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A NOTE ON SPLENECTOMY FOR TORSION OF THE SPLEEN IN A CHILD.
642
Clinical Notes : MEDICAL, SURGICAL, OBSTETRICAL, AND THERAPEUTICAL.
localised pockets of pus adjacent to the pericardium and on the left surface of anterior mediastinutn. Lower lobe, gangrenous stinking cavity 3 by 2 inches in dimensions, bounded below by the diaphragm and involving one-third of the mass of the lobe. The rest of the lobe shows resolving massive consolidation. Embolus or thrombus to account for the gangrene could not be found. Heart: Apparently normal; no ante-mortem clot.
Re1nat’ks. It may be that Case 2 was an abscess of the lung of other primary origin than an embolus, but the type of TWO CASES OF GANGRENE OF THE LUNG lesion post mortem certainly suggested embolic origin COMPLICATING INFLUENZAL PNEUMONIA. in spite of the fact that an occluded artery could not be demonstrated. These two cases occurred amongst a BY J. DE VILLE MATHER, M.D. MANCH., series of 49 other post-mortem examinations made ASSISTANT PHYSICIAN, MANCHESTER NORTHERN HOSPITAL ; the course of the epidemic. In two other of during AND these cases there were present small multiple abscesses, not gangrenous in type. In the comprehensive account F. B. SMITH, B.CH. CANTAB. of the disease and its pathology given by Drs. A. Abrahams, N. Hallows, and H. French in THE LANCET THE account by Dr. Cronin Lowe in THE LANCET of of Jan. 4th, 1919, no mention is made of pulmonary Jan. 15th of three cases of rsevere colitis found post embolism. mortem after influenza recalled the following two cases of gangrene of the lung seen by us during the same A NOTE ON influenza epidemic. In view of the similarity of one form of this disease to a true septicaemia such a com- SPLENECTOMY FOR TORSION OF THE SPLEEN IN A CHILD. plication might be expected to result from an embolus. At the time-i.e., June, 1918-March, 1919-no instance of pulmonary embolus recorded by others came to our BY A. H. SOUTHAM, M.A., M.CH.OXON., F.R.C.S. ENG., notice, and during the two years subsequently a search RESIDENT SURGICAL OFFICER, MANCHESTEB ROYAL INFIRMARY. through a considerable portion of the literature has failed to show any reference to the condition. The reason for recording the cases is not that we think them TORSION of a wandering spleen in a child, followed very unusual, but in order to ensure that the picture of by the operation of splenectomy, is a condition not often the disease may be made as complete as possible. One met with. The successful result makes the following case was diagnosed before death ; both were fatal. notes worthy of publication. CASE I.-Lieutenant -, aged 23. Admitted Oct. 21st, 1918, from J. H., a boy, aged 6 years, was brought to the Manchester Royal transport ship after reporting sick six days previously. Irritable Infirmary on Dec. 31st, 1920, with a diagnosis of acute appendicitis. dry cough. Temp. 101’4 F. Headache, sore throat; copious, blood- His mother stated that he had been seized with sudden abdominal stained purulent sputum for last 24 hours. Poor air entry over the previous evening at 10.30 P.M. whilst he was in whole of chest, with small localised area of broncho-pneumonia pain bed, and had been vomiting continuously ever since. He in the left lower lobe. 23rd: Pyrexia subsided by lysis; P. 60, R. 20, had never complained of abdominal pain previously. On chest remarkably clear of signs; patient merely exhausted. 27th : examination he was found to have a temperature of 100’F., and Allowed to sit up in easy chair. 29th: While sitting up in chair at a pulse of 120. The whole abdomen was held very rigid, with 6 P.M. sudden acute attack of pain in the left lumbar region. The tenderness and rigidity most marked over MeBurney’s point. patient likened this pain to lumbago ; its sharp stabbing onset was I decided to perform laparotomy immediately. When under the very noticeable. No physical signs obtained. Chest still clear. anaesthetic, a large and freely movable tumour was Dalpable in the 30th : T. 100, P. 90, R. 26. Examination of chest, abdomen, and right iliac fossa. The abdomen was opened through the right urine negative. No cough; patient could lie only on the right rectus muscle and the tumour was found to be an enlarged and side; abdominal muscles quite rigid. 