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PULMONARY EMBOLI OF LYMPHATIC ORIGIN
1409
CLINICAL AND LABORATORY NOTES PULMONARY EMBOLI OF LYMPHATIC ORIGIN BY ALEXANDER G.
CROSS, M.B. Camb.
RECENTLY HOUSE SURGEON TO THE SURGICAL ST. MARY’S HOSPITAL, LONDON
UNIT,
in
size, and they would finally pass through the pulmonary artery to cause obstruction of its branches in the lungs. I should like to express my thanks to Prof. C. A. Pannett for permission to record this case. REFERENCES
cysts of the mesentery and mesocolon first fully described by Rokitansky in 1842. 2
CHYLOUS were
Since then some 200 cases have been reported. 1 The following case is recorded because of the comparative rarity of the primary condition, and because of the features shown after operation. History.-A. B., aged 20, a nurse, was seen in January, 1935, and complained that for six years she had had a constant dragging pain in ’the left iliac fossa, with attacks of a colicky nature, when the pain radiated to the right iliac fossa. It had not been severe enough to keep her
getting worse. It was vomiting. It had no relation to food, and was not relieved by lying down. The appetite was good and the bowels open regularly without aperients. She had been kept in bed for a fortnight, six weeks previously, and the pain had been slightly relieved. awake
at night, but accompanied by nausea,
Benedict, A. L.: Bibliography of Chylous Cysts of the Mesentery, Surg., Gyn., and Obst., 1913, xvi., 606. 2. Collins, A. N., and Berdez, G. L.: Arch. of Surg., 1934, xxviii., 335.
ORCHIDECTOMY ON THE HIGH SEAS BY PHILIP E. F. SURGEON,
FROSSARD, M.R.C.S. Eng.
P. AND O. STEAM NAVIGATION CO.
was
but
no
- EMMMMMOM..—There was ill-defined tenderness in the left iliac fossa, with a feeling of resistance on deep palpation ; but no other abnormality was discovered by clinical examination. Radiography showed no lesion of the gastro-intestinal or renal tracts. Blood count showed a relative lymphocytosis. Vernes’s test was negative. At operation (Jan. 23rd, 9.50 A.M.) a midline subumbilical incision was made and a unilocular cyst, the size and shape of a butcher’s sausage, was found in the sigmoid mesocolon. On its outer surface were a number of small white spots. Some clear fluid was aspirated, the cyst excised, and the abdomen closed. Pathological reports.-Fluid of cyst : clotted rapidly ; nothing abnormal on bacteriological examination. Cyst wall: fibrous elastic tissue and muscular tissue arranged as in a vein ; in a few parts there is an endothelial lining, but often it is bare ; the white areas consist of fibrin, and necrotic tissue which is partially calcified. After-history.-On the day after the operation, at 10.20 A.M., the patient, who had been quite comfortable, had a sudden attack of dyspneea, with pain in the right side of the chest. She was pale, with a feeble irregular pulse. Oxygen was given continuously, and within two hours the pain and dyspncea had disappeared, and the pulse had become more regular. At 1.15 P.M. on the same day there was another attack of severe dyspnoea, with pain on both sides of the chest. She was pale, and the pulse Coramine 1’7 c.cm. was barely perceptible at the wrist. was given, with oxygen, and she became much better in an hour. On Jan. 29th, at 11 P.M., there was a third attack of dyspncea, with pain in the upper abdomen. The pulse and colour of the patient remained normal. Morphia gr. and oxygen were given, with improvement in an hour. The remainder of the convalescence was uneventful. She got up on Feb. llth, and was discharged on Feb. 24th. The three attacks of dyspnoea after the operation undoubtedly due to pulmonary emboli. They appeared, however, earlier than is usual in postoperative cases. No large vessels were encountered in the removal of the cyst from the mesocolon, and no ligatures were applied. The lymphatic connexions were severed and it is to be expected that clotting of lymph occurred in these lymphatics, extending centrally. Fragments of these clots probably reached the general circulation through the thoracic duct and lodged in the right auricle. There, by deposition of fibrin, they would increase were
1.
