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EXTRUSION OF A RENAL CALCULUS
230
Cinical Notes : MEDICAL, SURGICAL, OBSTETRICAL, AND THERAPEUTICAL. EXTRUSION OF A RENAL CALCULUS CAUSING A SINUS IN THE LOIN.
BY H. J.
ORR-EWING, M.C., M.D., B.S. LOND., M.R.C.S. ENG.,
ASST. MED. OFFICER, ENGLISH MISSION
THE
tollowing
presenting special
case
HOSPITAL, JERUSALEM.
recorded
unusual, features of interest :is
as
and
calculus in the absence of any indications of an affection of the kidney seemed to be uncalled for. I have no access to the literature of similar cases, but I seem to remember that most, if not all, of the recorded cases have given rise to suspicions as to their causation, by some, at any rate, of the symptoms and signs so conspicuously lacking in this case. It was quite a minute before I realised that I was looking at a renal calculus, and not at the possible result of an attack with a slung stone from the rear. A FURTHER NOTE ON THE
LYMPHOIDOCYTE AND ITS SIGNIFICANCE.
CLINICAL
BY A. KNYVETT GORDON, M.B. CANTAB., History.-N. G., a native Arab village woman, aged MEDICAL SUPERINTENDENT OF THE VIROL RESEARCH about 30, came to hospital from Nablous on Oct. 18th. LABORATORIES. :She stated that she was suffering from a wound in her for a year. She said that .back, which had been discharging she knew of no cause for this " wound " ; no history was IN a previous communication to THE LANCET of - obtainable of injury, acute illness, pain, or disability of 19th, 1919, I recorded the finding of lymphoidoJuly kind. In the she stated that it was " Min Moslem idiom, .any Allah "-in other words, it had developed spontaneously ; cytes-which are regarded as the parents not only of apart from the wouhd she felt very well. leucocytes and lymphocytes but of red cells alsoOn examination she proved to be a fine, apparently in the circulating blood in fatal illnesses other than healthy woman, who had all her life been accustomed to anaemia. I have since extended these -the hardest manual labour in a country where all the heavy primary and give a brief summary of the results. observations, work is done by women. Nothing abnormal was discovered in chest or abdomen ; the spine showed no tenderness, Twenty-six patients were selected, who were described deformity, or rigidity ; the urine was quite normal, specific as moribund, and who certainly appeared to be in extremis. gravity 1015, slightly acid, no albumin, no blood, no casts, Lymphoidocytes were found in 24, associated in every case no deposits of any kind visible to the naked eye. Over the with a marked leucopenia and the presence of leucoblastsleft loin, about 2 in. from the middle line, at the level of the the parent both of leucocytes and lymphocytes-and in six first lumbar vertebra, was a wound, or sinus, discharging cases with a few myelocytes also. The diagnosis is as yellow pus of a thin consistency; there was no urinary follows : Diabetic gangrene 3, carcinoma with generalised element in the discharge. The sinus passed downwards metastases 3, senile decay 2, advanced tuberculosis 6, .and outwards ; a probe was inserted and a foreign body cardiac valvular disease with broken-down compensation 7, was discovered lying 1 to H in. from the surface. This severe malaria 1, relapsing fever (with presence of the ’body felt like dead bone. A provisional diagnosis of tuber- characteristic parasites) 2. All of these subsequently died. culous abscess was made. The difficulty lay in the origin The two remaining somewhat unexpectedly recovered, and of the " dead bone " ; the wound was above the crest of the lymphoidocytes could no longer be found. One was the ilium, quite a distance from the vertebra, and the suffering from alcoholic pneumonia and cirrhosis of the twelfth rib could be traced intact above. The patient was liver, and the other from influenzal pneumonia. In addition, I have observed 15 cases of primary disease Admitted to hospital, where her temperature for three days of the hsemopoietic organs-namely, lymphatic leukaemia 6, remained subnormal and her pulse-rate 70-80. Treatnzent.