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NOTE ON A URETHRAL CALCULUS OF UNUSUAL SIZE.
1023
CLINICAL AND LABORATORY NOTES.
few illthick and corpora albicantia.
Ovaries: enlarged and fibrosed, containing developed Graafian follicles. The capsules were
fibrous and exhibited
numerous
catheter, which was removed on the fourth day. Slight leakage of urine occurred for a week. The wound was soundly healed on the nineteenth day after operation.
a
It appears from this and previously reported cases of " diabetes of bearded women," that in addition to the six characteristic signs of the condition (vide supra), the following three points may be of considerable diagnostic importance : 1. A minor degree 2. An increased basal of double exophthalmos. metabolic rate. 3. In the early stages a definite, although mild and transient, polycytheemia. Exophthalmos of slight degree with optic neuritis was reported in the cases of Cushing, Anderson, and Parkes Weber. Turney’s case showed retinal changes, three-fourths of the right disc being surrounded by a white subretinal exudation, and Parkes Weber remarked upon the presence of white foci around the discs of his case. In the case here described no retinal changes were associated with the exophthalmos. Polycytheemia was reported by Turney, and Parkes Weber’s case apparently had an abnormally high erythrocyte count in the earlier stages.33 In the light of these facts it is possible that the figure of 5,300,000 red cells per c.mm., recorded in the cases of Cushing and Langdon Brown, may have indicated an earlier
polycythsemia.
The
section it had a hard outer shell,
coveringalaminated phosphatic core. Owing to an
errorin gauge-
ing the focal distance
of
camera,
the e the
photograph here reproduced is a
Calculus removed from the bulb of. the urethra (slightly less than actual size).
little smaller than the actual size. The raised facet shown in the photograph was lying ventrally over the openings of
Cowper’s glands.
I
The basal metabolic rate has been recorded in only two of the above-mentioned cases. Parkes Weber’s case had a B.M.R. of plus 20, and Langdon Brown recorded a B.M.R. of plus 15. He remarks that this result is interesting in conjunction with the marked
’
stone
weighed 163 grains; its length was 1 in. and its greatest diameters werein. andi in. On
-
That there was considerable distension of the bulb was shown by the fact that, during convalescence, the patient had to press the perineum over the bulb after micturition in order to avoid dribbling of urine. When the tissues contract, as they will in the course of time, urination should become normal. ’
To adjudicate whether the stone was primary or The secondary is a matter of some difficulty. history suggests that it was primary.
obesity.
A NOTE ON THE I have not found any record of the microscopy of the capillaries in other reported cases, but the findings PAIN SENSE OF THE PARIETAL PLEURA. in the present case suggest that the remarkably poor BY A. I. G. MCLAUGHLIN, M.B., CH.M. SYD., definition and distortion of the outlines of these ASSISTANT MEDICAL OFFICER, TUBERCULOSIS DEPARTMENT, vessels may well be the explanation of the bruising ST. THOMAS’S HOSPITAL, LONDON. and petechial haemorrhages which have been features of almost all the cases recorded. IN a recent communication to THE LANCET1 on I have to thank Prof. F. Langmead for his kindness in permitting me to report the case when I was house the Mechanism and Elements of Pleural Pain, I stated that it is generally accepted that the visceral pleura physician to the Medical Unit. is insensitive, that the costal parietal pleura is supplied l’Acad. and J. : Bull de Thiers, Rejerences.-1. Achard, Ch., Med., 1921, lxxxvi., 51. 2. Apert, M. : Bull. de la Soc. Pédiat. with sensory nerves from the intercostals, and that de Paris, 1910, xii., 501 ; Presse Med., 1911, xix., 865. certain types of irritation or stimulus to the membrane 3. Brown, W. Langdon : Modern Medical Monographs Series, are experienced by the patient as definitely localised The Endocrines in General Medicine, London, 1927, p. 95. pain. I find, however, that some authorities, 4. Weber, Parkes : Brit. Jour. Derm. Syph., 1926, xxxviii., 1. influenced largely by the observations of Sir James Mackenzie, still state that the parietal pleura has no NOTE ON A pain sense. Samson Wright,2for instance, says :-
URETHRAL CALCULUS
OF UNUSUAL SIZE.
BY H. R. B. HULL, M.R.C.S.
ENG.,
AND
R. J. G.
PARNELL, M.R.C.S. ENG.,
SURGEON-COMMANDERS, R.N.; UROLOGICAL SPECIALISTS, MEDITERRANEAN FLEET.
