REBRINTED ER,QN1 
UNIVERSITY 
Medical Magazine. 
EDi'EO UNDER THE AUSPICES OF THE ALUMNI ANO FACULTY QF MEDICINE 
OF THE UNIVERSITY OF PENNSYLVANIA. 
EDITORIAL STAFF 
Armory CommrtW; 
E4te<»l Committor : €«•-...* umiMU 
CONTENTS. 
"3,"F"Z r-' ' • ' " 
«»».«-» * *"• ""* * 
V-ZT^-< * -Exr.Xi*- «.w 
mnvBASirv or reNNAVLVAXi* ium' 
rvtxcnc. «a.oo a x»r 
NOVEMBER, 1805 
TWO CASES OF CARCINOMA OF THE PANCREAS. 
BY A. O. J. KELLY, A.M., M.D., 
PHILADELPHIA, 
Pathologist to St. Agnes's Hospital; Assistant to the Medical Dispensary at the Hospital of the University of 
Pennsylvania ; Clinical Assistant in the Neurologic Department, Philadelphia Polyclinic. TWO CASES OF CARCINOMA OF THE PANCREAS. 
By A. O. J. Kelly, A.M., M.D., 
Philadelphia, 
Pathologist to St. Agnes's Hospital j- Assistant to the Medical Dispensary at the Hospital of the 
University of Pennsylvania; Clinical Assistant in the Neurologic 
Department, Philadelphia Polyclinic. 
It has recently been my fortune to conduct autopsies on two 
cases of carcinoma of the pancreas, both of which are alike interest- 
ing, because of the fact, if for no other, that in neither was the diag- 
nosis made antemortem. The rather incomplete clinical histories are 
as follows : 
Case I.-W. W., male, aged 39 years, a stone-cutter by occupa- 
tion, was admitted to the medical wards of St. Agnes's Hospital, 
July 12, 1894. His mother is living and well; his father died of a 
stroke of apoplexy; two brothers and two sisters died from causes 
unknown. During childhood patient had measles, and some few years 
ago is said to have had an attack of apoplexy. During his youth he 
contracted syphilis. Four months previous to his admission to the 
hospital he says he had an attack similar to the present one. He was 
admitted to the hospital complaining of dyspnea, which at times be- 
came very much aggravated, palpitation of the heart, attacks of severe 
coughing, edema of the legs, anorexia, and occasional vomiting. His 
legs were much swollen and tender and pitted upon pressure. His 
lungs were normal. His heart-beat was rapid, irregular, widely dif- 
fused, and had its maximum intensity at the level of the seventh rib 
in the nipple line. The area of cardiac dulness extended from the 
second interspace to the seventh rib, and from the left nipple line to 
two inches to the right of the midsternal line. Auscultation at the 
apex revealed rapid irregular heart-beat, systolic and diastolic mur- 
murs, the latter, as further examination demonstrated, transmitted 2 
A. O. J. Kelly. 
from the aorta. Pulsus celer. The edema of his legs continued to 
increase, and that of his scrotum became so great as to necessitate 
tapping, a quart of fluid being withdrawn towards the end of July. 
About this time his right arm gradually became rather markedly 
edematous; his left remaining normal. Towards the end of August 
his scrotum was again tapped; not so much fluid was withdrawn at 
the time of this operation, but the wound continued to discharge 
for some days ; and the same occurred when the abdomen was punc- 
tured a few days subsequently. Towards the middle of September 
the edema of the legs had become excessive, as was also that of the 
right arm, especially below the elbow. The left arm, more particu- 
larly the hand, was occasionally slightly edematous. The edema 
also affected the skin of the trunk as high up as the nipples. The 
peritoneal cavity contained free fluid. At this time the following 
measurements were taken: 
Around the chest at nipples 38 inches. 
" " umbilicus . " 
" " scrotum 14% " 
Right. Left. 
" " biceps 10% inches. 9 inches. 
" " elbow 12% " 8% " 
" " lower arm . . .... 13 " " 
" " wrist 8% " 6% " 
" " hand 9 " 8% " 
" " thigh 24 " 24% " 
" " knee 17 " " 
" " calf " 16% " 
" " ankle 15% " " 
" " foot 10% " 10% " ' 
The edema of the legs became so excessive as to necessitate 
small cutaneous punctures or slits for its relief. This operation, which 
was performed under antiseptic precautionsand repeated at intervals, 
was followed by marked benefit. The patient continued in varying 
states of comfort; at times the edema was excessive, again it would 
markedly improve, as did also his general condition, especially about 
the beginning of this year (1895). Then followed a repetition of the 
old state of affairs, the edema of his legs and right arm becoming 
excessive. Edema returned to his left arm and increased until it was 
quite marked. His urine, which varied in daily quantity from eighteen 
ounces to two or three quarts, when he was taking diuretics, so far 
as the examination went, revealed no pathological changes; it con- 
tained no albumin and no casts; there is no record of it having 
been examined for sugar. The treatment pursued was simply directed 
towards the relief of his most prominent and distressing symptoms, Carcinoma of the Pancreas. 
