Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 124

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

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least, would be saved. Naturally the prognosis is better in cases first seen in the stage of localized abscess, but nothing is . gained and much may be lost by allowing early cases to wait in hopes that walling off will occur.

To summarize: Pneumococcus peritonitis occurs more often in children than in adults, and more often in female than male children. There are two forms: the encapsulated, which exhibits a first period of invasion, a second period of localized abscess formation, and a third of spontaneous rup- ture of the abscess; and the diffuse form of general peri- tonitis rapidly fatal unless operated upon. The symptoms of onset in both forms, varying only in intensity, are abdominal pain, vomiting, fever, and diarrhea. Rigidity is not char- acteristic. The treatment is surgical intervention as soon as possible. The prognosis of the diffuse form is very bad; of the localized form, fairly good. The pus is characteristic, and often sufficient for diagnosis from its macroscopic ap- pearance alone.

In conclusion, I wish to express my indebtedness to Dr. Ney, of the Hebrew Hospital, for his kind assistance in placing the hospital records of the case at my disposal.

BIBLIOGRAPHY.

1. Dudgeon and Sargent: The Bacteriology of Peritonitis, London, 1905. A. Constable & Co.

2. Bozzolo: Centralbl. f. klin. Med., 1885, VI.

3. Sevestre: Bull. et mém. Soc. med. d. hop. de Par., 1890, 3 S., VII.

4. Nelaton: Bull. med., Par., 1890, IV.

5. v. Brunn: Beitr. z. klin. Chir., Tübing., 1903, XXXIX.

6. Jensen: Arch. f. klin. Chir., 1903, LXIX.

7. Annand and Bowen: Lancet, Lond., 1906, I.

8. v. Robbers: Deutsche med. Wchnschr., 1906, XXXII.

9. Williams: Brit. M. J., Lond., 1907, I.

10. Scannell: Boston M. & S. J., 1906, CLIV.

11. Nobécourt: Rev. gen. de clin. et de therap., Par., 1910, XXIV.

AN ANOMALOUS DUCT BELONGING TO THE URINARY TRACT .* By PAUL G. WOOLLEY, M. D., Professor of Pathology, University of Cincinnati, and

HERBERT A. BROWN, M. D., Cincinnati.

(From the Laboratories of the Cincinnati Hospital.)

'he specimen we wish to describe is of unusual interest use of its extreme rarity, for, in spite of a somewhat istaking search of the literature we have found no account iny similar condition. It was found during the post- tem on a patient in the Cincinnati Hospital (No. 153426) had been admitted for cutaneous blastomycosis, and who of the generalized form of that disease.

cause none of the symptoms of the patient could be re- d in any way to the condition of the genito-urinary tract hall omit the history and the report of the autopsy, and ead before the Cincinnati Society of Medical Research, May 1.

confine ourselves to an account of the condition only as it re- ferred to the specimens. We believe that the case has been discussed from the dermatological standpoint by Dr. Ravogli.

The left kidney weighed 200 gms. The capsule stripped with slight difficulty and left a moderately roughened, almost nodular surface. The cut section was rather pale, and the line of demarkation between cortex and medulla was indistinct. The cortex was of about normal thickness. The blood vessels were sclerotic. The right kidney showed the same general appearance. The left adrenal showed a somewhat evident hyperplasia of the medulla. The right adrenal was apparently absent.

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JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 85

Extending from the antero-mesial aspect of the upper pole of the right kidney, that is, from the normal site of the right adrenal, appeared a distended, tortuous, saculated tube, which ran parallel with the right ureter which it finally passed to enter the posterior surface of the prostate (Fig. 1). The average diamater of this sac was about 2 cm. In its wider parts it was distended to about 4-5 cm. At its lower end it was rapidly constricted, almost to occlusion. Through the lower end a fine probe could be passed into the posterior urethra at the site of the sinus pocularis. In the immediate vicinity of the prostatic part was a blastomycotic abscess which involved, to a minimal extent, the wall of the duct. The upper part of this distended duct ended in a mass of tissue of about 2 x 1 x 1 cm. in size, which was taken to be the remains of an atrophic adrenal and which later proved to contain only one small area which in anyway resembled adrenal tissue. This mass also contained abscesses. There was no connection whatever between the tube and the kidney, ureter or bladder. The pelvis of the kidney was not dilated. Both testicles were present and had undergone descensus.