A STEWARD,
aged 30,
with
no
previous history
of
disease, was admitted to the ship’s hospital at 6.30 P.M. He had been struck on the on Oct. 23rd, 1935.
by a cricket ball-a full pitch from a fast bowler-two hours previously. He was able to walk on board but was in considerable pain.
scrotum
Local examination revealed a firm, tender swelling of moderate size of the right side of the scrotum and contents. At this stage there was no pain, tenderness, or swelling over the inguinal canal. The patient was treated with rest and compresses, morphia being administered after examination. The progress was
gr. 1
The apparently satisfactory. patient was comfortable and the
swelling began
to subside.
Five
days later, on Oct. 28th, he complained of abdominal pain and of having had a restless night.
The temperature was 99° F. and the pulse-rate 80. There was an increase of swelling and tension. The scrotum was red and codematous. There was definite swelling and tenderness over the inguinal canal extending over its entire length and into the right iliac fossa. Owing to the exacerThe testis after removal, showing the injury. bation of symptoms and the The white line points of added infection, ’ it possibility ol to the split edge of was decided to explore the ginea. scrotal contents and operation was performed on the same day. The ship’s operating theatre (appointed for the purpose) was made ready and the patient was on the table within an hour and a half, the ship having eased down to dead
thetunica albu-
slow. The anaesthetic, administered by Dr. E. O’Brien, the assistant surgeon, consisted of ethyl chloride followed by open ether, a preliminary injection of morphia gr. and atropine gr. 1/100 having been given. Incision revealed the vaginal sac filled with blood clot and altered blood. The testis was seen to have been split near the centre right through to the epididymis, the split being in the transverse axis. The parenchyma bulged through the cleft tunica albuginea; the epididymis and cord were a dark purple, grossly swollen. It was evident that a condition of comparative local stasis of the blood
circulation was present. The left testis being uninjured and apparently normal, it was decided to remove the damaged organ, complete with the epididymis and cord at the level of the external abdominal ring. The infiltrated and inflamed scrotal sac was drained through a stab wound at the lower pole of
CLINICAL AND LABORATORY NOTES PULMONARY EMBOLI OF LYMPHATIC ORIGIN BY ALEXANDER G.
CROSS, M.B. Camb.
RECENTLY HOUSE SURGEON TO THE SURGICAL ST. MARY’S HOSPITAL, LONDON
UNIT,
in
size, and they would finally pass through the pulmonary artery to cause obstruction of its branches in the lungs. I should like to express my thanks to Prof. C. A. Pannett for permission to record this case. REFERENCES
cysts of the mesentery and mesocolon first fully described by Rokitansky in 1842. 2
CHYLOUS were
Since then some 200 cases have been reported. 1 The following case is recorded because of the comparative rarity of the primary condition, and because of the features shown after operation. History.-A. B., aged 20, a nurse, was seen in January, 1935, and complained that for six years she had had a constant dragging pain in ’the left iliac fossa, with attacks of a colicky nature, when the pain radiated to the right iliac fossa. It had not been severe enough to keep her
getting worse. It was vomiting. It had no relation to food, and was not relieved by lying down. The appetite was good and the bowels open regularly without aperients. She had been kept in bed for a fortnight, six weeks previously, and the pain had been slightly relieved. awake
at night, but accompanied by nausea,
Benedict, A. L.: Bibliography of Chylous Cysts of the Mesentery, Surg., Gyn., and Obst., 1913, xvi., 606. 2. Collins, A. N., and Berdez, G. L.: Arch. of Surg., 1934, xxviii., 335.
ORCHIDECTOMY ON THE HIGH SEAS BY PHILIP E. F. SURGEON,
FROSSARD, M.R.C.S. Eng.
