Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 110

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189

USA > Ohio > Hancock County > Findlay > Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens > Part 110

Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).

Konig (1884) was the first to recognize their tubercular origin, recognizing at the same time that they were formed by a coagulation necrosis of albuminous material.

Schuchardt acknowledges that rice body hygromas are al- ways tubercular, but does not think that rice bodies wherever found are always due to tubercle bacilli. It would take us to far to describe the pathology of rice bodies in relation to the various structures where they have been found. Some of the most useful literature describing these fibrinoid objects has been found in connection with ganglia and tubercular arthritis. Evans (Am. J. Med. Sc., 1892) wrote the most comprehensive work on the subject in English. Nicaise, Paulet and Vaillard include in their work a combined study of tuberculosis of bursa and tendons with rice body formations.

Schuchardt made a special study of fibrinoid degeneration of connective tissue under the heading "Tuberculosis and Syphilis of Tendon-sheaths."

We gather from the most enlightened and comprehensive recent writings that the rice bodies are to be considered a:

Digitized by Google

vi Har & coagulation necrosis of cells or inter- cellular substance in tubercular tissues.

There is considerable discussion of their mode of formation und relation to the tubercular walls of the containing sac whether bursa, tendon-sheath or joint. After all, we may go back to Virchow's expression of opinion to get at the basis of their formation. This includes some of the best that all ex- press. He says, "I had taken them for clots of fibrin laid lown concentrically, but I have since learned that they are organized excrescences. It is possible that they increase in ize by gradual fibrin deposits." He thus includes both of he methods of formation, that of an organized material un- lergoing coagulation necrosis,-the method Schuchardt de- 'ends and the credit for proving which he gives to Neumann (Arch. f. mikr. Anat., XVIII, 1880)-and the method of con- centric deposition of fibrin as advocated by Nicaise.

These bodies have been described by Nicaise as amorphous und slightly granular bodies with no enveloping membrane. 'They are stratified and here and there between the layers are ittle lacunæ containing bloody granules, refringent bodies like fat or round like leucocytes, but not taking the stain. There nay be some remains of connective tissue stained faintly red. . . . Perfect or incomplete tubercles are found in the sac valls-the very surface shows a varied structure sometimes of connective tissue fibres, again, a thin strip of reddish-brown homogeneous vitreous material under which may be seen a hemorrhagic film and a thin band staining like the rice bodies.

. In the center of these one sees vestiges of necrotic cells ;

it times there is seen a layer of elongated cells, vaguely cylin- Irical, ending in a mass of granulation tissue beneath. On a evel with the surface project some little irregular masses, lightly adherent like beginning rice bodies made of layers loubled on themselves."

Riese says: " The smaller bodies are a meshwork of flaky omogeneous masses running together to form bands taking he fibrin stain. The center is deepest stained. Between ingle bands there may be seen irregular gaps in which are nely granular masses containing very few leucocytes. At ne periphery are some large nuclei (without perceptible pro- plasm) and few leucocytes. In some there are seen masses { red blood cells stuck together by fine granules, but no brin is present in these."

The presence of tubercle bacilli was shown in the fibrin dies by all investigators either by staining them or inocu- ting guinea pigs.

The walls of the containing sac were invariably infiltrated ith round, epitheloid and giant cells in varying proportion, id as single or conglomerate or caseated tubercles. There is a varying amount of adherence to surrounding structures. he greatest attention has been paid to the inner lining-this at showing either caseation or degeneration in lesser degree cellular material growing as villi.

It was with the desire to decide whether or not these villi re the origin of the rice bodies that Riese, Nicaise, Poulet a Vaillard, and Schuchardt did such extensive work.

necrosis of this surface material as being the point of origin of the rice bodies, while Nicaise seemed to find fibrin deposits or curled masses to account for their origin.

Reinhardt deals with an entirely different condition of the bursa caused by tuberculosis-" Primary Sclerosing Tuber- culosis." It is analogous to the second case I describe.