In the expectation that sections of the specimen would be of some asistance, bits of tissue were taken from the nodule of tissue at the renal extremity, from the sac at its origin near this renal nodule and from the prostatic portion of the tube. The blocks of tissue taken from the uppermost part included the nodule itself and the kidney so that comparison could be made in the same section.

The sections made from these blocks can, for the purposes of description, be divided into three parts; one, representing the mass of the nodule; a second representing the kidney; and a third, the boundary zone between nodule and kidney.

The tissue of the first part was for the most part well- formed fibrous tissue enclosing large and small cystic spaces, large and small blood vessels, nerves, collections of epithelial cells (columnar, as a rule, occasionally cubical), which seem to represent cross sections of ducts (Fig. 6), and blastomycotic abscesses. The larger cystic spaces were lined with a single row of cuboidal epithelium and filled with a granular al- buminous material in which masses of desquamated epithe- lium, polymorphonuclear leucocytes, giant cells, and blasto- myces, were imbedded. The smaller cystic spaces were of two particular forms. One form was lined with one or more rows of cylindrical or high columnar epithelium and filled with desquamated cells, cellular detritus, leucocytes, and extra- and intra-cellular blastomyces; the other was lined with one or more layers-usually a single layer-of cuboidal epithelium and contained a material that resembled thyroid colloid (Fig. 4). Occasionally this colloid showed concentric lines and in some cases it was so changed that it stained with basic dyes and appeared quite similar in appearance to the cor- pora amylacea of the prostate (Fig. 5). As a rule, however, they were rather more irregular than the ordinary prostatic cor- pora amylacea, and had a striking resemblance to other similar bodies that are occasionally present in the ovary and other organs. The blood vessels had, as a rule, thickened walls and

in the majority of instances showed endothelial prolifieratisc. even, in some cases, to the point of obliteration. The nerves showed no abnormalities, either in cross or longitudinal sti- tions. No ganglion cells were observed.

The tissue of the second part represented merely a narrow zone of kidney tissue in which there were general changes thx: taken collectively indicated a chronic diffuse nephritis. moderate severity.

The boundary zone between the two parts already describe: was composed of fibrous tissue that firmly united the kidnes and the nodule. This zone was of some little width, but the line of demarcation was narrow, and was represented by : narrow line of renal capsule. In but a few sections, close ti the kidney, and yet separated distinctly from it were sma'! localized masses of tissue, glandular in structure, and quite similar to the tissue that is seen in adrenal and renal aden- mas, and in which was no sign of ganglion or chromaffin ce": (Figs. 3 and 4).

The general impression given by these sections was that one was dealing with a possible combination of renal, adrenal. and ovarian tissue indifferently arranged. Drs. Knower and Wieman have suggested the occasional resemblance to : Wolffian body.

The sections from the sac itself at the upper and lower ends show that the walls of the sac were composed of fibroes tissue with a minimal number of smooth muscle fibers and' were lined with low columnar or cuboidal epithelium (Fig. 11.

There are, under more or less normal circumstances, pri- sibilities of but three openings into the prostatic urethra- two, the openings of the ejaculatory ducts, which were presen .: in this case, and one, the opening of the united Müllerian ducts.

There is also the theoretic possibility that as a result of embryonic developmental variations as suggested by Pohlman the ureter might open into the prostatic urethra. Pohlman says that in changing its position on the Wolffian duct frem dorsal to lateral, at which time the ureter comes to open di- tinet from the Wolffian duct and would naturally open in common with it or into parts developed from its lower enl. or " the ureter might open laterally to the Wolffian duct aty! on a level with it. The opening in this case would be found! in the prostatic urethra."

If this be a true explanation, then the mass of tissue aboire the kidney is the remnant of an atrophic or hypoplastic kidney, or it is the remains of the Wolffian body. In the former case we should be dealing with a unilateral multi- plicity of kidneys, each with its ureter, one of which open: into the prostate; in the latter we should have to consider that the duct was the result of persistence of the united Wolffian duct and ureter.

There is the other possibility that in this case we are merely dealing with an abnormal course of a complete ureter with- out any participation of a Wolffian duct, as occasionally happens in cases with accessory ureters. It is to be noted that in such cases the one of the ureters, usually the one which

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FIG. 7.

