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A CASE OF TRAUMATIC PANCREATITIS.
495 central
system. The mediastinal pleura is with branches from the phrenic nerve, and the clinical history suggests that this nerve was dragged upon, or otherwise stimulated by the abscess cavity when this was full of pus. It is difficult, nervous
supplied
to understand how impulses could be conducted to the central ner-
however,
vous
the
system by phrenic
when it is recalled that half an inch of its length was excised in the neck about three before months the onset of the nerve
pain.
In the absence of a post-mortem it is only practicable to consider the possibilities, of which there to be appear three. The first is that some fibres have crossed the gap and descended the distal segment of the nerve to reach the vicinity of the abscess.
skin in the regions where the pain was experienced. The occurrence of the neuralgia in the upper part of the face is of greater interest and must involve connexions between the phrenic and the central terminations of the trigeminal nerve. It is well known that the spinal nucleus and tract of the latter well descends into the cervical cord, at least as low as the second cervical segment, so that the central fibres of the two nerves are very near and likely to be connected. It has been shown by anatomical and clinical researches1 that the caudal part of the spinal nucleus of the
fifth receives
re-
of generation peripheral
fibres
only from its ophthalmic division ; the most caudal part would be the segment nearest to the central fibres of the phrenic, and this
probably ex-
Observations upon the
nerve
plains the limiRadiogram showing the condition of the lung after artificial pneumothorax and before phrenicotomy. The large pulmonary abscess with a fluid level is not compressed, although the peripheral lung is well collapsed. There is considerable mediastinal dislocation, and a broad basal adhesion is present.
tation
of
the
neuralgia to the
distribution of underr the ophthalmic similar circumdivision of the stances render this explanation highly improbable, trigeminal nerve. A minor’ point of interest is the since the interval between the two segments development of clubbing of the fingers and toes in was so great. This explanation cannot, however, sixteen weeks. A somewhat similar case has been reported by be absolutely excluded. The second possibility is that fibres from the distal end of the proximal I Ricaldoni2 in connexion with artificial pneumothorax segment have sprouted out into the surrounding treatment. In this instance the neuralgia was more deep tissues, and some have passed down between widespread and this was considered to be due to the It disappeared with the fascial planes in the thorax and so extended to refilling of the pleural space. the neighbourhood of the abscess. This appears to the discontinuance of pneumothorax. be quite a reasonable possibility, as after section of a nerve it is well known that fibres grow out and A CASE OF TRAUMATIC PANCREATITIS. will travel along fascial planes, although most of the fibres usually cause a reaction in the neighbouring BY HERBERT R. MAYO, M.B., B.CHIR. CAMB., tissues which leads to the creation of an " end bulb." HON. MEDICAL OFFICER, GENERAL HOSPITAL, GREAT YARMOUTH ; A serious objection to this hypothesis is the short AND time which elapsed between the operation and the EDWARD A. ELLIS, M.B., B.CH. DUB., onset of the pain ; it appears hardly long enough to HOUSE SURGEON TO THE HOSPITAL. permit regeneration of nerve-fibres from the level of the section to the abscess cavity. The third, and A CASE of traumatic has lately been perhaps the most likely, explanation is the occurrence under our care in thepancreatitis General Hospital, Great of an accessory phrenic nerve. This arises usually Yarmouth. Medical literature in Great Britain has few from the fifth cervical nerve, and after passing in front records of such the only one recently recorded cases, or behind the subclavian vein joins the main phrenic ! to our knowledge is that of Waring and Griffiths.3 trunk near the thoracic inlet or in the thorax. This Therefore details of our case may be of interest. junction between the phrenic and the accessory was a Scotch girl of 18, from Stornoway, one The phrenic would be distal to the level of the section of of the patient fish-workers this port during the herring the former, and therefore a pathway from the pleura to fishing season, in thevisiting autumn. She was a strong, healthy the cervical spinal cord would persist after the opera- girl with no history of previous illness or accident. On tion. The occurrence of an accessory phrenic nerve is Oct. 14th she was caught between a wall and a lorry moving sufficiently common to render this suggestion highly sideways towards her, which nipped her at the level of the nerves
probable.
upper half the abdomen.
