Plate XVII
1.?Anteroposterior Fig. 1.?Antero-posterior
view. Fig. 2.?Right oblique oblique view. Fig. 2.?Right
view.
wmm
L^-
v
and phrenic of cyst removal of 3.?After removal cyst and evulsion, phrenic evulsion, Pig. Pig. 3.?After to recovery. leading leading to recovery.
THE INDIAN MEDICAL GAZETTE
244 A
CASE
LUNG,
OF
HYDATID
CYST
OF
THE
WITH POST-OPERATIVE TUBER-
CULOUS INVOLVEMENT By A. C. UKIL,
m.b., m.s.p.e.
(Paris),
f.s.m.f., f.n.i.
and S. K. GANGULI
(From the Department of Chest Diseases, Medical College Hospitals, Calcutta) Clinical history.?A Hindu male, aged 32 years, a dog lover, complained of irregular low fever (99?F. to 100?F.), heaviness of the right chest and cough which increased on trying to lie down on the right side, and recurrent small haemoptysis for three months. There As regards previous was no anorexia nor emaciation. history, it transpired that he was once treated for cervical adenitis at the age of 12 years. He was being treated for pulmonary tuberculosis by a physician outside. He came under our observation in August 1934.
Physical examination.?The right side of the chest showed loss of resonance from the level jof the fourth rib downwards. On auscultation, nothing beyond some diminution of breath sounds was noticed. Sputum examination was repeatedly negative for tubercle bacilli. X-ray examination?showed a circular opacity, with regular margin, about the size of a tennis ball above the diaphragm, but not adherent to its surface. The left lung showed a small healed tuberculous lesion at the apex. A provisional diagnosis of hydatid cyst of the lung was made on the strength of this evidence. To confirm the provisional diagnosis, a complementfixation test was performed at the Indian Institute for Medical Research, using the hydatid fluid from diseased sheep's liver as antigen. This proved to be strongly positive. The Wassermann reaction was negative. A differential count of blood showed an eosinophilia of a
7 per cent. On the 15th October, the patient had an acute attack of pleurisy when it was decided, in consultation with Lieut.-Col. F. J. Anderson, i.m.s., of the Medical College Hospitals, to operate on him in two stages. The first stage of the operation was done by Col. Anderson on 20th October by removing the anterior portions of the fourth and fifth ribs on the right side. The hydatid cyst was located by puncturing the cyst wall with a syringe; some fluid was taken out for microscopic examination (which showed echinococcus hooklets) and 5 c.cm. of 40 per cent formalin was injected into the cyst to kill the brood capsules and scolices. The operation was performed under local anaesthesia (novocaine 2 per cent), aided by a few whiffs of ether. The space between the visceral and parietal pleura was packed with corrugated drainage sheet to induce adhesions to form. After eight days, when it was found that the adhesions had walled off the site, the second stage of the operation was undertaken under local anaesthesia, aided by gas and oxygen. It was noticed that on account of the rise of the diaphragm after the first operation, the cyst was pushed much higher up than its original position before operation. A bloodless operation was done with the aid of the diathermy knife and the cyst (both ecto- and endo-cyst) was completely removed. _
The wound healed, except for a slight discharge from the previous track of the drainage tube, at the end of one month, but a slight afternoon temperature still persisted. A skiagraphic examination showed a diminution in the size of the area covered by the cyst, but a worrying incident occurred at this stage; the sputum _
[April,
1937
showed a few tubercle bacilli. This was in February 1935. With right phrenic evulsion and gold therapy (sanocrysin), carried out at the Madanapalle Sanatorium, the tubercle bacilli disappeared from the sputum and the patient made a steady recovery. The patient has been examined since and is keeping well.
In our opinion, the tubercle bacilli detected in the sputum after the operation were probably due to the injury of a tuberculous gland near the wall of the cyst. No serious damage to lung tissue occurred, probably because of a high degree of allergy on the part of the patient and also owing to the timely compression of the affected area by phrenic exairesis. In August 1934, Drs. Tulsi Dass and Pirthichand (Indian Medical Gazette, August 1934, pp. 448-449) reported a case of hydatid cyst of the lung where, thinking that they were dealing with a case of pleural effusion, anaphylactic shock occurred after aspiration and immediate operation had to be performed in a boy of 14. This was followed by recovery. We believe this is the first reported case where the cyst has been successfully removed without leakage. The are
skiagrams before and after the operation given (plate XVII, figures 1, 2 and 3).