3 
and in addition to the above-mentioned tappings and cutaneous punc- 
tures, consisted of various diuretics, cardiac and general stimulants. 
There was a progressive increase of all his symptoms until his death, 
which occurred May I, 1895. 
The following are the notes made at the autopsy, which was per- 
formed ten hours after death : Body of well-developed male; marked 
edema of all extremities, trunk, face, and neck. The edema of the 
right arm is more pronounced than that of the left. Panniculus adi- 
posus edematous. On incising the peritoneum a large quantity of 
clear, straw-colored serum escapes. The two layers of the pleura of 
the right lung are firmly united in their entirety ; the right lung is 
very edematous, but otherwise normal. The left lung and pleura show 
the same conditions except that the pleuritic adhesions are not quite 
so firm. The pericardial sac contains about twenty-five cubic centi- 
metres of clear straw-colored serum. The heart is greatly increased 
in size; the left ventricle is dilated and its walls almost twice their 
normal thickness. The mitral orifice admits two fingers, the leaflets 
and chordae tendineae are somewhat thickened. The tricuspid orifice 
readily admits four fingers. The pulmonary leaflets are normal. The 
aortic orifice is increased in size, and the free edges of the aortic 
leaflets have become diminished by the growing together of the 
valves. The aorta is somewhat atheromatous, especially the descend- 
ing portion. The liver is dense, increased in size, on section gener- 
ally yellowish with reddish-brown spots indicating centre of acini. 
The gall-bladder is much decreased in size and contains a few gall- 
stones. The spleen is enlarged, capsule thickened, organ dense; the 
pulp is dark brownish-red on section, trabecula increased. The kid- 
neys are slightly enlarged, dense, on section dark reddish-brown, cor- 
tex and medulla apparently otherwise normal. The stomach, the 
pylorus, the duodenum, the appendix, the cecum, the bladder, the 
large and small intestine are normal, except for excessive distention 
with gas of the transverse colon. The pancreas is somewhat increased 
in size and the entire organ changed into a firm solid tumor mass. 
The head seems to be especially the seat of tumor formation ; here 
and there in the body and towards the tail are appearances which 
suggested the normal pancreas ; the cut surface is whitish-gray, moist. 
The pancreatic duct is patulous. The retroperitoneal glands, the in- 
guinal glands, the bronchial glands, the cervical glands, and the 
axillary glands are all much enlarged. The axillary glands of the 
right side are particularly the seat of enlargement, as are also 
the cervical glands of the same side, and encroach upon the lumen 
of the axillary vein. 
Pathological Diagnosis.-Primary carcinoma of the pancreas A. O. J. Kelly. 
4 
metastasis throughout the lymphatic system; aortic and tricuspid, 
insufficiency ; atheroma of aorta ; cyanotic induration of liver, spleen, 
and kidneys ; chronic pleuritis. 
Unfortunately, the specimen was poorly cared for, and the 
necessarily unsatisfactory sections for microscopical study, which I 
was later enabled to make, precluded any possibility of detailing 
any of the minutiae, but showed the carcinoma to be of the scirrhous 
variety. 
Case II.-Mrs. M., aged 57 years; native of Ireland; house- 
keeper by occupation; was seen in private practice. The family 
history of the patient is negative. Of interest is it that her mother, 
after having been jaundiced for twenty weeks, recovered after the 
passage of a "stone." The patient presented herself March 8, 1895, 
complaining of jaundice. She stated that she had been feelingunwell 
for several weeks, complaining of general malaise, loss of appetite, 
and occasional vomiting. 
The jaundice, which the patient stated was of but a few days' dura- 
tion, was universal and very marked. There were no symptoms refer- 
able to the thoracic viscera, examination of which was negative. 
Examination showed the entire abdomen to be enlarged, but espe- 
cially the upper right hand portion. The liver dulness extended in the 
mammillary line from the sixth rib to a full hand's breadth below the 
margin of the ribs, being somewhat lower in this line than elsewhere. 
Palpation revealed a mass continuous with the right border of the 
liver. This mass was about the size of a goose-egg, was apparently 
somewhat roughened, and rather soft. It moved with respiration and 
was evidently attached to the liver. No other distinct nodules could 
be made out. The other organs were apparently normal. A diagnosis 
was made of cancer of the liver or gall-bladder, or both, and this opinion 
was shared by other physicians who saw the case. The jaundice, with 
persistent itch, bile-stained urine, and ashy-colored stools, remained 
unchanged, and emaciation, which was evident before, became more 
marked and progressive. The loss of appetite increased to absolute 
distaste for food. The mass, however, did not increase in size nor in 
any way change its characteristics, which fact led to a surgeon of 
eminence being called in consultation, having in view an exploratory 
operation as a relief for possible impacted gall-stones, though there 
was no evidence of the same except the persistent icterus. The sur- 
geon, however, also viewed the case as one of hepatic carcinoma and 
declined to operate. Except the presence of bile, examination of the 
urine revealed no abnormalities. The subsequent history of the case 
is that of progressive increase in all her symptoms, with the single 
exception of the abdominal mass, which continued the same size until Carcinoma of the Pancreas. 