31st: Haemoptysis of about congested spleen. The organ was without difyaculty delivered 20 oz. of dark blood, with striking relief of pain in the side ; through the incision, and the pedicle was then seen to be twisted diagnosis of pulmonary embolus made. Nov. 2nd: Sputum on itself two and a half times. The pedicle was transfixed and copious, muddy, limpid, no mucus, very offensive; small effusion ligatured in two halves, a second ligature encircling the whole of fluid left base; sputum showed no pus cells, appeared to be a pedicle. The pedicle was then divided, distal to the ligatures, and pure culture of a diplo-streptococcus. 8th: Left chest explored, the spleen removed. The abdominal incision was sutured in layers. fluid withdrawn having the same characteristics as the sputum. Convalescence was uneventful, and the child was discharged from half an hour lasted under chloroform and Operation.-This hospital on Jan. 19th, 1921. The spleen was found to weigh 14 oz.ether. A portion of the seventh rib was excised; incision opened three to four times the usual weight of the organ at this age. A blood film, taken immediately after the operation was comdirectly into a large gangrenous cavity in the deep substance of the lower lobe of the lung, apparently well shut off from the upper pleted, showed a slight polymorphonuclear leucocytosis, but otherpleural cavity. T. subnormal, P. 100, R. 28. Wide drainage. wise no change from the normal. A second film, taken the day 12th: Gaseous cellulitis of chest and loin; extensive incisions. before his discharge from hospital, showed a leucocytosis with Carrel-Dakin’s tubes. Impossible to apply local antiseptics to the some diminution of the colour index. Microscopical examination chest cavity on account of threatened asphyxiation of the patient of a section of the spleen showed extreme congestion of the by any fluid introduced. 18th: Extension of the cellulitis to the organ; no other pathological changes were to be found. buttocks; lobar pneumonia right lower lobe with clear pleural The cause of the enlargement of the spleen is effusion. 21st: Death. - Post-MM)?’fetK ./tM
Clinical Notes : MEDICAL, SURGICAL, OBSTETRICAL, AND THERAPEUTICAL.
localised pockets of pus adjacent to the pericardium and on the left surface of anterior mediastinutn. Lower lobe, gangrenous stinking cavity 3 by 2 inches in dimensions, bounded below by the diaphragm and involving one-third of the mass of the lobe. The rest of the lobe shows resolving massive consolidation. Embolus or thrombus to account for the gangrene could not be found. Heart: Apparently normal; no ante-mortem clot.
Re1nat’ks. It may be that Case 2 was an abscess of the lung of other primary origin than an embolus, but the type of TWO CASES OF GANGRENE OF THE LUNG lesion post mortem certainly suggested embolic origin COMPLICATING INFLUENZAL PNEUMONIA. in spite of the fact that an occluded artery could not be demonstrated. These two cases occurred amongst a BY J. DE VILLE MATHER, M.D. MANCH., series of 49 other post-mortem examinations made ASSISTANT PHYSICIAN, MANCHESTER NORTHERN HOSPITAL ; the course of the epidemic. In two other of during AND these cases there were present small multiple abscesses, not gangrenous in type. In the comprehensive account F. B. SMITH, B.CH. CANTAB. of the disease and its pathology given by Drs. A. Abrahams, N. Hallows, and H. French in THE LANCET THE account by Dr. Cronin Lowe in THE LANCET of of Jan. 4th, 1919, no mention is made of pulmonary Jan. 15th of three cases of rsevere colitis found post embolism. mortem after influenza recalled the following two cases of gangrene of the lung seen by us during the same A NOTE ON influenza epidemic. In view of the similarity of one form of this disease to a true septicaemia such a com- SPLENECTOMY FOR TORSION OF THE SPLEEN IN A CHILD. plication might be expected to result from an embolus. At the time-i.e., June, 1918-March, 1919-no instance of pulmonary embolus recorded by others came to our BY A. H. SOUTHAM, M.A., M.CH.OXON., F.R.C.S. ENG., notice, and during the two years subsequently a search RESIDENT SURGICAL OFFICER, MANCHESTEB ROYAL INFIRMARY. through a considerable portion of the literature has failed to show any reference to the condition. The reason for recording the cases is not that we think them TORSION of a wandering spleen in a child, followed very unusual, but in order to ensure that the picture of by the operation of splenectomy, is a condition not often the disease may be made as complete as possible. One met with. The successful result makes the following case was diagnosed before death ; both were fatal. notes worthy of publication. CASE I.