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Papers by the Staff

OF THE

MEDICAL FACULTY.

McGILL UNIVERSITY.

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CARCINOMA OF THE (KSOFHACCS WITH FATAL H.tMOKRHAGK
FROM THE SL'UCLAVIAN ARTERV.

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P.HJ.'^FINLKV. M.D.. iind J)/ P. ANDEKSON, Ml).

(Reprinted from the Monti'ntl Medical Jourual, February, ISiii.'.)

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C'AIHHNOMA UK TllK (RSOPIIAOITS WITH l'ATAI< II.KMOH.

hha(;k khu.m Till-: suuclavian aiitkuv,

HY
F. (i. KINI-RY. M. n. AND n. I». ANDKIISON, M.I);

.Tmuoa 11.— A cartor, aged 60. was adniittcd 1.. the Montri'iil Gcn.Tal
Hospital oil Sc|)|(.|iil)(.r i;. l8i)S, {'oiiipliiiiiiiij: of hoarseness and inability
to swallow solid food.

lie had used alcohol to excess for years, but was moderate in the use
of tobacco. In April, of the present year, he began to Buffer from a
slight congh, nnn in June, he first noticed difTieuIty in swallowing solid
food. He has been hoarse for six weeks.

Present Conditiun. He is a rather poorly nourished man. with a
blight degree of anaemia. The muscles are soft and small, and the sub-
cutaneous tissue scanty. Theie is complete aphonia, thi' patient heing
only able to speak in a whisper. iJr. Birkett reports that there is com-
plete paralysis of the left vocal eoril, and deficient adduction of the
right. A No. 8 a'sophageal sound was arrested 13 l-•^ inches from the
mouth, but a No. v passed into tlu stomach.

Apart from some arterial scle'.osis and emphysema of the lungs there
was no disease of any of the organs. The left radial pulse was noted as
much smaller than the right.

On September auth, the patient began to have evening elevations of
temperature, began to complain of a dull pain behind the sternum,
and the dilliculty in swallowing continued.

Oct. 10. A No. 3 oesophageal sound was arrested eight inches from
the teeth.

Nov. 4. Temperatures continue elevated, varying from 98 to 103.
There was a severe rigor yesterday, the thermometer registering 105 2-5.

Nov. 15. t'ough is more troublesome, but expectoration is scanty
and not fetid. Repeated examination never revealed any tubercle hacilli.
About this time the breath became offensive, and four days later this
feature became so marked that he was transferred to an isolation ward.
Septic temperatures, with occasional rigor,s, continued. Emaciation was
marked, but not extreme.

Nov. 25. At 7 p.m. there was a sliglit attack of coughing, immedi-
ately followed by a profuse haemorriiage. He asked for a towel, then
suddenly fell back, gave a few gasps and died.

Abstract of Autopsy — The body is that of a somewhat emaciated old
man.

At a point 3 1-3 cm. above the bifurcation of the trachea the
oesophagus only admits a small probe, and on its mucous surface there

«(

III

is an iil.'CT ;i cm. in cliainct.T. with an irivKulur base fr.m. wlucl. cuiili-
lluwcr-lik.' iMUHrtfs i.rojfft. SuiToun.liiiK tlif oom.phagiis at tins U'vH
is a liiH, mass al.uut tl.o size of a lien's vfi^i. Tliis K'rmvlh oM.n.ls t.. Ih."
IH't and siiri'nmuls tlw Irl't can.ti.l an.l siil.clavian arleru'S, conipreBsiuK
Ihosc vossi'ls an.l nanowinK tl.cir diannrls. 'I'he Krowtli U ..f vory Urni
consist ciu'is of whitisl. aiM>oaruncr. trav»T8o.l by glist^nm- bands and
i-xudinK a cancerous juice. TIm- adjacent lung in densely adherent
„,„| a gangrenous cavity about the si/e of a large api'le >« present at the
anev of tiu' lung, in close relation will, the tumor. This cavity is filled
with dark clotted blood, and a large division of the broiuiius opens into
it There are several small cancerous nodules in the left lung, ami small
patches of hronelio-pnt'iimonia. On the wall of the subclavian artery
•.' |-'v> inches from its origin is a small circular perforation, :» inches in
diameter. Tins oi.ening communicates witli the gangrenous cavity in

the lung.