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mutual vesicle.

any case we cannot account for absence of the adrenal pt on the basis of aplasia, or perhaps-if the nodule men- ed above be adrenal-hyperplasia. Either of these re- s, it might be suggested, may be the result of the develop- it of accessory renal tissue at the expense of adrenal. The ryonic relationships of the urogenital organs are so close the possibilities of variations are very numerous. Mar- id emphasized this from the side of the genito-adrenal ins when he suggested that variations in the sizes of enals and ovaries cannot be considered as purely fortuitous. ; is our misfortune that the anatomic evidence at our dis- il is not sufficient to permit us to come to any decision as whether we are dealing with the result of one or the other ne possibilities mentioned.

roniman. Amer. Med., 1904, 987.

Marchand: Intern. beitrage z. wissensch. Med. Virchows Fest- schrift. Bd. 1.

Aschoff: Pathologische Anatomie. Jena, 1909, Bd. 11, S. 506.

Kaufmann: Specielle Pathologische Anatomie. Berlin, 1907, S. 773.

ILLUSTRATIONS.

1. A photograph of the gross specimen.

2. The adrenal ( ?) rest.

3. Same as 2, enlarged.

4. Cystic spaces showing colloid.

5. Cystic space showing corpus amylaceum.

6. Ducts in the nodule above the kidney.

7. Wall of the large duct.

All of the illustrations except 1 and 3 were drawn with a camera lucida at table height using a Leitz ocular IV and obj. 3. Figure 3 was drawn with a Leitz ocular IV and a Spencer 4 mm. A. 0.80 objective.

JUTE CHOLECYSTITIS WITH LARGE AMOUNTS OF CALCIUM SOAP IN THE GALL-BLADDER.

By JOHN W. CHURCHMAN, M. D., Late Resident Surgeon, The Johns Hopkins Hospital.

i view of the great frequency with which the gall-bladder rained under conditions identical with those present in patient whose case is here reported, the absence of any lar case in the clinical literature emphasizes the unique- of the observation here made. Moreover-though soaps found in small amounts in the bile-I have been able to no reference, in the chemical literature of the subject, to ll-bladder contents composed almost entirely of soap. here was nothing unusual about the clinical features of case. The patient presented the typical picture of an cholecystitis. She had never had typhoid fever. The ss began two days before admission with chills, fever, and neral aching. Delirium appeared that night; and the day there was abdominal pain-at first general, later ized in the right side and radiating to the right shoulder. tea and vomiting were present, but there was no jaundice. physical signs were those of acute cholecystitis. The gall- ler was not palpable. The liver was slightly enlarged.

the operation straw-colored fluid was found in the peri- 1 cavity, cultures from which remained sterile. The ap- 'x was normal, but the gall-bladder was distended and inflamed. After isolating it with gauze, it was aspi- ; but instead of the pus which was expected a fluid, un- nything previously seen in the gall-bladder, appeared in arrel of the syringe. The color of this material but particularly its strange odor (suggesting a mixture of ver oil and turpentine) recalled the contents of a mes- c cyst operated on a few days previously; and it was moment uncertain whether what had been supposed to 1-bladder might not prove to be a cystic growth of the On opening it, however, a large number of bile-stained were found and removed. There was neither bile nor

pus in the gall-bladder. The cystic duct was completely blocked by stones. The contents of the distended gall-bladder consisted entirely of a material like that which had been as- pirated. The gall-bladder was drained in the usual manner. Convalescence was without event. Three small stones were found in the tube at the first dressing. The discharge from the biliary fistula was at first brownish, later purulent, then thin and mucoid; but it never contained bile.

The wound healed to a pin-point opening, through which

- Abdominal Wall

Sinus.

Gall bladder

Hepatic Duet

Cystic Duet.

Common Duct

the limpid mucoid material, characteristic of hydrops, con- tinued to drain. The sinus persisted, causing the patient al- most no inconvenience, but discharging at intervals. After a year had elapsed, she returned to have it closed. At this operation, the gall-bladder contained much clear mucoid fluid (from which no organism could be grown) and a few facetted, pigmented stones. The distended cystic duct contained many gall-stones and communicated with the gall-bladder by an opening so small that the stones could only with great diffi- culty be delivered into it. (See diagram.)

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JOHNS HOPKINS HOSPITAL BULLETIN.

The common and hepatic ducts contained no stones. The usual drainage was carried out. Bile appeared in the sinus on the seventh day and soon became profuse. The wound closed promptly and has remained healed.

The strange material removed from the gall-bladder at the first operation was grayish-white in color, glistening, opaque in mass, but slightly translucent in thin layers. It was fluid enough to run into a large aspirator, but its con- sistency was somewhat that of tooth paste and it could be picked up in mass. It had no property of adhesion whatever, and when handled, failed to come into intimate contact with the skin of the finger, from which it was separated, appar- ently by a thin layer of oil. None of it stuck to the finger, though its peculiar oily odor remained on the skin. It was ductile and could be pulled out in strands, like pulled candy ; but it was somewhat elastic.

