed in the usual manner. There were no fits of coughing while the fluid (which was bloody) was escaping. The improvement which followed the operation was but slight. The stethoscopic phenomena were unaltered. From the 1st to the 11th of February the patient's condition remained stationary; but, on the latter day, erysipelas set in. The effusion increasing, and threatening to suffocate her, I again performed paracentesis, and again drew off sero-sanguineous fluid. The oedema of the chest increased, her strength failed, and she gradually sank. At the autopsy we found the pleura cancerous, and convered throughout with fungoid tumours of encephaloid growth. It remains only to observe upon the age of the patient and the rapidity of the growth of the disease, and these both may be considered as intimately connected with the form of the carcinoma. Cruveilhier amd all subsequent pathologists have observed that this form of malignant disease (of which I have never seen a more characteristic specimen) is that to which the young are more liable, * which grows the most rapidly, *In the Richmond Hospital Museum, among other specimens, is one of very extensive haemorrhagic sarcoma in a child one year old*, and is so frequently attended with haemorrhages; that while they sometimes have actually proved fatal, it is very rarely that a post-mortem examination does not afford proof of their having occurred, and on more than one occasion'.
description: Numbering/sequence: Original reference number: 1974.