769 serous surfaces and the lower lobes were deeply congested. The left lung weighed 20 oz., the right lung 24 oz. The pericardium was normal; numerous petechial haemorrhages were seen on the epicardium, especially on the posterior aspect of the heart ; there was slight hypertrophy of the left ventricle to compensate a mild degree of mitral incompetence ; and the heart weighed 12 oz.
The stomach contained about 80 c.cm. of foul black slimy fluid. The gastric mucosa was red but had no gross lesion to account for the blood in the stomach. In the black slimy fluid were observed tiny white gritty particles. The particles were examined and were found to burn with a white luminous flame and to have a melting point of 138° C. A solution of one of these particles in a little water was acid in reaction and gave a purple colour with ferric chloride. Some of the particles were heated with methyl alcohol and sulphuric acid and gave the characteristic odour of wintergreen. Much aspirin was also found in solution in the stomach contents. The peritoneum was healthy. The liver weighed 59 oz. and appeared healthy. Microscopically the earliest stage of chronic venous congestion was seen-i.e., congestion and dilatation of the sinusoids in the central zone of the liver lobules. A few fat globules were present. Viewed under the high power of the microscope the liver cells were seen to contain very numerous tiny yellowish-black granules. The gall-bladder contained watery golden bile, but no stones. The spleen weighed 7 oz. and was congested. The kidneys each weighed 6 oz. and had the appearance of cloudy swelling. Microscopically examined, sections stained by haematoxylin and eosin showed that most of the glomeruli were congested with blood and swollen so as almost to fill the capsules of Bowman. Yellowishblack particles, similar to those found in the liver were present in the kidney especially in the glomeruli, but were not so numerous as in the liver. Cloudy swelling of renalepithelium was observed. The head was not examined.
Unfortunately no clue to the amount ingested by this patient was obtained.
of aspirin There is reason to believe that it had been obtained in the form of tablets, crushed in the hands and swallowed dry. The dose was probably taken between 1 P.M. and 3 P.M. The features of the case which appear to be important are : (1) the signs of very profuse perspiration ; (2) the presence of blood in the stomach and petechial haemorrhages on the serous membranes ; (3) the condition of the kidneys, amounting practically to a glomerulo-nephritis ; and (4) the presence of granules in the liver and kidney cells probably representing an attempt to deal with the drug. My thanks are due to Dr. C. C. Easterbrook for permission to
these details and to Mr.
county analyst, Dumfries, who assisted in identification of the
poison. SALIVARY GLAND TUMOUR
BY D. C. L. FITZWILLIAMS,
C.M.G., M.D. Edin.,
F.R.C.S. Eng. SENIOR SURGEON TO ST. MARY’S HOSPITAL, LONDON
MIXED tumours of the salivary glands so rarely death from secondary metastatic growths that the following case seems worthy of record. cause
patient, aged 48, a confidential maid, was admitted Hospital for the last time on June 20th, 1934. History.-In May, 1930, she had been operated upon in St. George’s Hospital for a submaxillary swelling. which on pathological examination resembled a mixed parotid to St. Mary’s
tumour. In December of the same year she had X ray treatment to the area, but whether because of recurrence or as a precautionary measure was uncertain. In 1932 the tumour recurred and was removed from the same region; it was described as a myxo-endothelioma. In October, 1932, another operation was performed in St. George’s Hospital for removal of a part of the same submaxillary gland. In June, 1933, she was sent by Dr. Fairfield Thomas to see me at St. Mary’s Hospital with a
large painful swelling under the left side of her jaw. The tumour was painful to touch, ached, and kept her awake, and she had to take sedatives to make her sleep. On ascertaining her history I thought it best to send her to see her former surgeon who had operated twice already. On being told that he could do nothing more for her she returned to me. Examination and treatment.-The swelling extended from near the symphysis back to the sternomastoid muscle and spread over the jaw on the left masseter muscle; it was fairly well defined, craggy and irregular, as if growing from a number of different centres. It was attached to the skin and deeper structures. It was obviously infiltrating tissue outside the old capsule of the submaxillary gland, and removal was not considered possible. No enlarged lymphatic glands could be felt in the neck. Radium was applied interstitially. Twelve 2 mg. needles were inserted in gridiron fashion under the tumour, eight horizontal and four vertical. They were removed on June 30th, 1933 (dose 5760 mg.-hours). Course of illness.-The patient left hospital on July 1st and reported at three-monthly intervals. As the result of the treatment the tumour fibrosed rather than disappeared, but the pain went and sleep returned. She On was quite well and gave up attending hospital. Oct. 19th, 1934, however, Dr. Fairfield Thomas again sent her to see me and she was again admitted to St.
Mary’s, as she complained of weakness, breathlessness, and being readily fatigued. She had the frequent reasonless little cough so characteristic of irritation of the vagus. The base of her right lung was dull from the seventh rib downwards, and the breath sounded distant. An exploring needle obtained no fluid. She had pain in her chest and a rub could be heard on the right side. There was no sign of her old tumour to be seen or felt locally. On Oct. 22nd half a pint of fluid was aspirated and her breathing improved; no organisms or characteristic cells were found. On Nov. 6th she still had pain and was breathless ; she was tapped again and a pint or more drawn off. On Nov. llth she still had pain and was breathless. She vomited and went rapidly down hill and died on Nov. 30th. Post-mortem.-There was a mass of hard growth on the left side of the neck extending from just below the auricle to the midline and reaching the lateral wall of the pharynx. It was impossible to identify either parotid or submaxillary glands in the mass, which was eroding the mandible in the submaxillary region. The deep cervical glands on the left were extensively involved. Both pleural cavities contained fluid, with more on the left. About forty plaques of growth 1-2’5 cm. in diameter were present on the left pleural surface of each lung, and one 4-5 em. in diameter on the left side. Similar nodules were seen on the pleural surface of the diaphragm, and rather larger nodules scattered through both lungs. Between the lobes were similar plaques, but here they were more confluent. The nodules were umbilicated on the surface and on section were cystic with small mucinous areas. Microscopical examination.-Portions of the growth from various parts of the neck and lung are essentially similar in structure. Some parts are very degenerate. They are best preserved in the lungs where the structure is that of a very cellular salivary gland tumour. The cells are sometimes polygonal in small solid masses, sometimes columnar in tubes and alveoli, and sometimes drawn out with long processes lying in a mucinous stroma. Mitotic figures are present in small numbers. Fibrous stroma is less than is usually seen in an innocent salivary gland
I have operated on some eighty mixed tumours of the salivary glands and I have never met a case similar to the above. Operation combined with a heavy dose of radium applied interstitially (40006000 mg.-hours) seems to cure these tumours absolutely. I can recall only two cases of recurrence since I adopted irradiation, and they date from the time that a less heavy dosage of radium was used. I fancy that the size of the tumours now encountered is smaller than formerly : in other words, an earlier diagnosis being made and early treatment adopted.