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amount of blood being forced into the internal viscera and overcoming the reflex contraction.
If the surface area to which the application is made is small, the reflex effect may be confined to the internal area in sympathetic relation therewith, and will be greater and more prolonged, for the reasons that, the reflex influence being concentrated upon the circumscribed area, the mechanical effect is distributed over the rest of the body, so it does not overshadow and wipe out, so to speak, the reflex effect in the smaller area involved.
And while it is not the amount of blood in a part that is injurious, but the pressure effects, and the collection of waste products, it is an indicator, and since, according to Ludwig, the lymph flow depends on the blood pressure in the capillaries, the value of thermic applications to maintain or increase the pumping action of the blood vessels (peripheral heart) is inestimable. On the other hand, it is clear the too prolonged or too intense application slows the transmission of impulses or so benumbs the nerve as to defeat the purpose.
CARCINOMA OF THE SPLEEN AND STOMACH
BY DR. A. M. SHOEMAKER, WHITE HAVEN, Pa.
M. K. Male, age 38, single. Came under my care November 12, 1909.
Previous history.-Typhoid fever twenty years ago; pleurisy six weeks ago; slight cough for thirteen years and history of catching cold very easily. Previous to the pleurisy he had apparently been in good health.
Family history-Father, mother, six brothers and one sister all living and well.
Subjective symptoms.-Slight cough; watery expectoration; poor appetite and poor digestion, with symptoms of fermentation, alternate constipation and diarrhoea; slight and intermittent pain in the left upper quadrant of the abdomen.
Objective symptoms.-Patient was emaciated (height 5 feet 4 inches; present weight, 1081⁄2 pounds; highest previous weight, 130 pounds, and average weight, 120 pounds); extremely anemic; skin of a sallow, pasty white, tongue red at the tip; beefy in appearance and coated posteriorly.
Physical examination.-Impairment of each apex, more marked on the right side, with increased vocal resonance at both apices, bronchial breathing at the right apex and bronchial vesicular at the left apex. At the left base there was movable dullness extending up to an inch above angle of the scapula and to a corresponding level in front.
Liver dulness began at the fifth interspace and extended in the mid-clavicular line to 21⁄2 inches below the costal margin. Stomach tympany began at the seventh rib and extended to the costal margin. Abdomen somewhat distended. Spleen and kidneys not palpable. Heart dullness apparently not extended to the right. There were no murmurs and the pulse was 120, small volume and regular. Temperature, 100 2-5 degrees.
Urine. Red, S. P. 1023, acid, no albumen or sugar.
Microscopical examination.-Few red blood cells, very few hyaline casts, oxalate calcium crystals. Repeated sputum examination negative for tubercle bacilli.
The evening of the day I examined him he vomited a lot of dark, foul smelling blood. November 19, blood examination showed red blood cells 1,960,000, hemoglobin 28 per cent., white blood cells 125,600. My first impression was that it was a medullary leukemia until it was shown that there were no myelocytes present. November 21, after course of treatment with Fowler's solution white blood cells were reduced to 84,000. At this time the spleen was easily palpated below and underneath the costal margin, and the stomach tympany pushed upward. At times his bowel movements were almost black. Ordinary microscopic examination showed unmistakable red blood cells. November 28, white blood cells 32,000, hemoglobin, 36 per cent. Tapped him posteriorly at the eighth interspace at point of the most intense dullness and drew 7 ounces of bloody serum. On the same day vaccinated with Koch's O. T. after method of Von Pirquet. No reaction.
November 30, complained of marked pain in the left upper quadrant of the abdomen and in the left lumbar region. Left lumbar region was tender and dull on percussion.
December 5, blood count, red blood cells 2,300,000, white blood cells 54,000, hemoglobin 28 per cent. Differential count, polymorphonuclear 80 8-10 per cent., lymphocytes 10 per cent., large mononuclear 6 8-10 per cent., eosinophiles 2 4-10 per cent. December 7, aspirated and withdrew 52 ounces bloody serum. He developed a general oedema even to the bulbar conjunctiva.
December 18, had a severe chill, with prostration, but recovered in a short while, and the next day felt as good as formerly.
December 20, died suddenly apparently of shock. During his whole course of illness he had but little fever, it averaging the first three weeks 97 degrees a. m. and 101 degrees p. m., being very irregular averages, the second and third weeks, from 97 degrees a. m. to 99 degrees p. m.
