1169CLINICAL AND LABORATORY NOTES

blood comes to be in sinusoids lined by the formercapillary walls. This is confirmed by the fact thatthe congested sinusoids are about equal in area tothe fat cells they replace. The engorgement of thesplenic pulp is another feature that seems to becommon to all cases.

SUMMARY

1. A case of hsemolytic icterus was observed fornine months before death. 2. Mean cell diametermeasurements by the Price-Jones method showed ahigh coefficient of variability, reaching 18 per cent.during the terminal crisis. Macrocytes and megalo-cytes were then equally balanced, so that the meandiameter remained within normal limits. 3. Autopsyfindings were enlargement of the liver and spleen,the splenic pulp being engorged with erythrocytes.The femur and humerus contained a rich red bone-marrow all through their length, composed mainlyof sinusoids filled with mature erythrocytes, andapparently derived from the pre-existing capillaries.The tibia was normal.

I should like to thank Prof. A. E. Naish for permissionto publish this case and for his help during the period ofthe observations. I also wish to thank Dr. Alice Stewartof the Royal Free Hospital, London, for making one ofthe Price-Jones determinations and for her interest andadvice.

REFERENCES

Beebe, R. T., and Hanley, E. P. (1936) J. Lab. clin. Med. 21, 833.Dawson, Lord (1931) Brit. med. J. 1, 921, 963.Hawksley, J. C. (1936) J. Path. Bact. 43, 565.Lederer, M. (1925) Amer. J. med. Sci. 170, 500.- (1930) Ibid, 179, 228.

Murray-Lyon, R. M. (1935) Brit. med. J. 1, 50.Price-Jones, C. (1933) Red Blood Cell Diameters, London.Reynolds, G. P. (1930) Amer. J. med. Sci. 179, 549.Scott, A. M. (1935) Lancet, 2, 872.Turnbull, H. M. (1936) in The Anæmias (Vaughan).Vaughan, J. M. (1936) The Anæmias, London.Whitby, L. E. H., and Britton, C. J. C. (1935) Disorders of the

Blood, London.

Clinical and Laboratory NotesLYMPHOSARCOMA SIMULATING

DUODENAL ULCER

BY S. KEYS, M.R.C.S. Eng.ASSISTANT PATHOLOGIST TO THE QUEEN MARY’S HOSPITAL

FOR THE EAST END, LONDON; AND

W. W. WALTHER, M.B. Lond.DIRECTOR OF PATHOLOGY AT THE HOSPITAL

Tms case shows under what a simple disguiselymphosarcoma may appear to the clinician. As arule it is possible to diagnose general lympho-sarcomatosis before the patient comes to the post-mortem room, but in this case the disease showed

symptoms referable to one organ only, and the truenature of the condition was only suspected a few daysbefore death.The patient was a man aged 23, lorry driver by occupa-

tion. He was admitted complaining of abdominal painof five years’ duration. The pain was just below theumbilicus and passed to either side of the abdomen. Atfirst it came on -1 hour after meals and lasted up to2 hours. The attacks came on spontaneously and usedto last for 3-4 weeks. There were free intervals of 3-4months. Lately the attacks had come on with greaterfrequency and five weeks before admission he vomitedfor the first time. The vomiting became more frequent,usually occurring up to 15 minutes after a meal, andmade no difference to the pain. There was no hsematemesis.Although the patient looked thin he did not complainof loss of weight. His appetite was good and bowels wereregular. He had never noticed signs of melaena.Occasionally he had attacks of flatulence.

The patient looked anaemic. The blood count was :hsemoglobin 44 per cent., red cells 3 million, colour-index 0-73, leucocytes 18,600 per c.mm. (polymorphs77 per cent., lymphocytes 19 per cent., monocytes 3 percent., eosinophils 1 per cent.). There was no abdominaltenderness present and no other abnormal physical signs.Below the left angle of the mandible there was an oval,mobile swelling, 1 in. by 3- in., which the patient appearedto have had is long as he could remember.A provisional diagnosis of duodenal ulcer was made

and the patient was treated by drip transfusions and diet.Frequent occult blood examinations were strongly positive,but a fractional test-meal could not be estimated owingto the gastric juice containing abundant altered blood.