URETHRAL calculi are usually secondary, that is to say, they do not originate in the urethra, but from small calculi passed into the urethra from the ureter, bladder, or prostate. Primary stones are rare, seldom attain a large size, and are with few exceptions single. Whatever their origin, their retention in the urethra without symptoms is most exceptional. The stone in this case was very large, and there were certain features which seem to us worthy of record. The patient, a stoker, who was in training for the Fleet
Marathon Race and had run six miles a few days before, sought advice on account of a thin mucoid gleet. There was a history of gonorrhoea seven months previously, complicated by epididymo-vasitis. Whilst palpating Cowper’s glands, a hard spindle-shaped body was found lying in the long axis of the bulbous urethra, apparently within its lumen. The patient was unaware of its presence. His health during the past four months had been excellent, and there was no history of impaction. Attempts at urethroscopy were unsuccessful, owing to the small calibre of the fossa navicularis. Operation was performed on board the hospital ship Maine. A sound was passed after meatotomy. This showed that the foreign body was a stone in the bulb and removal through a perineal incision was easily effected. The floor of the bulb was of normal thickness. The divided layers were sutured over a
" Irritation of the pleura reflexly produces coughing, but pain sensibility is present in the pleura. This statement greatly at variance with the well-known severe pain of pleural inflammation. Neither scraping nor penetration of the parietal pleura produces pain, as can be well shown when resections of the ribs are carried out under local anaesthesia. The nerve-supply to the pleura is not known ; cerebro-spinal nerve-fibres do not appear to have been traced into, nor do nerve plexuses lie in the surrounding connective tissue."
no seems
On the other hand, such writers as Behan3 and Schmidt4 are of the opinion that the parietal pleura is definitely sensitive. Behan states that the parietal pleura is innervated by the intercostal, sympathetic, and vagus nerves, and the visceral by the vagus and
sympathetic. Up to the present
little anatomical evidence ’has been adduced to support the theory that the parietal pleura is supplied from the intercostal nerves. Prof. F. G. Parsons,5however, in a recent dissection of a part of the chest wall, showed quite clearly branches from the intercostals going to the parietal pleura. A. S. Dogiel 6 demonstrated the presence of sensory end-bulbs in the human parietal pleura, and M. J. ging,8 quoted by H. A. Bray,’ found them in the parietal pleura of the rat, calf, rabbit, and guinea-pig.9 Bray also quotes the observations of S. V. Sewell who noted that in operations under local anaesthesia manipulation of the non-anaesthetised parietal pleura evoked exquisite pain. The important experimental and clinical work of J. A. Capps 10 on pleural pain showed very clearly that mechanical irritation of the inner surface of the costal parietal pleura nearly
CLINICAL AND LABORATORY NOTES.
few illthick and corpora albicantia.
Ovaries: enlarged and fibrosed, containing developed Graafian follicles. The capsules were
fibrous and exhibited
numerous
catheter, which was removed on the fourth day. Slight leakage of urine occurred for a week. The wound was soundly healed on the nineteenth day after operation.
a
It appears from this and previously reported cases of " diabetes of bearded women," that in addition to the six characteristic signs of the condition (vide supra), the following three points may be of considerable diagnostic importance : 1. A minor degree 2. An increased basal of double exophthalmos. metabolic rate. 3. In the early stages a definite, although mild and transient, polycytheemia. Exophthalmos of slight degree with optic neuritis was reported in the cases of Cushing, Anderson, and Parkes Weber. Turney’s case showed retinal changes, three-fourths of the right disc being surrounded by a white subretinal exudation, and Parkes Weber remarked upon the presence of white foci around the discs of his case. In the case here described no retinal changes were associated with the exophthalmos. Polycytheemia was reported by Turney, and Parkes Weber’s case apparently had an abnormally high erythrocyte count in the earlier stages.33 In the light of these facts it is possible that the figure of 5,300,000 red cells per c.mm., recorded in the cases of Cushing and Langdon Brown, may have indicated an earlier
polycythsemia.
The
section it had a hard outer shell,
coveringalaminated phosphatic core. Owing to an
errorin gauge-
ing the focal distance
of
camera,
the e the
photograph here reproduced is a
Calculus removed from the bulb of. the urethra (slightly less than actual size).
little smaller than the actual size. The raised facet shown in the photograph was lying ventrally over the openings of
Cowper’s glands.
I
The basal metabolic rate has been recorded in only two of the above-mentioned cases. Parkes Weber’s case had a B.M.R. of plus 20, and Langdon Brown recorded a B.M.R. of plus 15. He remarks that this result is interesting in conjunction with the marked
’
stone
weighed 163 grains; its length was 1 in. and its greatest diameters werein. andi in. On
-
That there was considerable distension of the bulb was shown by the fact that, during convalescence, the patient had to press the perineum over the bulb after micturition in order to avoid dribbling of urine. When the tissues contract, as they will in the course of time, urination should become normal. ’
To adjudicate whether the stone was primary or The secondary is a matter of some difficulty. history suggests that it was primary.
obesity.