The diagnosis was not made before death. Tuberculosis of the lungs, while possible, was doubted, and, if present, of not enough moment to cause his symptoms. Malignancy or a peri-nephritic abscess was suspected. The pleural effusion, because of the presence of blood, pointed either to an active tuberculosis of the pleura or malignancy. In view of the other symptoms, it was thought the condition was probably malignant, possibly sarcoma.
Autopsy. Upon opening the abdomen very little adipose tissue was present and there was a small amount of fluid in the peritoneal cavity. Liver extended downward about 3 inches below costal margin, left lobe was adherent to the diaphragm and the stomach. The omemtum was adherent to the organs in the left upper quadrant, spleen enlarged, extending below the costal margin about an inch and was adherent to the parietal peritoneum.
In separating the adhesions the spleen was ruptured posteriorly and found to be necrosed in its upper third. Behind it there was a large clot, its equal in size, and a large amount of necrosed tissue. Upon removal, in the centre of the ne
crosed area was found a growth the size of a large walnut which was harder than the surrounding tissue. Upon splitting, this growth was found to be pinkish white and extended into the spleen tissue in finger-like shoots. Stomach and intestines were distended and a small growth found at the cardiac end of the stomach adjacent to the spleen. The pancreas was apparently normal. The under surface of the diaphragm adjacent to the spleen apparently had the same growth. The left lung was absolutely collapsed. The left pleura over the diaphragm and the mediastinum thickened, roughened, and had several areas of congestion. There were a few recent cobweb adhesions from the lung to the pleura. The left pleural cavity was filled with serous fluid. The right lung showed marked anthracosis, some compensatory emphysema and thickening at the right apex, with some pleural adhesions at this point.
Kidneys showed chronic parenchymatous nephritis. From the extent and nature of the growth in the spleen, the smallness of the nodule in the stomach and the condition of it, and also from the history of the case and the course of the symptoms, it is to be presumed that the growth was primary in the spleen. Histological examination made by Dr. W. T. Cummins, Philadelphia, Pa.
Diagnosis. Acute fibrinous pleuritis.
Emphysema and Fibroid pneumonia (no tuberculosis).
Chronic parenchymatous nephritis.
Necrosis (post mortem) of pancreas.
Carcinoma simplex of stomach and spleen.
The diagnosis being rather a rare condition, I will quote in detail part of Dr. Cummins' report, which is as follows:
"Section through diaphragm and spleen.
"Upon that portion of the section which seems to be the pleural surface of the diaphragm there is a fibrino cellular exudate, beneath which and extending to the muscular tissue there is a round cell infiltrate. The remainder of the section closely resembles the description of spleen as noted below.
"Spleen.-Capsule moderately thickened with fibrous tissue: That part of the spleen lying immediately beneath this appears
quite loose, alveolated in character. A few malpighian corpuscles are to be seen. Another section shows the entire specimen to be alveolated. The normal splenic cells are seen in each section, but in addition many polynuclear neutrophiles and eosinophiles and cells with large, round and elliptical vasciular nuclei resembling epithelial cells.
"Stomach.-Three sections, all from cardia. These resemble each other rather closely, and in two of these, the mucosa is well outlined and in places the basement member appears lost. Throughout the submucosa and muscularis the tissue is densely packed with cells of irregular character, all of which, however, have vesicular nuclei. There is almost no fibrous tissue and blood vessels are but few in number. In portions of the sections polynuclear neutrophiles and eosinophiles and plasma cells are present. These are seen prominently near the mucous surface. (On account of the evident proliferation of the glandular epithelium, penetration of the basement membrane and the vesicular and epithelial character of the cells making up the major part of the tissue, a diagnosis of carcinoma is made)."
PRELIMINARY REPORT OF ITS OPERATIVE TREATMENT IN
BY DR. GRANVILLE T. MATLACK, WILKES-Barre, Pa.
The thyroid gland is a very vascular, dusky, brownish red body, which embraces the upper part of the trachea and extends up on each side of the thyroid cartilage. It consists of two lateral lobes, the right being the larger. Its weight is about one ounce and half. It is covered by a thin fibrous capsule, which divides posteriorly, one part covering the posterior side of the gland; the other going to the other side of the esophagus. It is attached to the trachea with the capsule. The isthmus crosses the trachea opposite the second, third and fourth rings. It is relatively larger in the female. The isthmus