She
was
rapidly conveyed
to hos-
pital and admitted between 8 and 9 P.:àI. On examination, Relation of Phrenic and Trigeminal Nerves. 1 The Function of the Spinal Nucleus of the Trigeminal It is easy to understand the referred pain in the Nerve, by J. S. B. Stopford, Journal of Anatomy, 1924-25, it to conis since to the refer shoulder, only necessary lix., 120. nexions between the central terminations of the 2 Pneumothorax artificiel et névralgie de la face, A. Ricaldoni, accessory phrenic and the central connexions of the Bull. et Mém. de la Soc. Méd. des Hôp. de Paris, 1921, 3e sér., 802; Abstract in Tubercle, March, 1922, p. 266. descending cutaneous branches of the third and xlv., 3 Waring, Sir Holburt, and Griffiths, H. E.: Brit. Jour. Surg., fourth cervical nerves which are distributed to the 1923-24, xi., 476.
496 no abrasion or bruise was present on the abdomen oramount. As rectal salines were discontinued glucose was: elsewhere. She was suffering considerably from shock, withgiven by the mouth. From Nov. 26th her condition steadily some diffuse abdominal pain. Temperature subnormalimproved, with colour returning to her cheeks. and pulse, 84, was thin. No signs of any gross lesion. She General massage was instituted to improve her muscular received the usual treatment for shock and was kept under tone and general metabolism on Dec. 7th. On the 16th careful and constant observation for any sign of internal the amount of insulin was reduced to five units once a day was 98° F. before the midday meal and this was discontinued on haemorrhage. The next morning the and in the evening rose to 99°. She said she was free from the 22nd. On the 13th she had been allowed to sit in a pain and her general condition was greatly improved. The chair, and day by day she was given further opportunity pulse was fuller. On the 16th her morning temperature for exercise in walking about the ward, and rapidly improved. had risen to 101°and the pulse-rate to 100, and she com- The bowels acted normally without enemata from Dec. 27th plained of vague abdominal pains, but the temperature fell onwards. She was discharged from hospital on Jan. 7th" to 99.4° in the evening and respirations increased to 40. 1928, with a perfectly healed scar and no sign of skin On the 17th the temperature continued to fall, but the pulse irritation around it. She stayed in the town a few days increased in frequency, though still of good volume. The and then returned by easy stages of one day’s travelling to pain increased and was accentuated by ingestion of food far-off Stornoway. Nearly a month later she wrote and and relieved by vomiting. The exhibition of bismuth and stated that she had continued to improve after reaching soda had no influence on the pain which was referred to her home and was rapidly regaining her strength. the epigastrium. The only similar case of which we can find a record is For the next two or three days the pain continued at the one of Delatour,4but there are many points in the but and diminished intervals, pulse respirations and frequency. The temperature was somewhat erratic but of difference. They agree in the age and incidence pain on fell to normal with a pulse-rate of 84 and respiration-rate and amount of shock after operation of 26 after a copious stool, which resulted from an enema exhibition of food. They differ in the amount of given on Oct. 20th. In the evening the temperature rose initial shock, irritation of skin by discharge from to 101.6° with pulse of 100, but in the morning of the drainage-tubes, and subsequent formation of a cyst. 21st it fell to normal again with pulse-rate 80 and respiraThe points to be noted in this case are : (1) The tions 24. During the next three days, though there was was not caused by a direct blow, but by a injury nothing alarming in the pulse and temperature, her consliding squeeze, producing a shearing effect on a dition became worse. She had a bad colour and the pain became so bad that morphia was given to relieve it on limited portion of the abdomen with no local marks the 24th, when operative interference was suggested. As on the skin. (2) The severity of the immediate her condition was much worse on the 25th she agreed to shock differing from the cases reported by Waring an operation. The left upper rectus was rigid and very and Delatour, and we suggest that this may have been sensitive to touch or pressure. There was some general due to direct irritation of the solar plexus. (3) The tenderness over the abdomen and some distension. Tha of the tardy symptoms development directly due abdominal pain was very marked, but it was most acute of (4) The free under the left upper rectus. The respirations had risen to 46. to the pancreatic