The crieo-artenoideus lateralis and posticus on the left side are mark-
idly atri.phied. Microscopical examination of the tissue from primary
.-■rowth in oesoi)hagus shows this to he compose.l mainly of fibrous tissue
with extensive inliltration of epithelial cells, these being arranged in
tubular and alveolar forms as in a carcinom.i. The secondary nodules
in the lung though of the same character, ditfer slightly in that the
cellular elements of growth are more of an endothelial type.

AnahmicaUyiaynosis. Cancer of oesophagu.s, Gangrene of lung.
Perforation of second portion of subclavian artery. Broncho-pneu-
monia and secondary growths in tissues of neck and epigastric glands.
Cloudy swelling of organs. Perforative appendicitis and peri-appendi-
cular abscess.

The diagnosis made during life was cancer of the cesophogus, fol-
lowed by gangrene of the lung.

The presence of dysphagia in an elderly and somewhat emanated
man at once drew attention to the oesophagus; obstruction about 8 1-2
inches from the teeth, as found at the second examination, corresponded
to about the bifurcation of the trachea, near which the stricture was ul-
timately found. J rs t
No obvious explanation was found for the fact that the sound first
l)assed i;5 1-2 down the oesophagus, and then was arrested. There was
no stricture at this i)oiut, and there was possiblv some error in obser-
vation.

In a case tinder the late Dr. Oo. lioss, one of us once passed an oeso-
phageal sound into a large gangrenous cavity„of the lung, and, so failed
to find obstruction in the oesophagus. At the autopsy some days later
the communication with the lung had closed. It is needless to say that
in the present case such a fallacy could not have occurred.

A featnre of interest was the extreme narrowing of the oesophagus,

fol-

wluch only .uln.itto.l a sn.nll ,.r..be. In epit.' ..f tins th.r.. was nov.r dU'-

Tlu. ansonution of ,.aralvBi« of the left vocal cord with a s.nall pul^o
i„ ,1... U.fl radial artery is a cmbinatiun whirl,, apart f,o.n a.uM.iiHn..

„,UK, he Komewhal rare. Tlie gruwlh nf Ih.. tu r amun,! thr ancrs

eunn.ressinK an.! narrowing itH lun.en. was very obvious at t''^' a"^"l-y-
.,nd satiHfaotorilv explains the charaetor uf the i-ulse. I'aralyB.B ol the h-lt
reeurrent larvngoal nerve is of frequent oe.nrre.ue in eaneer "^ '"^;;";;":
pha.us. and".KrasionaIlv both nerves ar.. altaek..!, so that by its.lf this
1,: would not nuslead'the clinician, it is. howe.er, .pt.te conceivable
that the ctubination of two such well known sigu. ol aneunsu, .u.gh-

in-ove deceptive. .

Douth Iron, luieiuorrhage is an unusu,,. ternm.atiou m oesoph.g.'ul
ean.rr. In our case th.- artery was a.lhereut lu the lung, and in clo.e
contact with the ga.tgreuous area, a.ul perforation occurred trou, e.x-
tension of the necrotic process. I'he haemorrhage thus took ph.ce ..to

" ga..gfenous cavity, and thence pass.d b.^ the hroudu to th.. mouth.
Taylor* has collected nine cases of fataliiaemorrhage trom the aorta, r.-
sulting fn.n> carcinoma of the oeso,.h s'us. In most of the.u .k-atu re-
sulted from siulden and profi.se vomiti.tg of blood, and m m^arly a 1
cases blood was found in the ston.aeh. I., his ow.. case the.-e was a hole
the size of a pea in the aorta; through this a portion of thr n.nligna..l
.rrowth from the oesophagus had extendel, presenti..g a shiv.l.ly fi a
ment free in the aorta. There was an ulcer opposite the hole u. tlie
aorta, probably produced by frictio.. with th. filamct of caneen.us t.s-
Bue. There was no external haemo.Tl.age, all the blood h.iving i..un.i .ts

way to the stomach. . .,

In our case the haemorrhage w.is fron, the a.'te.y u.to the gangren...i8
cavity, so that none reache.l the stomach. The small peri-a,.pendv-
ctuar abscess was not suspected during life, and the ..gors -hich^.c.ur,-ed
were attributed to an ulcerative p.-o>ess about the tun.or. That this
origin was probable is indicated by the facts that the ngors -jlv oeeu,--
red late in the disease, ami we.-e accompanied by co..gh. a,.d late, by
fetor of the breath, and sputa. ^

• Guy'.s Hospital U 'ports XLIX. ,1812

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