An agar slant was inoculated with some of the material and B. typhosus grew out in pure culture. The patient's Widal reaction was taken and found positive. It is interest- ing that cultures made from the gall-bladder at the second operation, one year later, were negative.

A chemical analysis of this material (kindly made by Dr. Slagle) showed it to consist largely of soaps of the calcium salts. Some free fatty acids were also present, but no bile pigments.

There is nothing in the secretion of the gall-bladder proper from which the soaps here present could have originated. This secretion has been carefully analyzed in two cases pre- senting biliary fistula and occluded cystic ducts, and the following composition found."

' Birch and Spong: Journal of Physiology, Cambridge, 1887, VIII, 378.

Water and gases.

979.7

Solids

20,3

Organic

Mucin

12.09

Inorganic

Albumin (a trace) Chlorine. Carbon dioxide. Sodium (combined with chlorine). Sodium (combined with CO,). Potassium salts and phosphates.

These findings agree with other examinations of the gal- bladder secretion.

Hammarsten's analyses of the bile in the liver and in il- gall-bladder showed the fats, soaps and fatty acids to be m .: abundant in the latter situation. His figures are as follows

COMPOSITION PER 1000 PARTS OF BILE.

The averages of Hammarsten's figures are here given approximately

Liver Bile.

Gall-bladder Bile.

Water.

About 970

About 835

Solids

# 161

Mucin and Pigments

. 49

Taurocholate

₩ 9%

Bile acids and Alkalis

9+ to 18+

87 to 9%

Glycocholate

6+ to 16+

67 to 6?

Fatty Acids and Soaps.

About 11

Cholesterin

to 1.6

Lecithin Fat

}

to 1.5

4 to ;

Soluble Salts

to 8

About 3

Insoluble Salts

to .5

The analyses of other investigators, though the figur- have shown some differences from those of Hammarsten, azne as to the substances found and, in an approximate way, as ?! their relative proportions. All observers have found a smal amount of fatty bodies (fatty acids, soaps, fats and lecithin . but none have found them in any such preponderance a: 53: the case in this patient.

NOTES ON NEW BOOKS.

Progressive Medicine, Vol. I, March, 1911. A Quarterly Digest of Advances, Discoveries and Improvements in the Medical and Surgical Sciences. Edited by HOBART AMORY HARE, M. D. (Philadelphia and New York: Lea & Febiger, 1911.)

The most important European and American articles on recent advances and theories in the treatment of the "Surgery of the Head, Neck and Thorax," "Infectious Diseases, including Acute Rheumatism, Croupous Pneumonia, and Influenza," " Diseases of Children," "Rhinology and Laryngology," and "Otology," are reviewed in this volume with the usual care and skill shown by the contributors. This work is of value to any practitioner who wishes to keep himself well informed on the progress of medi- cine in all its branches-a progress which is steady though some- times necessarily slow.

A Text-book of General Bacteriology. By EDWIN O. JORDAN, Ph. D. Fully illustrated. Second Edition. Thoroughly Revised. Price, $3.00. (Philadelphia and London: W. B. Saunders Company, 1910.)

As errors have been corrected and omissions repaired, which appeared in the first edition of this work, and several new sec- tions added, its real value, to which attention was drawn in our

issue of July, 1909, has been increased, and it is fortunate ths students have such a useful and reliable book to guide them i: their studies.

Accidental Injuries to Workmen, with Reference to Workmet Compensation Act, 1906. By H. NORMAN BARNETT, F. R. C.S. etc. With Article on Injuries to the Organs of Special Sens- by CECIL E. SHAW, M. D., etc. And Legal Introduction, ty THOMAS J. CAMPBELL. Price, $2.50. (New York: Rebman Company, 1911.)

This work is more adapted to the use of the English profession than to our own, but since injuries to workmen are as frequent here as elsewhere, and since the question of the proper respon- sibility in such cases is steadily becoming more acute in th: country, and more and more accident cases are being taken inte court, it is most satisfactory that American doctors should have such an excellent book to study when they have to deal with " accidental injuries, mechanical and chemical, to the varios organs and tissues of the body, including those of special sense. The treatment of such injuries properly finds no place in th work, but diagnosis is fully discussed, and also the remote effer? of injuries. This is in fact a text-book to guide physicians how ti study an injury which may result in a suit for damages. The.