lesion. Laparotomy was performed on Oct. 25th. As the bulk pus from the gall-bladder drain. (5) The exhibition of the pain and tenderness was on the left side. a paramedian of insulin on the theory of rest and regeneration of incision was made through the left rectus. There was no the pancreas and to assist in the absorption and sign of any damage to the abdominal wall. On opening utilisation of glucose, the most easily administered the peritoneal cavity a little free turbid fluid was noted, nutriment. (6) The most ready and constant response but there was no escape of gas or marked odour. Two or to hypodermic injections of eserine when such three small areas of fat necrosis were seen close to the stomach, which was undamaged. The pancreas was found generally accepted remedies as strychnine, camphor to be swollen with recent adhesions at its head. To obtain and ether and brandy were of no avail. (7) Despite the use of four separate drains and a discharge there-more easy access to the head of the pancreas and the gallbladder a transverse incision was made across the middle from lasting some five weeks, there was a very sound line and through the right rectus, above the umbilicus from abdominal wound, and as the bulk of this is above the the middle of the primary incision. The gall-bladder was umbilicus the risk of subsequent hernia is almost tense and somewhat hidden by recent adhesions. On gently no There was negligible. (8) sign of any cystwas seen to ooze freeing the gall-bladder with swabs pus formation. up from the direction of the head of the pancreas. The gallbladder was freed from its adhesions and pus removed with swabs. A rubber tube was sewn into the gall-bladder, a corrugated rubber and gauze drain to the head of the pancreas, and drainage-tubes to the right kidney pouch and Douglas’s pouch were inserted. The primary incision was sutured and all four drains concentrated in the middle of A CARBONIC ACID SNOW APPLICATOR. the second incision. After the operation she was in a IN the application of carbonic acid snow to state of great collapse with feeble pulse of 120, sighing respiration, and bad colour. Camphor and ether were warts, moles, and small nsevi the protection of the administered subcutaneously and four-hourly rectal salines. surrounding skin always presents a difficulty. The The next day, Oct. 26th, as her condition still remained pressure of the snow pencil creates a temporary crater,. very serious, five units of insulin were ordered twice daily, the sides of which are inevitably frozen and blistered with glucose added to the salines. On the 27th her con- so that the consequent scar is larger than desirable. dition improved slightly, but she. had tympanites, which it is not easy to apply it exactly to the Moreover, was much relieved by a turpentine which was enema, To obviate followed by a loose, copious stool. On the 28th the drainage- tumour. tube to Douglas’s pouch and the right kidney pouch were these drawbacks I have removed and as hiccup appeared eserine gr. 1/100 was given had made to my design four-hourly. On the 29th she was much improved, so the applicator here eserine was discontinued ; but as the improvement dis- illustrated. It consists appeared eserine was again given. of a circle of plate glass During the subsequent period there was a free discharge 2 in. in diameter, with of pus from the drain to the pancreas and the tube in the gall-bladder which at first discharged pure bile, then dis- an axial tube charged bile mixed with pus and, later, almost pure pus. 1 in. on one side, l6 on The skin round the drain was protected with zinc ointment the other. A solid glass and did not suffer from irritation as in the case reported rod to each packs the snow easily and tightly. The by Delatour.4 Her condition was curiously dependent lumen of the tube is exactly applied over the small upon the administration of eserine. When this was disconand the plate held in position by two fingers of tinued she rapidly became much worse, the pulse became one hand, while the desired degree of pressure is the rate did not increase feebler, though much, her colour became bad and she had marked depression and lethargy. maintained by a finger of the other on the end of the Simple enemata were given every alternate day with invari- rod. The app1icators are made in four sizes, , ,
temperature
’
discharge
_______________
New Inventions.
projectiiiu
tumour
ably good results.
On Nov. 5th the stitches were removed. On the 16th the tube from the gall-bladder and the drain from the head of the pancreas were removed, but bile and pus mixed continued to discharge from the sinus in gradually decreasing 4 Delatour, H. Beecham: Annals of Surgery, October, 1921.