1.?Anteroposterior Fig. 1.?Antero-posterior
view. Fig. 2.?Right oblique oblique view. Fig. 2.?Right
view.
wmm
L^-
v
and phrenic of cyst removal of 3.?After removal cyst and evulsion, phrenic evulsion, Pig. Pig. 3.?After to recovery. leading leading to recovery.
THE INDIAN MEDICAL GAZETTE
244 A
CASE
LUNG,
OF
HYDATID
CYST
OF
THE
WITH POST-OPERATIVE TUBER-
CULOUS INVOLVEMENT By A. C. UKIL,
m.b., m.s.p.e.
(Paris),
f.s.m.f., f.n.i.
and S. K. GANGULI
(From the Department of Chest Diseases, Medical College Hospitals, Calcutta) Clinical history.?A Hindu male, aged 32 years, a dog lover, complained of irregular low fever (99?F. to 100?F.), heaviness of the right chest and cough which increased on trying to lie down on the right side, and recurrent small haemoptysis for three months. There As regards previous was no anorexia nor emaciation. history, it transpired that he was once treated for cervical adenitis at the age of 12 years. He was being treated for pulmonary tuberculosis by a physician outside. He came under our observation in August 1934.
Physical examination.?The right side of the chest showed loss of resonance from the level jof the fourth rib downwards. On auscultation, nothing beyond some diminution of breath sounds was noticed. Sputum examination was repeatedly negative for tubercle bacilli. X-ray examination?showed a circular opacity, with regular margin, about the size of a tennis ball above the diaphragm, but not adherent to its surface. The left lung showed a small healed tuberculous lesion at the apex. A provisional diagnosis of hydatid cyst of the lung was made on the strength of this evidence. To confirm the provisional diagnosis, a complementfixation test was performed at the Indian Institute for Medical Research, using the hydatid fluid from diseased sheep's liver as antigen. This proved to be strongly positive. The Wassermann reaction was negative. A differential count of blood showed an eosinophilia of a
7 per cent. On the 15th October, the patient had an acute attack of pleurisy when it was decided, in consultation with Lieut.-Col. F. J. Anderson, i.m.s., of the Medical College Hospitals, to operate on him in two stages. The first stage of the operation was done by Col. Anderson on 20th October by removing the anterior portions of the fourth and fifth ribs on the right side. The hydatid cyst was located by puncturing the cyst wall with a syringe; some fluid was taken out for microscopic examination (which showed echinococcus hooklets) and 5 c.cm. of 40 per cent formalin was injected into the cyst to kill the brood capsules and scolices. The operation was performed under local anaesthesia (novocaine 2 per cent), aided by a few whiffs of ether. The space between the visceral and parietal pleura was packed with corrugated drainage sheet to induce adhesions to form. After eight days, when it was found that the adhesions had walled off the site, the second stage of the operation was undertaken under local anaesthesia, aided by gas and oxygen. It was noticed that on account of the rise of the diaphragm after the first operation, the cyst was pushed much higher up than its original position before operation. A bloodless operation was done with the aid of the diathermy knife and the cyst (both ecto- and endo-cyst) was completely removed. _
The wound healed, except for a slight discharge from the previous track of the drainage tube, at the end of one month, but a slight afternoon temperature still persisted. A skiagraphic examination showed a diminution in the size of the area covered by the cyst, but a worrying incident occurred at this stage; the sputum _
[April,
1937
showed a few tubercle bacilli. This was in February 1935. With right phrenic evulsion and gold therapy (sanocrysin), carried out at the Madanapalle Sanatorium, the tubercle bacilli disappeared from the sputum and the patient made a steady recovery. The patient has been examined since and is keeping well.
In our opinion, the tubercle bacilli detected in the sputum after the operation were probably due to the injury of a tuberculous gland near the wall of the cyst. No serious damage to lung tissue occurred, probably because of a high degree of allergy on the part of the patient and also owing to the timely compression of the affected area by phrenic exairesis. In August 1934, Drs. Tulsi Dass and Pirthichand (Indian Medical Gazette, August 1934, pp. 448-449) reported a case of hydatid cyst of the lung where, thinking that they were dealing with a case of pleural effusion, anaphylactic shock occurred after aspiration and immediate operation had to be performed in a boy of 14. This was followed by recovery. We believe this is the first reported case where the cyst has been successfully removed without leakage. The are
skiagrams before and after the operation given (plate XVII, figures 1, 2 and 3).