-Lieutenant -, aged 23. Admitted Oct. 21st, 1918, from J. H., a boy, aged 6 years, was brought to the Manchester Royal transport ship after reporting sick six days previously. Irritable Infirmary on Dec. 31st, 1920, with a diagnosis of acute appendicitis. dry cough. Temp. 101’4 F. Headache, sore throat; copious, blood- His mother stated that he had been seized with sudden abdominal stained purulent sputum for last 24 hours. Poor air entry over the previous evening at 10.30 P.M. whilst he was in whole of chest, with small localised area of broncho-pneumonia pain bed, and had been vomiting continuously ever since. He in the left lower lobe. 23rd: Pyrexia subsided by lysis; P. 60, R. 20, had never complained of abdominal pain previously. On chest remarkably clear of signs; patient merely exhausted. 27th : examination he was found to have a temperature of 100’F., and Allowed to sit up in easy chair. 29th: While sitting up in chair at a pulse of 120. The whole abdomen was held very rigid, with 6 P.M. sudden acute attack of pain in the left lumbar region. The tenderness and rigidity most marked over MeBurney’s point. patient likened this pain to lumbago ; its sharp stabbing onset was I decided to perform laparotomy immediately. When under the very noticeable. No physical signs obtained. Chest still clear. anaesthetic, a large and freely movable tumour was Dalpable in the 30th : T. 100, P. 90, R. 26. Examination of chest, abdomen, and right iliac fossa. The abdomen was opened through the right urine negative. No cough; patient could lie only on the right rectus muscle and the tumour was found to be an enlarged and side; abdominal muscles quite rigid. 31st: Haemoptysis of about congested spleen. The organ was without difyaculty delivered 20 oz. of dark blood, with striking relief of pain in the side ; through the incision, and the pedicle was then seen to be twisted diagnosis of pulmonary embolus made. Nov. 2nd: Sputum on itself two and a half times. The pedicle was transfixed and copious, muddy, limpid, no mucus, very offensive; small effusion ligatured in two halves, a second ligature encircling the whole of fluid left base; sputum showed no pus cells, appeared to be a pedicle. The pedicle was then divided, distal to the ligatures, and pure culture of a diplo-streptococcus. 8th: Left chest explored, the spleen removed. The abdominal incision was sutured in layers. fluid withdrawn having the same characteristics as the sputum. Convalescence was uneventful, and the child was discharged from half an hour lasted under chloroform and Operation.-This hospital on Jan. 19th, 1921. The spleen was found to weigh 14 oz.ether. A portion of the seventh rib was excised; incision opened three to four times the usual weight of the organ at this age. A blood film, taken immediately after the operation was comdirectly into a large gangrenous cavity in the deep substance of the lower lobe of the lung, apparently well shut off from the upper pleted, showed a slight polymorphonuclear leucocytosis, but otherpleural cavity. T. subnormal, P. 100, R. 28. Wide drainage. wise no change from the normal. A second film, taken the day 12th: Gaseous cellulitis of chest and loin; extensive incisions. before his discharge from hospital, showed a leucocytosis with Carrel-Dakin’s tubes. Impossible to apply local antiseptics to the some diminution of the colour index. Microscopical examination chest cavity on account of threatened asphyxiation of the patient of a section of the spleen showed extreme congestion of the by any fluid introduced. 18th: Extension of the cellulitis to the organ; no other pathological changes were to be found. buttocks; lobar pneumonia right lower lobe with clear pleural The cause of the enlargement of the spleen is effusion. 21st: Death. - Post-MM)?’fetK ./tM