He noticed about the trochanteric bursa a number of fibrous nodules. These were thick and of a grayish color going sud- denly over into the surrounding tissue. In them were seen little pinkish-gray areas 1 mm. in size. Microscopically they were dense connective tissue infiltrated by small round cells in areas; some fat was included. The connective tissue fibers were thick, interwoven and parallel. Some cells were elon- gated, some were more protoplasmic and stellate. The intima of the vessels was thickened and typical tubercles were seen near the perivascular infiltrated parts-consisting of giant cells of Langhans type, surrounded by epitheloid and round cells and leucocytes. Some areas were composed almost en- tirely of giant cells; some nodes showed central necrosis with broken down leucocytes or granular material.

Reinhardt records six cases like this and refers to their resemblance to fibroma and syphilitic gummata. The cases are in every respect like that of the prepatellar bursa de- scribed by me.

It is interesting to note in this place the varying form in which tuberculosis affects tissues. Reinhardt refers to the French authors, Poncet more especially, who wrote about " sclerosing tuberculosis due to a fibrous diathesis following finished tubercular processes." Ducroux, one of Poncet's fol- lowers, described a series of cases of tuberculosis of a " serous bursa " between the scapula and the chest wall which occa- sioned crepitus and friction sounds. " It is due to a chronic inflammation of a loose cellular tissue (a kind of spread out serous bursa)." He incidentally referred to Poncet's ideas about tuberculous rheumatism where specific anatomic lesions were wanting. He says, "This same condition occurred in tendons, bursæ, cellular organs and all tissues. Some of these cases might be called tubercular rheumatism."

We see in the two cases presented by me typical examples of the two types of tubercular involvement of bursa described by these writers. They agree with them in all particulars, both in symptoms and pathology.

The condition develops insidiously, sometimes requiring years before the patient considers it worth while to consult a surgeon. He may think it due to rheumatism or a sprain. Examination of the part does not necessarily elicit pain or con- siderable disability of the part involved until late. There is usually muscle atrophy more or less limited to the parts im- mediately surrounding the involved bursa; in my cases the deltoid muscle alone showed atrophy.

X-ray examination showed nothing specific by which a diag- nosis could be made in either case.

In one case the crepitus of masses in the bulging area was significant, whereas in the case of the prepatellar bursa there was nothing but a dense circumscribed projecting mass which

Digitized by

Google

158

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 212

could have been gummatous quite as well. It is interesting to note that in the shoulder case there was no involvement of the joint, whereas in the prepatellar involvement there were tuber- cular villi of long standing in the knee joint.

The main interest centers about the pathology of the cases- one representing the type of rice-body formation in a tuber- cular bursa, the other a chronic sclerosing tubercular process.

CASE I .- J. F., white male, age 22 years. Admitted to the Hebrew Hospital, July 26, 1909, complaining of pain at and loss of function of the right shoulder.

Family History .- Good. No tuberculosis.

Past History .- He has always been strong and healthy, never sick in bed in his life.

Present Illness .- For about three years his right shoulder has been stiff on getting up in the morning; this would wear off after he had worked awhile. For the past three months it has been painful all the time. He cannot work . because of the pain. It is more painful on motion. The pain is sharp, lancinat- ing in character.

Physical examination shows fullness of the right shoulder, more apparent over the coracoid process, and crepitus under palpating fingers in front of the joint. Tenderness localized at the acromion process. He cannot raise the arm nor place it behind him because of pain. His grip is as strong with the right as with the left hand. He allows the arm to hang helpless by his side.

Measurements:

Right axilla over acromion 1512 in.

Left axilla over acromion 16 in.

Right biceps 10 in.

Left biceps

101/2 in.

Right biceps (above) 9% in.

Left biceps (above)

1014 in.

July 29. X-ray shows rarefication over the tuberosity of the humerus and slight roughening here as well as at the upper portion of the glenoid fossa. Joint, negative.

July 29. Two milligrams tuberculin were injected subcu- taneously, to which he reacted locally, focally and generally. There was swelling, tenderness and redness at sight of injection, pain the following day at the shoulder, and the temperature rose from 97.3º F. to 100° F.

