Failed Splenectomy in Acholuric Jaundice
Authors: W. N. West-Watson, C. J. Young
Journal: BMJ (1938)

SUPERIOR PULMONARY SULCUS TUMOURTEDICAL JORNA 1305on the inner side of the left arm, with weakness of the hand- grip and fingers.On September 5 definite wasting of the left palmar rnuscles and loss of hand-grip were observed.He now received in- jections of N.A.B., bismuth, and sodium iodide.He was seen by Mr. Nightingale and Dr. Fisher.who thought this to be definitely a case of new growth at the left apex (? origin, but probably bronchial).On the 12th there was oedema and swelling of the left arm ('? due to lymphatic or venous obstruction), and left Horner's syndrome.Another radio- graph taken on the 15th showed that the condition was worse: there was more erosion of the seventh cervical vertebra : the first rib had disappeared, and the second partly disappeared at the head and neck (Plate, Fig. 1).From this time the patient went rapidly downhill, his temperature became elevated, and he died on September 28.Post-mortem Examtiiation.-Alarge mass was found at the left apex involving the-lung, upper three ribs, and the vertebrae, and surrounding the left subclavian vein, which was thrombosed.No primary was present elsewhere, but there was terminal pericarditis and pyaemic abscess of the kidney.The growth had the consistency of an unripe pear, and had completely replaced the upper two ribs, which could be cut easily with the knife.Sections of lung, ribs, and cervical glands were made.Report of Sectionts.-Allsections showed squamous-celled carcinoma with cell-nest formation (Plate, Fig. 2).Catarrhal pneumonia was present in the lung. CommentaryThis case corresponds exactly to the description given by Pancoast, and is actually more complete owing to our being able to obtain a full necropsy.None of the original cases apparently were examined post mortem.The result of microscopy does not settle the vexed question of the origin of the tumour, which Pancoast suggested was in the remnants of the fifth branchial cleft.A tumour in this situation gives none of the common symptoms of carci- noma of the lung, such as cough, sputum, or haemoptysis: its symptoms and signs are due entirely to pressure and mechanical involvement of the structures in its neighbourhood; consequently the picture may be given by any tumour which encroaches upon this particular situation.Cases described by Evans, Tobias, Steiner and Francis, Jacox, and others all exhibited the typical x-ray appearances and clinical features, but were shown to be due to various tumours, such as thymomas, sympathoblastomas, secondary growths from stomach and cervix uteri, and breast and bronchial carcinoma.The last-mentioned forms the largest proportion of the cases, and probably is the usual cause of the syndrome.Browder and de Veer, in describing another case, suggested that the name of carcinoma of the pulmonary apex is more appropriate than that applied by Pancoast.Our case may therefore have been a squamous-cell type of carcinoma at the apex, originating most probably in the lung but possibly in a branchial remnant.The differential diagnosis includes several widely differ- ing conditions.Cervical rib and syringomyelia may be excluded by the x-ray appearances.Tuberculous fibrosis at the apex does not cause destruction of the ribs or vertebrae.Endothelioma of the pleura spreads more rapidly, and again there is no bone change.Osteogenic I am indebted to Dr. M. K. Jardine for assistance with the