A CASE 
OF 
INTRA-THORACIC CANCER. 
BY 
J. H. POOLEY, M.D., 
Professor of Surgery in Starling Medical College, Columbus, Ohio 
[REPRINTED PROM THE OHIO MEDICAI. AND SURGICAL JOURNAL.] 
COLUMBUS: 
NEVINS AND MYERS, BOOK AND JOB PRINTERS. 
1877. A CASE 
OF 
INTRA-THORACIC CANCER. 
BY 
J. H. POOLEY, M.D., 
Professor of Surgery in Starling Medical College, Columbus, Ohio 
[Reprinted from th* Ohio Medical and Surgical Journal.] 
COLUMBUS: 
NEVINS AND MYERS, BOOK AND JOB PRINTERS. 
1377. INTRA-THORACIC CANCER. 
On the 15th day of March, 1877, I was requested to see 
Miss C., aet 59, of whose case I received the following history: 
She had been sick for about three years, complaining of 
cough, pain in the chest, and gradual loss of appetite and 
strength. Simultaneously with, or a little later than the 
beginning of, her other complaint, a tumor had made its ap- 
pearance on the left side of her neck, which, six months 
before my seeing her, had softened on the surface and had 
been opened by a physician, who supposed it to be an abcess, 
but nothing flowed out but blood and a little thin watery 
fluid; it has remained open ever since, and several other 
tumors, presently to be alluded to more particularly, have 
since made their appearance. She has been under the care 
of several physicians, but nothing that has been done for 
her has been of any service, except that a year before, her 
eough, which was very severe, was benefited by some pre- 
scription of a homoeopathic physician, and has never been 
so bad since. Family history good, free from cancer. 
I found her in bed, considerably emaciated, with an ex- 
pression of painful anxiety upon her countenance, but she 
said she had no pain anywhere, only a difficulty of breathing, 
and occasional cough, with almost complete sleeplessness, 
loss of appetite, distressing weakness, and a pruriginous or 
papular eruption over the whole surface, the itching of which 
tormented her beyond measure, and had caused her to scratch 
in such a way as to have marked her whole body and limb3 
with her nails. Though she was pale as well as thin there 
was no sallowness of hue, nor so-called cachetic appearance. 4 
Her pulse was one hundred, temperature normal, respira- 
tion, when quiet, very little quickened, but the least exer- 
tion made it very rapid and disturbing. 
• There was dullness on percussion over the front of the 
chest extending from the top of the sternum, and for two or 
three inches on either side of it; heart sounds weak and in- 
distinct; breath sounds normal and somewhat puerile, or ex- 
aggerated on both sides. She had a rather troublesome 
cough, but very little expectoration, and that of a thin 
mucus. The tumor on her neck, already alluded to, was 
situated about the middle of the left lateral cervical region, 
as large as an orange, round, uniform, unlobulated, with a 
large, irregular crater form opening on its summit, with 
ragged, undermined edges, and the cavity filled with very 
irregular granulations with deep depressions between; it 
exuded a thin sanies of a peculiar faint, disagreeable odor. 
It was neither painful nor tender. 
There was another tumor, about the size and shape of a 
hen’s egg, just under the chin; this was quite soft, and about 
its middle was a purplish soft spot, which fluctuated quite 
distinctly. 
There was another hard tumor on the anterior edge of the 
left axilla, about the size of the one under the chin, but 
rounder and nodulated; two small ones in the left breast and 
one in the right. None of these swellings gave her any 
pain, nor were they the cause of any complaint; she sought 
relief for her pulmonary troubles, her weakness, and, above 
all, the tormenting itching which made her miserable by 
day and by night. An attempt was made to remove a por- 
tion of the open tumor for microscopical examination, but 
owing to her extreme nervousness and timidity only such a 
small piece was obtained that it proved of no value. Notwith- 
standing this I felt very little hesitancy in making the 
diagnosis of intra-thoracic cancer. I’ prescribed iron and 
arsenic, a wash of hydrate of chloral for her prurigo, and one 5 
grain of codeine occasionally, to relieve her distress and pro- 
mote sleep. 
These means proved of benefit to her, the chloral abated 
the itching very materially, and the codeine proved a mosf 
admirable sedative, and gave her much needed sleep. 
She went on without much change for a month, except 
that her dyspnoea slowly increased, but the cough became 
better and soon ceased to trouble her at all. By the latter 
part of April or first of May her dyspnoea became so great 
that she could no longer lie down at ail, but sat constantly 
in an easy chair, and very soon she became incapable of 
straightening herself up in the chair, but sat bent forward 
as far as possible the whole time. There was no change in 
the thoracic signs, except slight increase of the dullness in 
front, while the heart sounds became feebler and more indis- 
tinct. During the month of May edema of the feet and legs 
came on, but never became excessive, being relieved by open- 
ings that formed spontaneously at points where she had 
scratched herself deeply; here superficial ulcers formed, 
which never healed up, but never spread or became trouble- 
some, from which Die dropsical fluid constantly oozes away 
in large quantities Her urine, which was repeatedly ex- 
amined, never yielded any trace of albumen. She lost her 
appetite entirely, and experienced, besides, some difficulty 
in swallowing, so that she took no food at all, nothing except 
a little wine, and occasionally a very little milk; she refused 
all medicines except her powders of codeine, which she said 
were the only comfoit she had. For many weeks it was a 
mystery how life was maintained. 