Aug. 2. Operation, under ether: Incision from the acromion process outwards and downwards toward the deltoid insertion three inches long, through the deltoid muscle exposing a thick gray sac; this was easily exposed by blunt dissection anteriorly, but owing to adhesions about the tuberosity of the humerus and difficulty in getting the sac away above the coraco-acromial liga- ment, the sac was incised, when about 400 multifacetted bodies flattened against one another shot out, together with a thin serous fluid. The sac was now removed without difficulty. An incision was made into the joint at the point of greatest adhesion -near the greater tuberosity; the joint was normal. The bone too was normal. The cartilaginous tip of the acromion process appearing translucent and soft, a longitudinal section 1.5 cm. long, was removed for examination. The muscle was sewed with a continuous cat-gut suture. Skin closed with continuous sub- cutaneous silkworm gut suture. A small wick of iodoform introduced; arm bandaged with Velpeau bandage, with a Gillette pad in the axilla.

Aug. 5. First dressing: Iodoform drain removed, wound dry. Aug. 19. Patient discharged healed per primam.

Sept. 8. Patient readmitted, complaining of pain in his shoulder and a small sinus at the region of the acromion process in the line of incision. An X-ray was taken showing the joint

negative-osteophytes are evident about the tuberosity of the humerus where an exploratory operation was done at the time of excising the bursa.

The sinus was treated and closed by September 22. He was discharged September 29 with arm in a sling, Gillette pad in axilla.

The patient was treated off and on for fistula which forme about the site of the old operation-one forming posterior to axilla at the apex of the axillary fold. One formed about junction of the outer and middle third of the clavicle and inch below it.

Jan. 24, 1910. While treating the sinuses it was noted that was coughing and an examination for admission to the J Consumptive Home at Reisterstown showed both apices of lungs to be involved by tuberculosis. He was sent to the where I treated him. He was discharged much improved as regards his lungs and shoulder. He then went to the co., and returned in excellent condition.

Oct. 15, 1910. The sinuses are all closed and the patient: has been using the arm off and on since the operation constantly using it. The muscles over the joint have not covered their tone, but the biceps reacts strongly and I atrophied.

PATHOLOGICAL DESCRIPTION OF THE CASE.

The sac containing about 400 grayish-white translucen; bodies pressed into multiform shapes resembling in size and shape facetted gall stones, was 11 x 6 x 3 cm. in size, elongated oval in shape. Its wall varied in thickness from 3 mm. to 1 5/10 cm., was firm, homogeneous and gray in color witt. pinkish areas throughout. At its uppermost end under the acromion process it was a dense fibrous tongue of tissue wedged against the softened cartilaginous tip of the acromion procese. Its inner lining was softer and of yellowish color, but smooth for the greater part, trabeculated here and there. The rice bodies stuck firmly in this meshwork. There were some fer nodular areas, but no villous processes could be picked of until deeper in the walls of the sac. These nodular areas re- sembled the material of the rice bodies but were softer. The sac was in layers 2 mm. thick at the outermost shell. The outermost walls were hemorrhagic and shreddy, but dense con- nective tissue existed where the sac was adherent. The con- tents consisted of round, oval and facetted bodies varying from to 2 to 8 mm. in size; these were so densely packed that some force was required to separate numbers of them. Many of them fitted snugly depressions and pockets among the tra- beculæ in parts of the wall of the sac. They were of a grayisb- white color and translucent appearance-not very firm, the center being darker and softer than the periphery. They con- sisted of layers, the outermost being 2 mm. thick. These could be picked apart, easily cut, so that free hand sections were made for staining for fibrin and tubercle bacilli while yet fresh. There were some elongated shreds resembling the abore but softer and more shreddy and darker, resembling blood- stained fibrin. Microscopic examination showed the bodies to be a granular loculated material staining with Weigerti fibrin stain and showing flakes, granules and strands. Traces of nuclei were faintly stained here and there. Tubercle bacilli were found with the Ziehl-Neelsen's stain.

In acetic acid this material swelled showing a fenestrate!

Digitized by Google

CASE I .- BEFORE OPERATION.