There was no improvement whatever. In spite of thedrip transfusions the hemoglobin fell, although at timesa rise of 1-3 points was recorded. He vomited on severaloccasions and each time the vomit contained alteredblood. Three weeks before death a white cell count was11,500 per c.mm. with the differential count of polymorphs74 per cent. lymphocytes 25 per cent., and monocytes1 per cent. A week before death the blood-serum wasnoted to be icteric and gave a direct positive van denBergh reaction. This suggested the possibility of malignantdisease obstructing the flow of bile, and on examinationa tumour was discovered in the epigastrium. There wasalso general enlargement of the cervical glands. Afixed mass in the pelvis was found just before death.Altogether the patient was in hospital about seven weeks.

POST-MORTEM FINDINGS

Emaciated young man. Slight fullness of the thyroidgland. A few visibly enlarged glands in the neck.Abdomen distended. Tonsils not enlarged. The peri-cardial sac contained about 6 oz. of clear straw-colouredfluid. The heart was normal in size, but the pericardialsurface was covered by many patches of secondary growth ; ythe chordae tendiniae also contained a few nodules, butthe rest of the endocardium was normal. The lungs werecongested ; there were secondary deposits of growth inthe right and left fourth ribs. The left lobe of the thyroidwas normal; the right lobe was somewhat enlarged andcontained a hard growth about the size of a walnut ;the cut surface was hard and homogeneous.The abdomen contained numerous loculated collections

of faintly purulent fluid. The omentum was invaded bygrowth and was lying rolled across the epigastrium. Allthe abdominal lymphatic glands were greatly enlargedand matted together. A large mass of glands was presentin the pelvis. The inguinal glands were enlarged. Thestomach was infiltrated by growth and the mucousmembrane showed numerous round ulcers with raised

edges. One very large ulcer, 1 in. in diameter, hadcompletely perforated the posterior gastric wall and itsedges were adherent to the liver.The pancreas was one mass of growth. Glisson’s capsule

contained a secondary deposit, but the liver itself appearednormal. The spleen was also of normal size and lookedhealthy. Neither of these two organs contained macro-

scopical deposits of growth. Both kidneys were greatlyenlarged and contained circumscribed neoplastic depositsof various sizes. There were a few enlarged glands alongthe left ureter. The bladder was normal. Both testicleswere normal. The brain and skull showed no abnormality.

MICROSCOPICAL EXAMINATION

Glands in neck.-Filled with large round cells, contain-ing a well staining nucleus almost filling the cell. Thecells are attached to a faint, branching reticulum, and showactive mitosis. The very scanty lymphoid tissue is

compressed at the periphery of the gland. Bands offibrosis can be seen traversing the gland.

OMMM/t.—The mucous membrane shows partial destruc-tion by sarcoma cells. There is derangement of thealveolar structure of the mucosa. The spread appearsto take place through the submucosa, which containsan uninterrupted solid mass of sarcoma cells. The gastricmuscle is partially invaded by growth.Omentum.-Complete invasion by growth.Liver.-The liver cells contain a considerable amount of

pigment, but appear otherwise normal. The hepatic

1170 CLINICAL AND LABORATORY NOTES

arteries are clear but the portal veins contain numerousmalignant cells, which as yet show no evidence of invasion.

Spleen.-The lymphatic element is replaced by largeround cells with deeply staining nuclei. There is consider-able congestion. The sinuses are filled with bloodcorpuscles and the sinusoidal walls appear normal.Heart.-Shows the growth infiltrating between the

muscle strands and separating them. A coronary arteryshows invasion of the adventitia, but media and intimaare free of growth.Thyroid.-Shows invasion of the right lobe. The

left lobe appears normal.

It is impossible in this case to determine the siteof the primary growth, the enlarged gland in theneck being the only lymphatic abnormality to haveexisted for any length of time. It seems unlikelythat the gastric symptoms could have been due inthe first place to a neoplasm of such undoubtedmalignancy, for the patient would probably not havelived for five years.

It is interesting to note that generalisation ofthe disease occurred without alteration of thelymphocyte count. The raised polymorph countcan be accounted for by the local peritonitis causedby the gastric ulceration.We are grateful to Mr. H. W. B. Wright for permission

to publish this case.

LYMPHATIC CYST OF THE MESENTERY

AND VOLVULUS IN A CHILD

BY REGINALD C. JEWESBURY, D.M. Oxon.,F.R.C.P. Lond.

PHYSICIAN IN CHARGE OF THE CHILDREN’S DEPARTMENT,ST. THOMAS’S HOSPITAL, LONDON

THE patient, a little girl aged 5 years and 8 months,was well until 2 years of age when she first complainedof abdominal pain. Six months later she had anotherattack of pain accompanied by vomiting. At the ageof 3 years and 9 months she was seen for the firsttime by a doctor. She then complained of acuteumbilical pain and suffered from retching but didnot vomit. Her pulse-rate was 100 and her temperature98.4° F. ; the only physical sign was some epigastrictenderness. The bowels were regular. Taking onlyfluids by mouth (with lemon and glucose solutionto combat acetonuria + +) this attack was over inthree days. During the attacks of abdominal painshe always adopted a kneeling position keeping herhead bent down.