A NOTE ON THE I have not found any record of the microscopy of the capillaries in other reported cases, but the findings PAIN SENSE OF THE PARIETAL PLEURA. in the present case suggest that the remarkably poor BY A. I. G. MCLAUGHLIN, M.B., CH.M. SYD., definition and distortion of the outlines of these ASSISTANT MEDICAL OFFICER, TUBERCULOSIS DEPARTMENT, vessels may well be the explanation of the bruising ST. THOMAS’S HOSPITAL, LONDON. and petechial haemorrhages which have been features of almost all the cases recorded. IN a recent communication to THE LANCET1 on I have to thank Prof. F. Langmead for his kindness in permitting me to report the case when I was house the Mechanism and Elements of Pleural Pain, I stated that it is generally accepted that the visceral pleura physician to the Medical Unit. is insensitive, that the costal parietal pleura is supplied l’Acad. and J. : Bull de Thiers, Rejerences.-1. Achard, Ch., Med., 1921, lxxxvi., 51. 2. Apert, M. : Bull. de la Soc. Pédiat. with sensory nerves from the intercostals, and that de Paris, 1910, xii., 501 ; Presse Med., 1911, xix., 865. certain types of irritation or stimulus to the membrane 3. Brown, W. Langdon : Modern Medical Monographs Series, are experienced by the patient as definitely localised The Endocrines in General Medicine, London, 1927, p. 95. pain. I find, however, that some authorities, 4. Weber, Parkes : Brit. Jour. Derm. Syph., 1926, xxxviii., 1. influenced largely by the observations of Sir James Mackenzie, still state that the parietal pleura has no NOTE ON A pain sense. Samson Wright,2for instance, says :-
URETHRAL CALCULUS
OF UNUSUAL SIZE.
BY H. R. B. HULL, M.R.C.S.
ENG.,
AND
R. J. G.
PARNELL, M.R.C.S. ENG.,
SURGEON-COMMANDERS, R.N.; UROLOGICAL SPECIALISTS, MEDITERRANEAN FLEET.
URETHRAL calculi are usually secondary, that is to say, they do not originate in the urethra, but from small calculi passed into the urethra from the ureter, bladder, or prostate. Primary stones are rare, seldom attain a large size, and are with few exceptions single. Whatever their origin, their retention in the urethra without symptoms is most exceptional. The stone in this case was very large, and there were certain features which seem to us worthy of record. The patient, a stoker, who was in training for the Fleet
Marathon Race and had run six miles a few days before, sought advice on account of a thin mucoid gleet. There was a history of gonorrhoea seven months previously, complicated by epididymo-vasitis. Whilst palpating Cowper’s glands, a hard spindle-shaped body was found lying in the long axis of the bulbous urethra, apparently within its lumen. The patient was unaware of its presence. His health during the past four months had been excellent, and there was no history of impaction. Attempts at urethroscopy were unsuccessful, owing to the small calibre of the fossa navicularis. Operation was performed on board the hospital ship Maine. A sound was passed after meatotomy. This showed that the foreign body was a stone in the bulb and removal through a perineal incision was easily effected. The floor of the bulb was of normal thickness. The divided layers were sutured over a
" Irritation of the pleura reflexly produces coughing, but pain sensibility is present in the pleura. This statement greatly at variance with the well-known severe pain of pleural inflammation. Neither scraping nor penetration of the parietal pleura produces pain, as can be well shown when resections of the ribs are carried out under local anaesthesia. The nerve-supply to the pleura is not known ; cerebro-spinal nerve-fibres do not appear to have been traced into, nor do nerve plexuses lie in the surrounding connective tissue."
no seems
On the other hand, such writers as Behan3 and Schmidt4 are of the opinion that the parietal pleura is definitely sensitive. Behan states that the parietal pleura is innervated by the intercostal, sympathetic, and vagus nerves, and the visceral by the vagus and
sympathetic. Up to the present
little anatomical evidence ’has been adduced to support the theory that the parietal pleura is supplied from the intercostal nerves. Prof. F. G. Parsons,5however, in a recent dissection of a part of the chest wall, showed quite clearly branches from the intercostals going to the parietal pleura. A. S. Dogiel 6 demonstrated the presence of sensory end-bulbs in the human parietal pleura, and M. J. ging,8 quoted by H. A. Bray,’ found them in the parietal pleura of the rat, calf, rabbit, and guinea-pig.9 Bray also quotes the observations of S. V. Sewell who noted that in operations under local anaesthesia manipulation of the non-anaesthetised parietal pleura evoked exquisite pain. The important experimental and clinical work of J. A. Capps 10 on pleural pain showed very clearly that mechanical irritation of the inner surface of the costal parietal pleura nearly