18 ℮

CASE I .- AFTER OPERATION.

CASE II.

CASE II .- TUBERCULAR BURSITIS.

TUBERCULAR BURSA WITH FIBRIN BODIES.

Digitized by Google

Google

Digitized by

us rather porous but showed no cellular infiltration or hemor- hage. The bone cells and lacuna showed no pathological Iteration.

The softened tip of the acromion process showed mucoid egeneration of the cartilage cells, some of them appearing in tellate forms.

Sections were made from many portions of the sac through 's entire thickness. It showed typical tuberculosis and of arying histological structure, dense fibrous tissue containing reas of small round cells, small round cells and epithelioid ells, sometimes giant cells, sometimes caseation with these or reas where caseation was the only microscopic change seen. n places there were single and conglomerate tubercles. Many essels were occluded by two or three giant cells with few pithelioid cells, some small round cells about them. Fre- uently a gradation could be traced from the dense fibrous uter structure to the cellular, infiltrated, softer inner wall, degenerated non-staining cells and lastly to a lining of ranular or flaky non-staining material, with apparent lines f cleavage traversing it in some sections.

Where adhesions held the sac to surrounding parts near the iberosity of the humerus the outermost tissue was very much ongested and hemorrhagic, but was fairly well distinguished :om the sac by the latter's dense structure, and its containing ounded spaces lined by tubercular giant cells. There were no filtrating round cells or giant cells in this adherent wall.

CASE II .- The second case is one where there was associated iberculosis of the neighboring joint.

C. R., white male, age 24 years. Admitted to the Hebrew ospital, February 18, 1910, complaining of swelling over the repatellar bursa and swollen, painful left knee.

Family History .- Father died of Bright's disease. A brother ed of tuberculosis. Wife healthy, two sons healthy.

Past History .- No serious illness until 20 years of age, when › had typhoid fever. Never had venereal infection. He later id pleurisy.

Present Illness .- Patient has had the swelling (nodular mass) er his patella for several years; it has not bothered him. He w complains of pain in the knee-joint which he traces to a fall ovember 27, 1909, when he struck the left knee; two days later e knee began to be painful. The pain was so great at night at he could not sleep. He was treated in the Dispensary of 9 Hebrew Hospital, getting relief, so that the pain was inter- ttent. He could move the leg all right, except when it locked occasions.

A physical examination showed the patient to be well de- loped and normal except for a tubercular focus in the apex right lung.

Vote of Resident Physician .- The left thigh and leg are smaller in the right. The left knee is thickened and warmer than the ht, and tender on both inner and outer sides. There is a ap over the patella the size of a hickory nut, elastic to the ch, freely movable under the skin. The left leg may be ted on the thigh to a little more than a right angle.

"he tuberculin test was positive. There were 8800 leucocytes. Differential blood count:

Polymorphonuclears 57.00%

Small mononuclears 37.50

Large mononuclears 1.50

Transitionals 2.50

Eosinophiles 1.50

the joint and the symptoms pointing to such a condition, he was operated upon on February 19, 1910.

Operation .- A long incision (4 inches) on the inner side, to include the prepatellar bursa, was made, and a shorter one along the outer side of the knee-joint.

The capsule was incised and a number of tags of a pinkish- yellow color were removed. The largest of these 21/2 cm. in length and pedicled, was loose in the joint. After closing the capsule with a continuous silk suture, the prepatellar bursa, a dense fibrous mass, was excised. The skin wounds were closed with subcutaneous silk-worm gut sutures, and the limb put in a plaster of Paris cast.

The wound did badly-the prepatellar area healed by granu- lation but the joint and surrounding tissues became involved in an active tubercular process until amputation of the limb was necessitated on August 11, 1910.

The mass removed from the prepatellar region, measuring 4 x 3 x 2 cm., was solid, fibrous, glistening white material which cut with difficulty, but showed softer grayish areas here and there. It faded gradually into the surrounding fat.

Microscopically it was a dense fibrous mass containing islands of small round cells, epithelioid and giant cells, and some caseous areas. It extended into the fat tissue by dense fibrous bands.

