Report on Mental Diseases

HENRY R. STEDMAN
1904 Boston Medical and Surgical Journal  
one-half inches in width with the stump of the appendix as a center, was excised. This opening was closed by two rows of Lembert sutures of silk. A chain of small glands beneath the cecum was then excised, and the abdominal wound closed. The patient made an uninterrupted recovery, and at the present time is in excellent condition. The pathological report by Dr. Channing C. Simmons follows. pathological examination. Appendix. -The appendix was 6 cm. long and of uniform diameter but firm and
more » ... r but firm and somewhat thickened. The peritoneal surface was roughened, slightly injected, and adherent to the mesentery, which extended to the tip of the organ, by fine fibrous adhesions. On section the walls were somewhat thickened, more so at the tip than at the base. For 1 cm. at the base the coats were not as clearly marked as in other parts of the organ and the tissues were firm and of a whitish color. No tumor or anatomical tubercle could be distinguished. In gross the mucosa was without ulcération and appeared normal. Microscopic examination. -The specimen was hardened in formalin, and the sections stained with hemotoxylon and eosin, and by Van Gieson's method. Examination of a section from the base showed the walls somewhat thickened. The longitudinal muscular layer appeared nearly normal, the main thickening occurring in the circular layer, which was partly replaced by loose fibrous tissue, and in the submucosa which showed extensive round cell infiltration. The mucosa was in some places normal while in others it was partly necrotic and infiltrated with leucocytes. A lymph follicle in some of the sections extended one half way around the lumen. In the submucosa and extending through both muscular layers were several small solid masses of atypical epithelial cells. The clumps of cells were, as a rule, far apart but in one section several nests in the submucosa were in close apposition. The areas were larger and more numerous in the submucosa than in the muscular coats, and in several places in the latter the cells were arranged in columns as if occupying the position of a lymph space. The cells were small, closely packed together, with round or somewhat oval nuclei and deeply staining protoplasm which, however, did not have sharply marked outlines. A few mitotic figures could be found on careful search. There was in no place any tendency to gland formation. The growth had no definite borders and was not associated with the mucosa, in no place reaching the lumen of the gut but rather occupying the deeper layer of the submucosa. Examination of sections from other portions of the appendix showed some small round cell infiltration of the submucosa and considerable lymph adenoid tissue. There was no evidence of any new growth and the sections were not remarkable. Cecum. -The specimen consisted of a disc-shaped piece of tissue from the head of the cecum, 6 cm. in diameter. Eccentrically placed on the peritoneal surface was a line of silk sutures which, on being separated, showed the stump of the appendix. Around this the peritoneum was slightly injected and showed a fine line of subperitoneal hemorrhage 2 em. long running towards the edge of the specimen and probably representing the attachment of the mesentery. On section through the base of the appendix the walls were slightly thickened and inflamed but there was no evidence of any new growth. Elsewhere the gut appeared normal. Microscopical examination of a section through the base of the appendix and the cecum showed the walls somewhat edematous, infiltrated with small round cells and containing many dilated vessels. The tie used in securing the base of the appendix could easily be distinguished and was infiltrated with granulation tissue in which were large numbers of foreign body giant cells. There was in no section any evidence of a new growth. Sections from other portions of the cecum showed nothing remarkable. Microscopic examination of three lymph nodes removed from the subcecal region, showed hyperplastic lymphadenoid tissue. Diagnosis. -Carcinoma of the appendix of rather a scirrhus type. Chronic appendicitis.
doi:10.1056/nejm190411241512105 fatcat:fvrejw4okfe3xfy5dqizc67wa4