5 
her death, which occurred June 8, 1895, the diagnosis remaining 
unchanged. 
The autopsy was held twenty-four hours after death. I was per- 
mitted to examine the abdomen only. The body was that of a small, 
markedly emaciated, deeply icteric female. Panniculus adiposus 
almost wanting. The abdominal cavity contained no fluid. The 
liver was enlarged, elastic, on section deeply green in color; the bile- 
ducts were much dilated and contained bile. The gall-bladder was 
about twice its natural size, soft and elastic to the touch. On section 
it was found to contain about an ounce of light-yellowish, somewhat 
inspissated bile, and about 150 gall-stones about the size of small 
peas. The pancreas was diminished somewhat in size, of very firm 
consistence; on section it was whitish-gray and yellowish; nowhere 
was the normal pancreatic structure demonstrable,-the entire organ 
being converted into this tumor mass. The pancreatic duct was not 
patulous. The gastro-hepatic omentum was infiltrated. The common 
bile-duct was obliterated. That portion of the gall-bladder nearest 
the cystic duct was yellowish-white in appearance, rather suggestive 
of carcinomatous change. The spleen was bile stained, otherwise 
normal. The kidneys were enlarged and bile-stained. The stomach, 
duodenum, small and large intestine, bladder, and genital organs were 
apparently normal. The retroperitoneal glands were not enlarged. 
The pathological diagnosis was carcinoma of the pancreas, with 
consecutive closure of the ductus communis choledochus,-cholelithi- 
asis. 
I was not permitted to retain the specimen for microscopical 
examination. 
From our mistakes in diagnosis, and from our failure to make 
diagnoses, we are ofttimes enabled to profit more than from those 
cases in which our surmises are confirmed by post-mortem examina- 
tion. I venture the assertion that most of our delinquencies in 
matters of diagnosis are traceable to incompleteness of examination, 
and the question suggests itself, Was the diagnosis of carcinoma of 
the pancreas possible in either of the cases here reported ? In Case I, 
I think not. There were no symptoms whatever to direct one's atten- 
tion to the pancreas, and because of the fatty and edematous abdomi- 
nal walls, and the ascites, it would have been impossible to palpate 
the organ. The early development of edema of the right arm and 
the later gradual development of edema of the left arm, seemingly 
independent of the edema of the legs, manifestly due to the condition 
of his heart, might have suggested first right-sided, later left-sided 
metastasis to the axillary and cervical glands from a common source ; 
but how unlikely! The detection of fatty stools or of sugar in the 6 
A. O. J. Kelly. 
urine might have directed one's attention to the pancreas, but even 
with very marked disease of the pancreas one or both of these symp- 
toms may be absent. While the occurrence of fatty stools usually 
presupposes the absence in the alimentary canal of the pancreatic 
secretion, on the other hand, the bile alone seems capable at times of 
causing full absorption of the fat; and thus with a markedly diseased 
pancreas, fatty stools may be absent. The interest which is attached 
to pancreatic diabetes is only intensified by the fact of the occurrence 
of diffuse carcinoma of the pancreas without the presence of sugar in 
the urine; quite a number of such cases having been reported. A 
possible explanation of this fact is sought in the supposition that the 
cancer cells being derived as they are from the pancreatic cells, while 
they have lost all secretory function are still capable of performing 
their antidiabetic action. In this case I am certain the diagnosis 
could not have been made. 
In Case II, a careful examination of the stools and the detection 
of quantities of fat therein might have brought the diagnosis of car- 
cinoma of the pancreas among the possibilities. The tumor could 
not have been felt because of the enlarged liver and distended gall- 
bladder, but the deep jaundice, with progressive emaciation and fatty 
and greasy stools, in conjunction with the fact that the palpated tumor 
-the distended gall bladder-did not enlarge nor materially change 
in any of its characteristics, might have rendered the diagnosis of 
carcinoma of the pancreas somewhat probable. But even with com- 
pleteness of examination, inquiry into the occurrence of fatty stools 
and the presence of sugar in the urine, among other investigations, it 
will always require great diagnostic acumen to distinguish carcinoma 
of the pancreas from carcinoma of other organs in the same region,- 
more particularly of the gall-bladder or of the pylorus with involve- 
ment of the glands in the hilus of the liver. The exclusion of the 
one or the other by the absence of the symptoms pertaining to it, of 
course, renders the other more probable, and while I think in such 
cases the question of carcinoma of the pancreas should always be 
considered, diagnosing it will at best be a hazard.