CYST in the posterior mediastinum was once regarded as an inexplicable rarity. To-day, thanks to better radiography, and surgical success within the thorax, fore-gut cysts of the mediastinum are being found more commonly and recognition is being followed by cure. Further, their association both with intraabdominal and with vertebral abnormalities has come to be realized. T h e present study attempts to distinguish the various types of these cysts and to trace their relationship with the other abnormalities. T h e facts now available but not yet widely appreciated are of broad surgical significance, and it is hoped that the hypothesis offered here concerning their development will lead to a clearer understanding of this group of lesions. CASE REPORTSCase I.-Male, aged 22. This man was referred from an orthopiedic unit where he was undergoing treatment for old-standing injuries received in previous road accidents. A physician was asked to see him because of trivial pain in the anterior part of the chest, and, although physical examination was negative, a chest radiograph disclosed an abnormal shadow in the lower right hemithorax.He was transferred to this Centre and found to be well-developed, muscular, and in good condition ; his only complaints were of a little pain to the left of the sternum in front and some pain down the back of the right leg. Physical examination of the chest failed to reveal any abnormality. Detailed neurological examination was negative (C.S.F. normal, Queckenstedt normal), the Wassermann was negative, and bronchoscopy showed the trachea and main bronchi to be normal. A barium swallow showed that the oesophagus was displaced anteriorly. The barium was then seen to fall to the left iliac fossa and films showed the greatly elongated stomach extending from the diaphragm to the iliac fossa. The chest radiograph (Fig. 634) showed a large elongated mass occupying the mediastinum, and projecting into the right hemithorax at its lower expanded end. The upper part of the shadow seemed to extend into the superior mediastinum above the aortic arch. A right anterior oblique view (Fig. 635) showed that the mass was behind and separate from the cardiac shadow, and it was further noted that there was a posterior gap in the vertebral arch of the second dorsal vertebra. A pre-operative diagnosis of mediastinal tumour was made and operative treatment advised and accepted.AT OPERATION.-The chest was opened through the bcd of the resected eighth right rib. The right pleural cavity showed neither fluid nor adhesions. A large mass was seen to occupy the whole of the posterior part of the mediastinum, extending from the thoracic inlet to the diaphragm. It was covered by mediastinal pleura and constricted by the arch of the azygos vein above the lung hilum ; large thin-walled vessels were visible on its surface. The vagus nerve was seen closely applied to the lateral aspect of the mass, with the larger branches of its pulmonary plexus radiating forwards on the anterolateral surface. The mediastinal pleura was now ...
Median followup was five years. Nineteen patients (34%) were improved clinically at follow-up; 32 (57%) were unchanged; and 5 patients (9%) developed new or worsened neurologic deficits. Serial imaging studies after radiosurgery showed a reduction in tumor volume in 23 patients (41%); 30 (54%) showed stable disease; 3 patients (5%) had tumors which increased in size (2 being outside the radiosurgery treatment site). The actuarial freedom from progression rate (defined as further tumor growth) was thus 95%, with a median imaging follow-up of 26 months (range, 6-66 months). Although further follow-up is necessary, the results of this series clearly demonstrate that these lesions are feasible for treatment by modern radiosurgical techniques. Linac radiosurgery can stabilize skull base meningiomas, with decreased or unchanged tumor volumes on radiologic follow-up in approximately 95% of patients. Radiosurgery is a low-morbidity, effective technique as adjunct and sometimes primary treatment of small to moderate-sized meningiomas of the skull base.
LUNG injury in the intact thorax-apart from a few isolated cases-has found little mention in English surgical literature. The possibility of its occurrence, however, is familiar to most surgeons, especially after the experiences gained in war, and in the ever increasing variety of civilian injuries. There are nevertheless many instances in recent literature of failure to diagnose lung rupture when it existed : in none of the 4 fatal cases described by Villegas and de 10s Angeles was a diagnosis of lung rupture made, and in recent books dealing with athletic injuries there is no mention of this form of trauma.It can be assumed that the trauma has been applied to healthy lungs, as it is well known how easily lungs affected with tuberculosis and other lesions give way-sometimes indeed spontaneously. It must be accepted also that there is a group of cases of pneumothorax due, with or without the aid of trauma, to rupture of superficial blebs, bullre, or cysts, which, according to Gordon, cannot often be demonstrated during life. Again, the literature presents several cases of rib fracture or dislocation associated with lung injury (Lamballe, Nankivell, du Skjour, and others), but as there is often no local lesion, e.g., pleural tears, or pleural or lung contusions, these fractures or dislocations must be regarded as coincidental and not causative.The occurrence of this type of injury was recognized and described as early as 1761, when Morgagni reported the post-mortem findings in two cases. Schwartz and Dreyfus gave a good account of the condition and a review of the literature in 1907, and Fischer wrote an excellent monograph in 1912.The first recorded case in English is probably that of R. W. Smith, of Dublin, in 1840. A few points from his notes are interesting : " A man of large size was knocked down by the Inniskillen Mail which passed over his body. He was admitted to hospital with intense dyspncea and extreme emphysema at the root of the neck and chest wall. There was no hremoptysis and he died in threequarters of an hour after admission. Post-mortem examination showed collapse of the right lung with extensive pneumothorax. There was a large quantity of blood around the roots of the great vessels and aorta. There were three separate lacerations in the substance of the right lung, but no tear of the pleura was demonstrated. There were no fractured ribs." Smith described three other personal cases, one being of a dog over whose body a carriage had passed. Examination of the body showed no fractured ribs, but extensive lacerations of a lung.Many of the cases reported were the result of severe crushing violence to the chest and the diagnosis was usually not made until post-mortem examination. The diagnosis in the following case, occurring after comparatively mild trauma, was suspected clinically, and confirmed by X-ray examination.
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