The tags removed from the joint showed masses of round and epithelioid cells and areas of degeneration.

The examination after operation of the muscle, glands and necrotic material from the joint showed active tuberculosis mostly epithelioid, giant and small round cells, with many poly- morphonuclear leucocytes infiltrating the softer parts. Many conglomerate tubercles were present.

SUMMARY.

It will be seen that our cases correspond exactly to the types of tuberculosis of bursa containing rice bodies, described, as in the first case, by Nicaise, Poulet and Vaillard, Leriche and Rhenter, and Schuchardt, and in the second case to the scleros- ing type described by Reinhardt and Ducroux.

We can add nothing new to their work either in connection with the clinical findings or pathology. We trust that by call- ing attention to the rarity of the condition and giving refer- ences to the best that has been written in regard to this subject, besides adding our own confirmation of their findings, we may aid others in studying tuberculosis of bursa.

BIBLIOGRAPHY.

Baer, W. S .: The Operative Treatment of Subdeltoid Bursitis. Johns Hopkins Hosp. Bull., 1907, XVIII. 282.

Bousquet: Un Cas de bursite tuberculeuse primitive de la bourse séreuse sous-deltoidienne. Montpel. Med., 1904, XIX, 42. Brackett, E. G .: Gluteal Bursitis. Tr. Am. Orthop. Asso., 1897, X, 123.

Churchman, J. W .: Luetic Bursopathy of Verneuil. Am. J. M. Sc., 1909, CXXXVIII, 371.

Clarke, W. C .: The Pathogenesis of Ganglia with a Description of the Structure and Development of Synovial Membrane. Surg., Gyn. and Obstet., 1908, VII, 56.

Codman, E. A .: Subacromial Bursitis or Periarthritis of the Shoulder Joint. Boston M. and S. J., 1908, CLIII, 159.

Cullen, T. S .: A Large Cystic Tumor Developing from the Iliopsoas Bursa. J. Am. M. Ass., 1910, LIV, 1181. Da Costa, J. C .: Mod. Surg., 1910.

Ducroux, E .: Craquements et frottements sousscapulaires par bursite de nature tuberculeuse. Lyon, Thèse, 1905.

Digitized by Google

160

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 24?

Duplay, S .: De la peri-arthrite scapulo-humerale et des raid- eurs de l'épaule qui en sont la conséquence. Arch. gen. de méd., 1872, 6 S., XX, 513.

Evans, Chas. S .: Ganglion and Teno-synovitis Tuberculous. Am. J. M. Sc., 1892, CIII, 643, and CIV, 38.

Finney, J. M. T .: Johns Hopkins Hosp. Bull., 1894, V, 83.

Goldmann, E. E .: Ueber das reiskoerperchenhaltige Hygrom der Sehnenscheiden. Beitr. z. path. Anat. u. z. allg. Path., 1889, VII, 299.

Kaumheimer, L .: Paraartikuläre Pneumokokkeneiterungen im fruehen Kindesalter. Bursitis und Tendovaginitis pneumococcica purulenta. Mitt. a. d. Grenzgeb. d. Med. u. Chir. Jena, 1910, XXI, 599.

Kreuter, E .: Ein Fall von Bursitis subdeltoidea als Beitrag zur Hygromfrage. Deutsche Ztschr. f. Chir., 1904, LXXII, 136.

Leriche and Rhenter: Un Cas de hygroma sous-deltoidien à grains riziformes. Lyon med., 1908, CXI, 215.

Lund, F. B .: Iliopsoas Bursa: its Surgical Importance and the Treatment of its Inflammatory Conditions, with Report of Three Cases. Boston M. & S. J., 1902, CXLVII, 345.

Mosengeil, K .: Arch. f. klin. Chir., 1871, XII, 73

Nicaise, Poulet et Vaillard: Nature tuberculeuse des hy- gromas et des synovites tendineuses à grains riziformes; cas

rare d'hygroma à grains riziformes de la cuisse. Rev. de chir. 1885, V, 609.