About the beginning of June, a hemorrhage, of large ex- 
tent, took place from the open tumor in the neck, which had 
been gradually ulcerating more deeply into the tissues. 
This was checked by packing the sore with Rohland’s 
styptic cotton; it recurred once or twice, but only to a small 
amount. This haemorrhage prostrated her very much, and for a few 
days she seemed to be sinking, but after that she rallied 
again, and continued to li ve in the condition I have described, 
and without any change worthy of note until July 31, when 
she quietly expired at 7 P. M. 
Autopsy Twenty-one hours after Death.—Body very much ema- 
ciated, cadaveric rigidity well marked; no sallowness or 
icteroid hue of surface. 
In addition to the external tumors already described, two 
more as large as large marbles were found on the left arm, 
near the insertion of the detoid; they were round, hard, even, 
and freely moveable under the skin. 
Only the thorax and abdomen were examined. On at- 
tempting to remove the sternum, it was found firmly adhe- 
rent to an abnormal mass of tissue underneath, and was with 
difficulty separated from it. 
After accomplishing its removal the whole of the anterior 
mediastinum was found to be filled with a firm, white tumor, 
which crowded the heart backwards, and somewhat down- 
wards, and encroached on either side for an inch or two upon 
the sides of the lungs. On removing the whole of the tho- 
racic contents the following additional observations were 
made: 
The cancerous mass occupying the mediastinal space was 
much thicker above than below; it not only overlapped the 
lungs on either side, but the roots of the lungs themselves 
were infiltrated to a slight extent. There was no enlarge- 
ment or other alteration in the bronchial glands. The lower 
portion of the new growth Avas blended inextricably with 
the pericardium, which Avas thoroughly invaded by the dis- 
ease. The interior surface of the pericardial sac, and the 
surface of the heart Avere thickly sprinkled over with hard, 
white patches, looking like irregularly disposed droppings 
of Avax or spermaceti. Upon opening the cavities of the 
heart its Avails were found infiltrated with the cancer; on the 7 
upper part or base of the ventricular walls it was fully half 
an inch in thickness. The muscular tissue of the heart was 
pale and flabby; the valves were perfectly healthy. 
There was a small nodule on the convex surface of the 
liver, one in the spleen, and a much larger one attached to 
the uterus by a slender pedicle. The uterus, kidneys, and 
intestines and mesentery, with its glands, were healthy. 
The large mass occupying the mediastinum was very firm, 
hard seirrhus cancer, the other deposits were softer, and some 
of them presented the characteristics of encephaloid. 
Though not excessively rare, intra-thoracic cancer is suffi- 
ciently uncommon to make it desirable to record all the cases 
in order that future investigators may have extended material 
from which to study this interesting subject. 
The diagnosis in this case, aided as it was by the co-exist, 
ence of external tumors, was easy enough, but in many in- 
stances it is far otherwise; nor, I am sorry to say, does the 
present case aflord any symptom that can be considered 
patpognomonic or clearly distinctive of the disease. The 
peculiar form of dyspnea, necessitating the constant bowed 
position of the patient, has been noticed in many cases of 
mediastinal cancer, and together with extensive dullness in 
the front and median portion of the chest, would seem to be 
deserving of careful attention. 
The utter absence of any peculiar tinge of skin, hereditary 
history, and the very slight amount of pain, are also important 
particulars, and militate strongly against the value of these 
signs so much and so long relied on in the diagnosis of can- 
cerous disease. 
Notice of a case of intra-thoracic cancer will be found in 
another part of this journal, and three recent cases are given 
by Dr. William Pepper in the Philadelphia Medical Times 
for August 4, 1877. 
In addition to these and other cases scattered throughout 
the journals, I would take the liberty of indicating the fol- 8 
lowing sources of special information for the benefit of those 
who wish to pursue the subject: 
1. Cancerous and other Intra-Thoracic Growths. J. Eisdon Bennet. 
London. 1872. 
2. On Intra-Thoracic Cancer. By John Cockle, M.D. London. 1865. 
3. Kleffens on Pulmonary Cancer. 1841. 
4. Henri Gintrac. Sur les Tumuers Intra-Thoracique. These de Paris. 
1345. 
5. E. Kohler. Inaugural Dissertation Tubingen. 1847. 
6. Kilgour. Edinburgh and London Medical and Surgical Journal, 
October, 1844; and Edinburgh Monthly Journal, 1850. 
7. Aviolat. Du Cancer du Poumon. These Paris. 1861. 
8. Dr. Budd. Paper on Cancerous Tumors within the Chest. Med. 
Chir. Trans. Vol. 43. 1859. 
9. Struve. Diss. de Fungo Pulmon. Lips. 1839. 
10. Lacaze Dutliiers. Mai. Cane, des Pleur. These Paris. 
11. Schuster. Inaugural Dissertation. Ueber Thoraxgescliwiilste. 1851. 
12. Falcon. Eneophaloid Diseases of Thymus Gland. London. Medi- 
cal Gazette. Vol. 31, p. 731. 1838. 
13. Symes Thompson. On Mediastinal Tumors. Medical Mirror, 1865. 
No doubt some, perhaps important contributions have been 
overlooked, but I believe not many, and those here indicated 
will include all that are necessary for most purposes.