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siau w ve anie to call

ir attention to it, for the author has handled his material lfully and written interestingly. The publishers are also to be nmended for the quality of the paper which makes the book ht and easily held in one hand-so many publications are msy and fatiguing to hold.

rgery of the Brain and Spinal Cord. Based on Personal Ex- periences. By PROF . FEDOR KRAUSE, M. D. Translated by PROF. HERMAN A. HAUBOLD, M. D. Vol. I. (New York: Rebman Company, 1909.)

n his introduction to this work Prof. Krause states that he does attempt to offer a text book on neurology but "to present nerous ilustrations from nature which are destined to con- ute an accurate picture of the status of the surgery of the brain ! spinal cord as it stands at this writing." The work therefore s not take up the pathology, pathological physiology, sympto- :ology, and diagnosis of surgical neurological conditions, but is with some of the surgical problems relative to these condi- Is and the surgical procedure used in attacking them which in author's hands have proven most satisfactory. It is evident n his introduction that Prof. Krause still holds the view that internist and neurologist should make the diagnoses of sur- il neurological conditions for the operating surgeon; a view h which we are not at all in accord.

book dealing with such a special branch of surgery will have arying degree of usefulness. To the general surgeon who has little or no special training in neurological surgery it will be great aid, for the author has had a large experience in this ich of work and the technic he describes in dealing with va- s intracranial lesions is superior to that employed by the age general surgeon. To those who intend to devote them- es to neurological surgery the book will be a valuable addi- , for the author has appreciated and correctly grasped many he problems which tend to make neurological surgery a special of work. To the relatively few who have had considerable rience in the surgery of the brain, this volume will be an in- sting exposition of a single operator's technic and experiences eurological surgery, but will offer little that is especially new. le first 50 pages of the book are devoted to trephining, the rol of hemorrhage from scalp and bone and the method of ing osteoplastic flaps in the approach to lesions in different ons of the brain. It would seem that the method of Von lenhain or the plates of Kredel which he employs for the con- of hemorrhage from the scalp are unnecessary and time-con- ng procedures. A well fitted tourniquet practically always s the purpose. He describes various methods for controlling rrhage from the bone, but admits total inexperience with the useful of methods, i. e., the use of Horsley's wax. In the ation of osteoplastic flaps he rightly, we think, advocates the of hand-driven instruments rather than electrically-driven es. His flaps could be improved upon; a bevelled upper edge with a Gigli saw prevents the flap from pressing down upon ura; and if the base of the flap is made narrow and directed ward toward the temporal region it can be fractured and the f injury to dura by cutting across it avoided. In agreement many operators Krause prefers a two stage operation, the tage ending with the formation of the bone flap. He speaks frequency of collapse at the end of the first stage; an occur- which we have very rarely seen. Collapse at this time must undue hemorrhage although Krause states that it often without much loss of blood. While two stage operations adoubtedly necessary in some instances, we have been ac- ned to see the entire operation completed at one sitting; and ily a one stage procedure is to be preferred if it can be ac- ished with no additional risk to the patient.

factory. He employs a sitting position which is not only difficult to maintain but is bad for the patient, trying to the anaesthetist and inconsistent with perfect asepsis. Certainly the position used by Cushing is greatly to be preferred. Krause makes use of a unilateral osteoplastic flap which in states of increased pres- sure must be a difficult and bloody procedure. The exposure of only one cerebellar hemisphere does not allow sufficient disloca- tion for a complete and satisfactory exploration; indeed, it is only by a wide exposure of both hemispheres that a complete explora tion of the cerebellum and lateral recesses is possible. Experience teaches that a lesion, such as a cyst, occupying one hemisphere may by pressure cause symptoms entirely referable to the oppo- site intact lobe; and therefore it is possible that a lesion might escape detection with a unilateral exposure.

His treatment of various lesions of the brain exposed at opera- tion he describes for the most part by citing examples from his series of cases. In the main his treatment is good. He recognizes the necessity of preventing injury to vessels which may cause post- operative cerebral softening, of careful control of hemorrhage and of preventing injury to the pia-arachnoid. It would appear that he drains too frequently. He packs cyst cavities with gauze to oblite- rate them; we believe that every effort should be made to remove the cyst wall even though thin. He has observed the rapid oblitera- tion of cavities left after removal of tumors or other lesions, but often drains these cavities, which, with careful control of hemor- rhage, is unnecessary.

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 124

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

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