A CASE OF COMPLETE REMOVAL OF A MULTILOCULAR CYSTIC TUMOUR OF THE PANCREAS;

JohnD Malcolm
1906 The Lancet  
1676 when very numerous had the appearance of a reticular skein with denser portions here and there ; in fact, it had exactly the felted honeycomb appearance of a streptothrix preparation. The skein-like character was exceedingly remarkable and gave the impression of being due to the windings of one continuous thread. It is more probable, however, that the meshwork is due to the close apposition of rods lying inclined at all angles to each other, for in some cells the vacuole was filled with
more » ... was filled with perfectly discrete small thick rods. I have never seen these bodies inclosed in other than large mononuclear cells. Regarding Burnett's statement that he had noted the bodies very rarely in polynuclear cells, I should certainly think that he had mistaken a detached portion of the nucleus for one of these bodies. Such detached nuclear portions are exceedingly frequent in the polynuclear cells which exhibit marked winding of the nuclear chromatin. Kurloff's statement that the body may ultimately break through the enveloping protoplasm and leave the cell I have been unable to verify. It is quite true that in the preparation of the films a body may become dislocated from the cell protoplasm but I have never found an apparently free body far away from a large mononuclear cell. I should therefore think that the body, whatever be its nature, develops and disintegrates in loco. Evidence of such disintegration is frequently seen in the faint staining power or even complete disappearance of the contained granular matter. The number of these vacuolated cells varies in different animals. On an average they form about 8 per cent. of the total leucocytes with a variat:on of from 4 per cent. to 11 per cent. As regards the age at which these vacuolated cells appear in the blood of guinea-pigs I have been impressed with the fact that in animals under three weeks old none of these peculiar cells are to be seen in stained films. In one case a female guinea-pig was killed during pregnancy. Blood from the placenta showed numerous vacuolated cells but in the heart blood of the foetus I was unable to find any. Neither did I find any in films prepared from the foetal spleen and marrow, though they were very numerous in films from the maternal organs. In other cases the blood of young guinea-pigs has been examined from birth onwards, but, as a rule, definite vacuolated cells like those of the adult do not appear till about the third week. An interesting question is the distribution of these cells in the organs. In splenic films they are frequently very numerous, far more so than in the marrow. There is no difficulty in distinguishing them from the blood-corpusclecontaining cells (Blutkörperchenhaltige Zellen) which may occur in large numbers in the spleen pulp. On examining the fresh, unstained spleen pulp on the warm stage one can readily recognise these cells by the large straw-coloured homogeneous vacuole filling sometimes three. fourths of the cell body, the nucleus being pushed to the side. Also, in fresh blood the same appearance is observed. No trace of the body inside the vacuole is seen in the fresh unstained condition but by adding neutral red to the blood on the warm stage it is found that the only substance which takes up the stain immediately is the body inside the vacuole. It may appear as reddish granules in active Brownian movement or as distinct rods or even round and irregular clumps. In sections of the spleen stained by Giemsa these cells form a very striking picture. The vacuole is stained a pale pink and appears quite homogeneous. Probably the procedure employed in the fixation of the tissue has caused a dissolution of the granular matter. In one spleen which I examined these cells were present in enormous numbers in the pulp but were quite absent in the Malpighian follicles. Curiously enough, in other spleens it is difficult to demonstrate any in sections. The question now arises, What is the significance of these bodies ? If they represent some Secretstoff, as Ehrlich thought, one might expect to find them in the blood of other members of the Caviidæ. To settle this question I have had an opportunity of examining the blood of four allied animals, agoutis and cavies. These were Dasyproctida cristata, Dasyproctida prymnolopha, Dasyproctida punctata, and Ccelogenys paca. In none of these animals did I find anything approaching the structures found in guinea-pig's blood, although the leucocytic formulas of these animals resembled closely that of the guinea-pig. The peculiar structure of the body suggested the idea of its being a parasite or leucocytozoon of some sort. In favour of this view is the fact that these bodies are not found in young animals or in allied species and that they occur in such varying numbers in different animals. When fresh blood in normal salt solution is carefully watched on the warm stage the vacuole is so highly refractile that the included body is invisible. It immediately comes into view, however, on adding a trace of neutral-red solution, while the nuclei of the leucocytes and the granules of the polymorphonuclear cells take up the stain much more slowly. There is no evidence that the body makes its exit from the vacuole or that definite free motile forms appear, although the amoeboid character and the peculiar spermatozoid-like form of the blood-platelets are undoubtedly apt to lead to some confusion owing to their close resemblance to flagellated parasites. On the other hand, in the absence of any definite proof of parasitic origin, the morphological structure of these bodies in stained films and their inclusion in vacuoles of the cytoplasm suggest a marked analogy to the so-called parasitic vaccine bodies or cell inclusions first described by Guarnieri (cytoryctes variolas or vaccinias) and since confirmed by numerous observers in lesions of the cornea, epidermis, &c., in experimental variola and vaccinia. Further investigations of these bodies are in progress. THE case here recorded is the second in which I have been so fortunate as to be able to remove completely a multilocular cystic tumour of the pancreas. The patient, a female, aged 50 years, felt something move in her abdomen and was very sick about six months before she sought medical advice. This disturbance soon passed off and she "forgot " about the I I lump " but she began to lose flesh and strength about that time. A month before I saw her she fainted and was very pale for the following week. The fasces were " like ink " for three days and then resumed their natural colour. Apparently there had been a haemorrhage into the upper part of the alimentary tract. The patient again became conscious of something abnormal in her abdomen and consulted Dr. Basil G. Morison who sent her to me. Her general condition was good, the urine was normal, and the bowels acted well without medicine. There was an oval, hard tumour in the left side of the upper abdomen measuring about four inches in its lateral diameter and rather more from above downwards. It had considerable mobility exactly resembling that of a large loose kidney, the greatest fixity being towards the spine. The percussion note over the most prominent parts was dull before and behind, the area of dulness varying with the position of the tumour. The right kidney was somewhat mobile. I diagnosed a malignant growth in a loose left kidney, the capsule of which had not yet raptured. At the Samaritan Free Hospital, on April 26th, 1905, I opened the abdominal cavity by an incision outside the left rectus muscle. The transverse colon was displaced downwards and pressed forwards by a growth which was seen between it and the Etomach. There was only one layer of serous membrane over the tumour which apparently had developed to the left of the lesser sac of the peritoneum. The kidney was in normal position behind the neoplasm and the tail of the pancreas lay across the upper inch or rather more of its anterior surface intimately attached to it. Many vessels over the tumour were ligatured as they were divided and the mass was gradually freed without much loss of blood until its only attachment was to the pancreas. I cut into this gland so as to get the whole growth away. The pancreatic tissue bled freely but it showed no friability and ligatures applied to it held well. A large vein, quite a third of an inch in diameter, was cut across and there was a 1 A paper read before the Clinical Society of London on May 11th, 1906.
doi:10.1016/s0140-6736(01)83744-2 fatcat:biuj32jodrebjlondwrffzyaju