After this attack further medical advice was sought,a diagnosis of " acidosis " was made, and the appro-priate treatment ordered. Following this she hadseveral minor attacks for which it was not necessaryto call her doctor. When aged 41 years she hadanother fairly severe attack and was given glucoseby mouth and per rectum. Two months later cameanother less severe attack and there was anotherone again after two more months’ interval. At thisperiod the urine showed coli bacilluria which re-

sponded to treatment. There were no further attacksfor about 7 months, after which she again sufferedfrom abdominal pain and vomiting ; during this attackthe pulse rose to 110, and there was some abdominaldistension.

I saw the child for the first time on the third dayof this attack; the abdomen was distended and

rigid, but free from pain or tenderness. The pulse-rate was 120 and the facies was " abdominal" ; infact the signs were those of acute obstruction witbgeneral peritonitis. Laparotomy was performed thai

same day, as speedily as could be arranged, by MrMax Page.The whole of the small intestine was distended and

deeply congested, as was also the whole of the mesentery.The bowel was completely obstructed after having becomerotated on the mesentery. The strangulation was reducedby rotating the whole of the small intestine through threecomplete turns. In the cavity of the pelvis, and risingslightly out of it, was a large butter-yellow-colouredcyst which at first looked like a distended bladder ; thecyst was opened and about 15-16 oz. of thin milk-likefluid was evacuated ; the cyst was situated in the mesenteryclose to its attachment to the small intestine about 2 ft.above the ileocsecal valve. The cyst wall was removedand tied off, and the abdominal wound closed, a drainagetube being left in.The child died about four hours after the operation.The following are notes from post-mortem report

by Dr. S. Wyard.The whole of the small bowel from the duodenojejunal

flexure to the ileocsecal valve is enormously distended;the wall is plum-coloured and there are numerous subserousand submucous haemorrhages. The surface is smooth andshining. About half an inch above the ileocsecal valve isa mark encircling the bowel obviously due to a tightstrangling constriction. The caecal and ascending meso-colon is congested and shows many haemorrhages, thewhole of the mesentery is also congested and hsemorrhagic.About two feet below the duodenojejunal flexure is asurgical incision about four inches long, involving themesenteric border of the bowel; the incision has beencompletely closed by sutures. Fluid removed from cyst,pale yellow and turbid, contained much albumin but noorganised elements. The wall of the cyst on section

appeared to consist of mesenteric tissue.The time of origin of this cyst is doubtful, it may

have begun when the child was two years old, or it mayhave been congenital. Its recognition during the earlystages was obviously difficult, but the recurrentattacks of abdominal pain and sickness were probablydue to it. Refuge in the diagnosis of " acidosis "was a misleading factor in this case as it has been inothers.Lymphatic cysts of the mesentery are rare and not

many cases have been recorded in children.Bland-Sutton (1922) comments on " a rare but

interesting lesion known as chyle cyst of the mesen-tery." He compares them to omental hydroceles andovarian cysts, and he states further that in infantsor children, where many of them are found, thesecysts are connected closely to the mesenteric borderof the intestine and push their way between the layers

. of the mesentery. He concludes that these cystsare important, for they have caused fatal intestinalobstruction.

’

Swartley (1927) has written an interesting articleL on " mesenteric cysts " and describes the case of

. a girl, aged 7 years, which is very similar to the

case which I now publish.3Eve (1898) reports the case of a cyst between theJ

layers of the mesentery of the jejunum in a male childj aged 11 weeks ; and also in a child aged 3 years andl’ 8 months, who had been admitted to hospital fors " intestinal obstruction." Braquehaye (1892) classifies

’s mesenteric cysts as follows :-

i 1. Sanguineous cysts-usually traumatic and occurringlr as diffuse haemorrhages into the mesentery, into pre.

, existing cysts, or into solid tumours.,l 2. Lymphatic cysts, comprising chylous and most of

the serous cysts. These arise in the thoracic duct, in they chylous vessels, or in the lymphatic glands of thed mesentery.- 3. Congenital cysts, chiefly dermoid, but occasionallyn cysts of the Wolffian body.h Lymphatic cysts are usually situated in the mesenterytt of the small intestine, usually near the spinal border,