Painter, C. F .: Subdeltoid Bursitis. Boston M. & S. J., 190%, CLVI, 345.

Reinhardt, A .: Die primäresklerosierende Tuberkulose der Schleimbeutel. Deutsche Ztschr. f. Chir., 1909, XCVIII, 63.

Riese: Die Reiskörperchen in tuberkulöserkrankten Synovial- säcke. Deutsche Ztschr. f. Chir., 1896, XLII.

Schuchardt, K .: Tuberkulose und Syphilis der Sehnenscheiden Beiträge zur Kenntniss der fibrinoiden Entartung des Binde gewebes. Arch. f. path. Anat., 1894, CXXXV, 394.

Sterne, J .: Hygroma aigu à pneumococques consecutif à une pneumonie. Rev. med. de l'est, Nancy, 1908, XL, 440.

Teale, T. P .: On Suppuration of the Bursa over the Trochanter Major and its Occasional Imitation of Hip Disease. Lancet, 1904, II, 1355.

Thurston, E. O .: Bilateral Tuberculous Bursitis of Hips. Am. Surg., 1907, XLVI, 919.

Virchow, R .: Krankhafte Geschwülste, 1863, I, 208.

Wietung, J .: Beitrag zu den Affectionen, namentlich der Tuberkulose der Schleimbeutel in der Becken-Hueftgegend. Deutsche Ztschr. f. Chir., XXXIII.

Zuelzer, R .: Die Schleimbeutel der Huefte und deren Er- krankungen. Deutsche Ztschr. f. Chir., 1898, XLIX, 148.

A DEVICE TO AID IN KEEPING THE PATIENT DRY AFTER A SUPRAPUBIC CYSTOSTOMY.

BY GEORGE WALKER, M. D., Associate in Surgery, Johns Hopkins University, Baltimore, Md.

36 inches

-6in :-

The device consists of a pure gum rubber sheet, 1 yard square, with a round hole in the center 6 to 8 inches in diam- eter. The material is similar to that used by dentists.

The sheet is laid on the patient immediately next to the skin so that the opening falls over the suprapubic wound. The usual amount of absorbent gauze is then laid on the wound, and the borders of the sheet are folded in, covering the gauze completely. The sheet with the enclosed gauze is held in place by an ordinary abdominal binder or Scultetus bandage.

By this arrangement whenever the gauze becomes saturated the fluid drains into the dependent portion of the sheet, where it collects and allows almost no leakage for several hours, dur- ing which time the patient's bed and clothing are kept dry.

When properly adjusted the sheet is also of very materis! aid in protecting the clothing when the patient is in a wheel chair or walking about.

A large opening in the rubber is necessary in order to supply a sufficient absorptive surface for the gauze.

This arrangement has been found to work admirably with some patients, keeping them almost dry; for others, owing to the configuration of the abdomen, it will prove less satis- factory, but in all cases it undoubtedly adds to the general comfort.

Digitized by Google

IN MEMORIAM.

DR. CHRISTIAN A. HERTER.1

Christian Archibald Herter was born in Glenville, Connecti- ut, September 3, 1865, and died at his home in New York 'ity, December 5, 1910, in the forty-sixth year of his age. fis early education, partly by private teachers and at the Columbia Grammar School, was largely influenced and di- ected by his father, a man of wide culture and schol- rly attainments. He was graduated Doctor of Medicine at he College of Physicians and Surgeons (Columbia Univer- ity) in 1885. He pursued graduate professional studies at ne Johns Hopkins University, and later in Germany and 'rance. He was Visiting Physician to the New York City [ospital from 1894 to 1904, Professor of Pathological Chem- stry at the University and Bellevue Hospital Medical College :om 1898 to 1903, and since 1903 Professor of Pharmacology nd Therapeutics at the College of Physicians and Surgeons. [e was a member of the Board of Referees appointed by the 'resident of the United States to act as advisers to the De- artment of Agriculture in the enforcement of the National food and Drugs Act.

Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.

Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 110

Author: Jacob Anthony Kimmell Publication date: 1910 Publisher: Number of Pages: 1189

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189