P. AND O. STEAM NAVIGATION CO.
was
but
no
- EMMMMMOM..—There was ill-defined tenderness in the left iliac fossa, with a feeling of resistance on deep palpation ; but no other abnormality was discovered by clinical examination. Radiography showed no lesion of the gastro-intestinal or renal tracts. Blood count showed a relative lymphocytosis. Vernes’s test was negative. At operation (Jan. 23rd, 9.50 A.M.) a midline subumbilical incision was made and a unilocular cyst, the size and shape of a butcher’s sausage, was found in the sigmoid mesocolon. On its outer surface were a number of small white spots. Some clear fluid was aspirated, the cyst excised, and the abdomen closed. Pathological reports.-Fluid of cyst : clotted rapidly ; nothing abnormal on bacteriological examination. Cyst wall: fibrous elastic tissue and muscular tissue arranged as in a vein ; in a few parts there is an endothelial lining, but often it is bare ; the white areas consist of fibrin, and necrotic tissue which is partially calcified. After-history.-On the day after the operation, at 10.20 A.M., the patient, who had been quite comfortable, had a sudden attack of dyspneea, with pain in the right side of the chest. She was pale, with a feeble irregular pulse. Oxygen was given continuously, and within two hours the pain and dyspncea had disappeared, and the pulse had become more regular. At 1.15 P.M. on the same day there was another attack of severe dyspnoea, with pain on both sides of the chest. She was pale, and the pulse Coramine 1’7 c.cm. was barely perceptible at the wrist. was given, with oxygen, and she became much better in an hour. On Jan. 29th, at 11 P.M., there was a third attack of dyspncea, with pain in the upper abdomen. The pulse and colour of the patient remained normal. Morphia gr. and oxygen were given, with improvement in an hour. The remainder of the convalescence was uneventful. She got up on Feb. llth, and was discharged on Feb. 24th. The three attacks of dyspnoea after the operation undoubtedly due to pulmonary emboli. They appeared, however, earlier than is usual in postoperative cases. No large vessels were encountered in the removal of the cyst from the mesocolon, and no ligatures were applied. The lymphatic connexions were severed and it is to be expected that clotting of lymph occurred in these lymphatics, extending centrally. Fragments of these clots probably reached the general circulation through the thoracic duct and lodged in the right auricle. There, by deposition of fibrin, they would increase were
1.
A STEWARD,
aged 30,
with
no
previous history
of
disease, was admitted to the ship’s hospital at 6.30 P.M. He had been struck on the on Oct. 23rd, 1935.
by a cricket ball-a full pitch from a fast bowler-two hours previously. He was able to walk on board but was in considerable pain.
scrotum
Local examination revealed a firm, tender swelling of moderate size of the right side of the scrotum and contents. At this stage there was no pain, tenderness, or swelling over the inguinal canal. The patient was treated with rest and compresses, morphia being administered after examination. The progress was
gr. 1
The apparently satisfactory. patient was comfortable and the
swelling began
to subside.
Five
days later, on Oct. 28th, he complained of abdominal pain and of having had a restless night.
The temperature was 99° F. and the pulse-rate 80. There was an increase of swelling and tension. The scrotum was red and codematous. There was definite swelling and tenderness over the inguinal canal extending over its entire length and into the right iliac fossa. Owing to the exacerThe testis after removal, showing the injury. bation of symptoms and the The white line points of added infection, ’ it possibility ol to the split edge of was decided to explore the ginea. scrotal contents and operation was performed on the same day. The ship’s operating theatre (appointed for the purpose) was made ready and the patient was on the table within an hour and a half, the ship having eased down to dead
thetunica albu-
slow. The anaesthetic, administered by Dr. E. O’Brien, the assistant surgeon, consisted of ethyl chloride followed by open ether, a preliminary injection of morphia gr. and atropine gr. 1/100 having been given. Incision revealed the vaginal sac filled with blood clot and altered blood. The testis was seen to have been split near the centre right through to the epididymis, the split being in the transverse axis. The parenchyma bulged through the cleft tunica albuginea; the epididymis and cord were a dark purple, grossly swollen. It was evident that a condition of comparative local stasis of the blood
circulation was present. The left testis being uninjured and apparently normal, it was decided to remove the damaged organ, complete with the epididymis and cord at the level of the external abdominal ring. The infiltrated and inflamed scrotal sac was drained through a stab wound at the lower pole of