-On the 22nd she was anxsthetised and a 1 pernicious " anaemia 3, secondary carcinoma of the bonetransverse incision was made with a view to enlarging the marrow 2, myeloid leukaemia 2, Banti’s disease 2, in all of A probe was now passed beyond the which death took place, and lymphoidocytes were present opening of the sinus. foreign body, and the sinus found to go directly in the in the circulating blood. The proportion of lymphoidocytes direction of the left kidney. The supposed bone was in the films varied in the first series from 3 to 11 per cent., grasped by necrosis forceps and pulled out through the and in the second from 5 to 20 per cent. I do not, however, enlarged exit wound. It was found to be a large renal suggest any correlation between these proportions and the - calculus, roughly circular in circumference, and somewhat severity of the disease, as it is by no means certain that the aoaf-shaped. It was encrusted thickly with what was proportion of primitive cells of various types does not vary ’presumably uratic substance, and the interior, I imagine, from time to time when they are present. was uric acid (I did not cut it up owing to the patient’s These observations show that the appearance of ,desire to possess the trophy) ; the diameter of the stone the primordial cell in the circulation is not confined would be about five-eighths of an inch. The sinus was then thoroughly cleared, packed with iodoform and drained, to disease of the haemopoietic organs, though I have She has been unable to find any record of their presence in the remainder of the wound being sutured. made a good recovery : in no way affected by a tem- man except in the leukaemias. So far as this goes, perature of 1010 F. the night after the operation, and 1035° it serves, I think, to emphasise the importance of the next night; this proved upon blood examination to be the histological features of the blood cells due to the ubiquitous malarial parasite, and speedily yielded studying to appropriate treatment. The sinus is healing up from the instead of merely relying on their numerical proporbottom, and although once in the daily dressing I washed tions as found in a mechanical count where they are It is frequently possible out of the wound some gravelly has not classified under rigid types. been the sligbtest urinary odour, nor any evidence of the not only to trace in the same film gradations between the recognised mature cells and their progenitors, presence of urinary matter in the discharge. Remarks.-The woman, who was carefully ques- but also to observe a shift towards one or the other tioned in view of the findings above, still denied any end as the patient improves or gets worse, and it is history of pain such as renal colic, and stated that therefore probable that as our knowledge of the she never had any pain during micturition, never biology of the blood cells deepens, the opinion of the suffered from frequency, nor had she had any passage pathologist on the extent of the patient’s resistance Her obstetric history had been un- to disease in general will become of increasing service of gravel. The history in these cases is notoriously to the clinician. The value of a mechanical count with inaccurate, but there seems no reason to suspect the haemocytometer is but small, unless it be suppledeception. The patient is an exceptionally intelligent mented by a histological study of the cells themIn these days such selves in properly stained films. For this purpose I woman for her class and race. have found Leishman’s stain useful for a general even in Palestine the cases must be fairly rare ; native usually seeks medical advice comparatively survey of the film, but for the finer details Pappen.early. Nothing either in the history, symptoms, or heim’s panoptic stain is preferable and less liable to urinary investigation led us to suspect the renal cause variation. Latterly I have come across no fewer of the trouble ; true, there were difficulties in the than five different samples of alleged Leishman stain
material, there
eventful.
spinal caries diagnosis, but tuberculosis, especially of bones and joints, is very prevalent amongst the Fellaheen and Bedouin Arabs, and to suspect renal
which were quite useless for haematological work, and could not be made to give the characteristic reactions by any manipulation whatsoever.
Cinical Notes : MEDICAL, SURGICAL, OBSTETRICAL, AND THERAPEUTICAL. EXTRUSION OF A RENAL CALCULUS CAUSING A SINUS IN THE LOIN.
BY H. J.
ORR-EWING, M.C., M.D., B.S. LOND., M.R.C.S. ENG.,
ASST. MED. OFFICER, ENGLISH MISSION
THE
tollowing
presenting special
case
HOSPITAL, JERUSALEM.
recorded
unusual, features of interest :is
as
and
calculus in the absence of any indications of an affection of the kidney seemed to be uncalled for. I have no access to the literature of similar cases, but I seem to remember that most, if not all, of the recorded cases have given rise to suspicions as to their causation, by some, at any rate, of the symptoms and signs so conspicuously lacking in this case. It was quite a minute before I realised that I was looking at a renal calculus, and not at the possible result of an attack with a slung stone from the rear. A FURTHER NOTE ON THE
LYMPHOIDOCYTE AND ITS SIGNIFICANCE.