,and in. Nsevi of more than in. in diameter can be treated with an unprotected pencil. I have used them with the greatest satisfaction both in private and in hospital practice. The intense cold does not crack or evnn chip the glass. T. B. SELLORS, M.D. Durh.
system. The mediastinal pleura is with branches from the phrenic nerve, and the clinical history suggests that this nerve was dragged upon, or otherwise stimulated by the abscess cavity when this was full of pus. It is difficult, nervous
supplied
to understand how impulses could be conducted to the central ner-
however,
vous
the
system by phrenic
when it is recalled that half an inch of its length was excised in the neck about three before months the onset of the nerve
pain.
In the absence of a post-mortem it is only practicable to consider the possibilities, of which there to be appear three. The first is that some fibres have crossed the gap and descended the distal segment of the nerve to reach the vicinity of the abscess.
skin in the regions where the pain was experienced. The occurrence of the neuralgia in the upper part of the face is of greater interest and must involve connexions between the phrenic and the central terminations of the trigeminal nerve. It is well known that the spinal nucleus and tract of the latter well descends into the cervical cord, at least as low as the second cervical segment, so that the central fibres of the two nerves are very near and likely to be connected. It has been shown by anatomical and clinical researches1 that the caudal part of the spinal nucleus of the
fifth receives
re-
of generation peripheral
fibres
only from its ophthalmic division ; the most caudal part would be the segment nearest to the central fibres of the phrenic, and this
probably ex-
Observations upon the
nerve
plains the limiRadiogram showing the condition of the lung after artificial pneumothorax and before phrenicotomy. The large pulmonary abscess with a fluid level is not compressed, although the peripheral lung is well collapsed. There is considerable mediastinal dislocation, and a broad basal adhesion is present.
tation
of
the
neuralgia to the
distribution of underr the ophthalmic similar circumdivision of the stances render this explanation highly improbable, trigeminal nerve. A minor’ point of interest is the since the interval between the two segments development of clubbing of the fingers and toes in was so great. This explanation cannot, however, sixteen weeks. A somewhat similar case has been reported by be absolutely excluded. The second possibility is that fibres from the distal end of the proximal I Ricaldoni2 in connexion with artificial pneumothorax segment have sprouted out into the surrounding treatment. In this instance the neuralgia was more deep tissues, and some have passed down between widespread and this was considered to be due to the It disappeared with the fascial planes in the thorax and so extended to refilling of the pleural space. the neighbourhood of the abscess. This appears to the discontinuance of pneumothorax. be quite a reasonable possibility, as after section of a nerve it is well known that fibres grow out and A CASE OF TRAUMATIC PANCREATITIS. will travel along fascial planes, although most of the fibres usually cause a reaction in the neighbouring BY HERBERT R. MAYO, M.B., B.CHIR. CAMB., tissues which leads to the creation of an " end bulb." HON. MEDICAL OFFICER, GENERAL HOSPITAL, GREAT YARMOUTH ; A serious objection to this hypothesis is the short AND time which elapsed between the operation and the EDWARD A. ELLIS, M.B., B.CH. DUB., onset of the pain ; it appears hardly long enough to HOUSE SURGEON TO THE HOSPITAL. permit regeneration of nerve-fibres from the level of the section to the abscess cavity. The third, and A CASE of traumatic has lately been perhaps the most likely, explanation is the occurrence under our care in thepancreatitis General Hospital, Great of an accessory phrenic nerve. This arises usually Yarmouth. Medical literature in Great Britain has few from the fifth cervical nerve, and after passing in front records of such the only one recently recorded cases, or behind the subclavian vein joins the main phrenic ! to our knowledge is that of Waring and Griffiths.3 trunk near the thoracic inlet or in the thorax. This Therefore details of our case may be of interest. junction between the phrenic and the accessory was a Scotch girl of 18, from Stornoway, one The phrenic would be distal to the level of the section of of the patient fish-workers this port during the herring the former, and therefore a pathway from the pleura to fishing season, in thevisiting autumn. She was a strong, healthy the cervical spinal cord would persist after the opera- girl with no history of previous illness or accident. On tion. The occurrence of an accessory phrenic nerve is Oct. 14th she was caught between a wall and a lorry moving sufficiently common to render this suggestion highly sideways towards her, which nipped her at the level of the nerves
probable.
upper half the abdomen.
She
was
rapidly conveyed
to hos-
pital and admitted between 8 and 9 P.:àI. On examination, Relation of Phrenic and Trigeminal Nerves. 1 The Function of the Spinal Nucleus of the Trigeminal It is easy to understand the referred pain in the Nerve, by J. S. B. Stopford, Journal of Anatomy, 1924-25, it to conis since to the refer shoulder, only necessary lix., 120. nexions between the central terminations of the 2 Pneumothorax artificiel et névralgie de la face, A. Ricaldoni, accessory phrenic and the central connexions of the Bull. et Mém. de la Soc. Méd. des Hôp. de Paris, 1921, 3e sér., 802; Abstract in Tubercle, March, 1922, p. 266. descending cutaneous branches of the third and xlv., 3 Waring, Sir Holburt, and Griffiths, H. E.: Brit. Jour. Surg., fourth cervical nerves which are distributed to the 1923-24, xi., 476.
496 no abrasion or bruise was present on the abdomen oramount. As rectal salines were discontinued glucose was: elsewhere. She was suffering considerably from shock, withgiven by the mouth. From Nov. 26th her condition steadily some diffuse abdominal pain. Temperature subnormalimproved, with colour returning to her cheeks. and pulse, 84, was thin. No signs of any gross lesion. She General massage was instituted to improve her muscular received the usual treatment for shock and was kept under tone and general metabolism on Dec. 7th. On the 16th careful and constant observation for any sign of internal the amount of insulin was reduced to five units once a day was 98° F. before the midday meal and this was discontinued on haemorrhage. The next morning the and in the evening rose to 99°. She said she was free from the 22nd. On the 13th she had been allowed to sit in a pain and her general condition was greatly improved. The chair, and day by day she was given further opportunity pulse was fuller. On the 16th her morning temperature for exercise in walking about the ward, and rapidly improved. had risen to 101°and the pulse-rate to 100, and she com- The bowels acted normally without enemata from Dec. 27th plained of vague abdominal pains, but the temperature fell onwards. She was discharged from hospital on Jan. 7th" to 99.4° in the evening and respirations increased to 40. 1928, with a perfectly healed scar and no sign of skin On the 17th the temperature continued to fall, but the pulse irritation around it. She stayed in the town a few days increased in frequency, though still of good volume. The and then returned by easy stages of one day’s travelling to pain increased and was accentuated by ingestion of food far-off Stornoway. Nearly a month later she wrote and and relieved by vomiting. The exhibition of bismuth and stated that she had continued to improve after reaching soda had no influence on the pain which was referred to her home and was rapidly regaining her strength. the epigastrium. The only similar case of which we can find a record is For the next two or three days the pain continued at the one of Delatour,4but there are many points in the but and diminished intervals, pulse respirations and frequency. The temperature was somewhat erratic but of difference. They agree in the age and incidence pain on fell to normal with a pulse-rate of 84 and respiration-rate and amount of shock after operation of 26 after a copious stool, which resulted from an enema exhibition of food. They differ in the amount of given on Oct. 20th. In the evening the temperature rose initial shock, irritation of skin by discharge from to 101.6° with pulse of 100, but in the morning of the drainage-tubes, and subsequent formation of a cyst. 21st it fell to normal again with pulse-rate 80 and respiraThe points to be noted in this case are : (1) The tions 24. During the next three days, though there was was not caused by a direct blow, but by a injury nothing alarming in the pulse and temperature, her consliding squeeze, producing a shearing effect on a dition became worse. She had a bad colour and the pain became so bad that morphia was given to relieve it on limited portion of the abdomen with no local marks the 24th, when operative interference was suggested. As on the skin. (2) The severity of the immediate her condition was much worse on the 25th she agreed to shock differing from the cases reported by Waring an operation. The left upper rectus was rigid and very and Delatour, and we suggest that this may have been sensitive to touch or pressure. There was some general due to direct irritation of the solar plexus. (3) The tenderness over the abdomen and some distension. Tha of the tardy symptoms development directly due abdominal pain was very marked, but it was most acute of (4) The free under the left upper rectus. The respirations had risen to 46. to the pancreatic lesion. Laparotomy was performed on Oct. 25th. As the bulk pus from the gall-bladder drain. (5) The exhibition of the pain