CLINICAL
BY A. KNYVETT GORDON, M.B. CANTAB., History.-N. G., a native Arab village woman, aged MEDICAL SUPERINTENDENT OF THE VIROL RESEARCH about 30, came to hospital from Nablous on Oct. 18th. LABORATORIES. :She stated that she was suffering from a wound in her for a year. She said that .back, which had been discharging she knew of no cause for this " wound " ; no history was IN a previous communication to THE LANCET of - obtainable of injury, acute illness, pain, or disability of 19th, 1919, I recorded the finding of lymphoidoJuly kind. In the she stated that it was " Min Moslem idiom, .any Allah "-in other words, it had developed spontaneously ; cytes-which are regarded as the parents not only of apart from the wouhd she felt very well. leucocytes and lymphocytes but of red cells alsoOn examination she proved to be a fine, apparently in the circulating blood in fatal illnesses other than healthy woman, who had all her life been accustomed to anaemia. I have since extended these -the hardest manual labour in a country where all the heavy primary and give a brief summary of the results. observations, work is done by women. Nothing abnormal was discovered in chest or abdomen ; the spine showed no tenderness, Twenty-six patients were selected, who were described deformity, or rigidity ; the urine was quite normal, specific as moribund, and who certainly appeared to be in extremis. gravity 1015, slightly acid, no albumin, no blood, no casts, Lymphoidocytes were found in 24, associated in every case no deposits of any kind visible to the naked eye. Over the with a marked leucopenia and the presence of leucoblastsleft loin, about 2 in. from the middle line, at the level of the the parent both of leucocytes and lymphocytes-and in six first lumbar vertebra, was a wound, or sinus, discharging cases with a few myelocytes also. The diagnosis is as yellow pus of a thin consistency; there was no urinary follows : Diabetic gangrene 3, carcinoma with generalised element in the discharge. The sinus passed downwards metastases 3, senile decay 2, advanced tuberculosis 6, .and outwards ; a probe was inserted and a foreign body cardiac valvular disease with broken-down compensation 7, was discovered lying 1 to H in. from the surface. This severe malaria 1, relapsing fever (with presence of the ’body felt like dead bone. A provisional diagnosis of tuber- characteristic parasites) 2. All of these subsequently died. culous abscess was made. The difficulty lay in the origin The two remaining somewhat unexpectedly recovered, and of the " dead bone " ; the wound was above the crest of the lymphoidocytes could no longer be found. One was the ilium, quite a distance from the vertebra, and the suffering from alcoholic pneumonia and cirrhosis of the twelfth rib could be traced intact above. The patient was liver, and the other from influenzal pneumonia. In addition, I have observed 15 cases of primary disease Admitted to hospital, where her temperature for three days of the hsemopoietic organs-namely, lymphatic leukaemia 6, remained subnormal and her pulse-rate 70-80. Treatnzent.-On the 22nd she was anxsthetised and a 1 pernicious " anaemia 3, secondary carcinoma of the bonetransverse incision was made with a view to enlarging the marrow 2, myeloid leukaemia 2, Banti’s disease 2, in all of A probe was now passed beyond the which death took place, and lymphoidocytes were present opening of the sinus. foreign body, and the sinus found to go directly in the in the circulating blood. The proportion of lymphoidocytes direction of the left kidney. The supposed bone was in the films varied in the first series from 3 to 11 per cent., grasped by necrosis forceps and pulled out through the and in the second from 5 to 20 per cent. I do not, however, enlarged exit wound. It was found to be a large renal suggest any correlation between these proportions and the - calculus, roughly circular in circumference, and somewhat severity of the disease, as it is by no means certain that the aoaf-shaped. It was encrusted thickly with what was proportion of primitive cells of various types does not vary ’presumably uratic substance, and the interior, I imagine, from time to time when they are present. was uric acid (I did not cut it up owing to the patient’s These observations show that the appearance of ,desire to possess the trophy) ; the diameter of the stone the primordial cell in the circulation is not confined would be about five-eighths of an inch. The sinus was then thoroughly cleared, packed with iodoform and drained, to disease of the haemopoietic organs, though I have She has been unable to find any record of their presence in the remainder of the wound being sutured. made a good recovery : in no way affected by a tem- man except in the leukaemias. So far as this goes, perature of 1010 F. the night after the operation, and 1035° it serves, I think, to emphasise the importance of the next night; this proved upon blood examination to be the histological features of the blood cells due to the ubiquitous malarial parasite, and speedily yielded studying to appropriate treatment. The sinus is healing up from the instead of merely relying on their numerical proporbottom, and although once in the daily dressing I washed tions as found in a mechanical count where they are It is frequently possible out of the wound some gravelly has not classified under rigid types. been the sligbtest urinary odour, nor any evidence of the not only to trace in the same film gradations between the recognised mature cells and their progenitors, presence of urinary matter in the discharge. Remarks.-The woman, who was carefully ques- but also to observe a shift towards one or the other tioned in view of the findings above, still denied any end as the patient improves or gets worse, and it is history of pain such as renal colic, and stated that therefore probable that as our knowledge of the she never had any pain during micturition, never biology of the blood cells deepens, the opinion of the suffered from frequency, nor had she had any passage pathologist on the extent of the patient’s resistance Her obstetric history had been un- to disease in general will become of increasing service of gravel. The history in these cases is notoriously to the clinician. The value of a mechanical count with inaccurate, but there seems no reason to suspect the haemocytometer is but small, unless it be suppledeception. The patient is an exceptionally intelligent mented by a histological study of the cells themIn these days such selves in properly stained films. For this purpose I woman for her class and race. have found Leishman’s stain useful for a general even in Palestine the cases must be fairly rare ; native usually seeks medical advice comparatively survey of the film, but for the finer details Pappen.early. Nothing either in the history, symptoms, or heim’s panoptic stain is preferable and less liable to urinary investigation led us to suspect the renal cause variation. Latterly I have come across no fewer of the trouble ; true, there were difficulties in the than five different samples of alleged Leishman stain
material, there
eventful.
spinal caries diagnosis, but tuberculosis, especially of bones and joints, is very prevalent amongst the Fellaheen and Bedouin Arabs, and to suspect renal
which were quite useless for haematological work, and could not be made to give the characteristic reactions by any manipulation whatsoever.