and tenderness was on the left side. a paramedian of insulin on the theory of rest and regeneration of incision was made through the left rectus. There was no the pancreas and to assist in the absorption and sign of any damage to the abdominal wall. On opening utilisation of glucose, the most easily administered the peritoneal cavity a little free turbid fluid was noted, nutriment. (6) The most ready and constant response but there was no escape of gas or marked odour. Two or to hypodermic injections of eserine when such three small areas of fat necrosis were seen close to the stomach, which was undamaged. The pancreas was found generally accepted remedies as strychnine, camphor to be swollen with recent adhesions at its head. To obtain and ether and brandy were of no avail. (7) Despite the use of four separate drains and a discharge there-more easy access to the head of the pancreas and the gallbladder a transverse incision was made across the middle from lasting some five weeks, there was a very sound line and through the right rectus, above the umbilicus from abdominal wound, and as the bulk of this is above the the middle of the primary incision. The gall-bladder was umbilicus the risk of subsequent hernia is almost tense and somewhat hidden by recent adhesions. On gently no There was negligible. (8) sign of any cystwas seen to ooze freeing the gall-bladder with swabs pus formation. up from the direction of the head of the pancreas. The gallbladder was freed from its adhesions and pus removed with swabs. A rubber tube was sewn into the gall-bladder, a corrugated rubber and gauze drain to the head of the pancreas, and drainage-tubes to the right kidney pouch and Douglas’s pouch were inserted. The primary incision was sutured and all four drains concentrated in the middle of A CARBONIC ACID SNOW APPLICATOR. the second incision. After the operation she was in a IN the application of carbonic acid snow to state of great collapse with feeble pulse of 120, sighing respiration, and bad colour. Camphor and ether were warts, moles, and small nsevi the protection of the administered subcutaneously and four-hourly rectal salines. surrounding skin always presents a difficulty. The The next day, Oct. 26th, as her condition still remained pressure of the snow pencil creates a temporary crater,. very serious, five units of insulin were ordered twice daily, the sides of which are inevitably frozen and blistered with glucose added to the salines. On the 27th her con- so that the consequent scar is larger than desirable. dition improved slightly, but she. had tympanites, which it is not easy to apply it exactly to the Moreover, was much relieved by a turpentine which was enema, To obviate followed by a loose, copious stool. On the 28th the drainage- tumour. tube to Douglas’s pouch and the right kidney pouch were these drawbacks I have removed and as hiccup appeared eserine gr. 1/100 was given had made to my design four-hourly. On the 29th she was much improved, so the applicator here eserine was discontinued ; but as the improvement dis- illustrated. It consists appeared eserine was again given. of a circle of plate glass During the subsequent period there was a free discharge 2 in. in diameter, with of pus from the drain to the pancreas and the tube in the gall-bladder which at first discharged pure bile, then dis- an axial tube charged bile mixed with pus and, later, almost pure pus. 1 in. on one side, l6 on The skin round the drain was protected with zinc ointment the other. A solid glass and did not suffer from irritation as in the case reported rod to each packs the snow easily and tightly. The by Delatour.4 Her condition was curiously dependent lumen of the tube is exactly applied over the small upon the administration of eserine. When this was disconand the plate held in position by two fingers of tinued she rapidly became much worse, the pulse became one hand, while the desired degree of pressure is the rate did not increase feebler, though much, her colour became bad and she had marked depression and lethargy. maintained by a finger of the other on the end of the Simple enemata were given every alternate day with invari- rod. The app1icators are made in four sizes, , ,
temperature
’
discharge
_______________
New Inventions.
projectiiiu
tumour
ably good results.
On Nov. 5th the stitches were removed. On the 16th the tube from the gall-bladder and the drain from the head of the pancreas were removed, but bile and pus mixed continued to discharge from the sinus in gradually decreasing 4 Delatour, H. Beecham: Annals of Surgery, October, 1921.
,and in. Nsevi of more than in. in diameter can be treated with an unprotected pencil. I have used them with the greatest satisfaction both in private and in hospital practice. The intense cold does not crack or evnn chip the glass. T. B. SELLORS, M.D. Durh.