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Syphilis of the urinary bladder with report of six cases
Progress
NEW SERIES VOL. III, No. I
and ending at the base. BIaustein the term “incIine bIadder” for this He uses a 2 per cent or 2.3 per cent sodium iodide instead of the 12.5 cent strength commonIy used for
proposes condition. soIution of or 15 per this work.
BALLENGER, EDGAR G., and ELDER, OMAR F., AtIanta, Ga. Post-operative cystitis. South. iU. J., ApriI, 1927, xx, 321. Concerning the cause or causes of the cystitis which fohows operations, when the bIadder has become overdistended and urethra1 catheterization is required, the genera1 assumption seems to be that an infection has been carried by the catheter. AIthough this may at times be a factor, it is not the primary factor in the majority of instances. The actua1 cause of the cystitis more frequentIy is trauma in the form of smaII Iacerations of the mucosa from sudden overdistention of the bIadder. These minute injuries afford an entrance for organisms passing down from the kidneys or up through the urethra. When the distention of the bIadder is graduaI in onset, as in prostatic obstructions or tabes, the pavement epithehum grows as the residua1 urine increases and the minute Iacerations do not deveIop as they apparentiy do in rapidIy distended bIadders. Danger of prompt or repeated catherizations is trivia1 compared with danger of injury to the bIadder mucosa by overdistention. This view is strongIy supported by the rarity of cystitis after operations when the bIadder has not become overfiIIed and by the infrequency of cystitis from urethral instrumentation. Overdistention of the bIadder aIways precedes this type of cystitis. The mucous membrane when damaged by overdistention or trauma from chemica1 agents becomes a Iess efficient barrier against infection, just as does the injured epidermis. Surgeons shouId Ieave a standing order after operations for carefur observation of the patient’s hIadder in order that it may be emptied before harmfuI distention occurs. Furthermore, it may be of vaIue, when catheterization becomes necessary, to inject a miId germicide into the bIadder after it has been emptied to contro1 or Iimit the infection if damage has been done to the mucosa by the overdistention. MOORE, THOMAS D., Memphis. The diagnosis of bIadder atony. J. Tennessee M. A., Feb., 1927, xix, 286. Diagnosis
of
bIadder
atony
is
important
in
Surgery
American Journal of Surgery
97
because of the evident tendency to ascribe the patient’s symptoms to some obstructive condition, resuIting in futiIe surgica1 interference. Two of the cases reported had been subjected to prostatectomy without reIief, due to such erroneous diagnoses. The outstanding features of the disease are five in number: (I) Marked urinary diffrcuIty; (2) residua1 urine, usuaIIy a Iarge amount; (3) the absence of any discoverabIe obstruction to the urinary stream; (4) poor detrusor tonus as noted by the sIow dribbIing from an inserted catheter or manometer reading, and (3) diminished sensory responses. Three patients, two men and one woman, having atony of the bIadder, were subjected to careful examination of the centra1 nervous system, incIuding study of the spina fluid. In a11 of them the resu1t.s were negative. Studies of the intravesica1 tension with a water manometer reveaIed a curve somewhat typical of the disease. BIadder sensory tests discIosed varying degrees of anesthesia for tactiIe, thermaI, and pain stimuli. These findings favor the opinion that atony of the bIadder is dependent upon some disturbance in the IocaI nerve supply, probabIy a degenerative process invoIving the hypogastric pIexus or interference with the refIex tract through the vesica1 center in the Iumbar cord. TURNER, B. WEEMS, Houston, Texas. Syphilis of the urinary bIadder with report of six cases. South. M. J., ApriI, 1927, xx, 289. Primary and secondary syphilitic manifestations in the bIadder are as a ruIe comparativeIy insignificant. They vary from a generaIized reddening of the mucosa to a discrete, macuIar or petechia1 reddening which readiIy cIears under treatment of the disease. VesicaI gummata are among the rare syphiIitic manifestations, and as a rule are probabIy not recognized unIess uIceration with secondary infection and hemorrhage directs attention to the bIadder. The characteristic pathoIogica1 finding of syphiIis of the bIadder in its tertiary manifestations is a true cystitis, with thickening of the entire waI1 of the bladder and resuItant contracture and reduction in its capacity. The Iesions more frequentIy appear at the base, usuahy some portion of the trigone, and it is beIieved that this predilection possibIy arises from the Iocation of the Iymph gIands and gIanduIar tissue in that region. Given a Iesion in the bIadder, the differentia1 diagnosis is to be
98
AmericanJournaIof Surgery
Progress
made between eIusive uIcer, papiIIomata, carcinoma, tubercuIosis and sarcoma. It is not possibIe to make an absoIute diagnosis with cystoscope aIone, but certain characteristics are fairIy significant and warrant seeking other evidences. Among these are generaIized thickened, reddened mucosa with macuIes distributed at the base, pearIy, opaIescent papuIes occurring as buIIae adjacent to the uIcer or papiIIomata, with an absence of the typica eIevation and infiItration seen in maIignancy. It seems that syphiIis is not a factor in production of papiIIomata, although two of Turner’s cases showed definite papiIIomata, with papiIIary vegetations coexisting with the bIadder Iesion. It is aIso quite evident that maIignancy can be engrafted upon a syphiIitic Iesion of the bIadder. J. T., MeIbourne. Prostatectomy and its after-resuIts. Med. J. Australia, ApriI 16, I9271 Pa 571.
TAIT,
Of eighty patients admitted 82 per cent were operated upon in one stage and 18 per cent required the two-stage method. The two groups were distinguished by genera1 cIinica1 examination rather than by the renaI function test. The operative mortaIity for suprapubic prostatectomy in one stage was 4.6 per cent, the mortaIity for a11 cases being 8,75 per cent. In 85 per cent of one-stage operations for prostatic disease of innocent nature the Iate resuIts were satisfactory, though IO per cent of the patients had an attack of epididymitis after discharge from hospita1. In the remaining IO per cent there was persistent cystitis. In 12 per cent of cases histoIogica1 examination showed that maIignant change was present in the prostate and of these patients onIy 50 per cent were we11 two years after operation. A reIativeIy frequent seque1 of two-stage prostatectomy was postoperative hernia, otherwise the Iate results were comparabIe to those of the operation in one stage. J., Paris. ResuIts of suprarenaIectomy in spontaneous gangrene of the extremities. (ResuItats de Ia surrenaIectomie dans Ies gang&es spontankes des membres). Presse mid., ApriI_g, 1927, No. 29, 454.
S~N~QUE,
SCnitque reviews the”Iiterature on the treatment of gangrene and especiaIIy thromboangitis obIiterans by means of excision of the
in Surgery Ieft suprarena1 gIand. He quotes the statistics of Herzberg in I IO cases, of which 8 were Herzberg’s. Of this series, 14 were reported to have been cured. In a11 but three, results are too recent to be of much vaIue. It has been cIaimed that there is definite ameIioration of the symptoms, disappearance of pain, cure of the uIcers and in some cases even reappearance of the peripheral circulation. %n&que observes with justice that this operation is faIIing into disrepute even among those who were its most staunch protagonists. He beIieves that the operation is not founded on firm anatomopathoIogica1 grounds and that it finds no warrant in cIinica1 experience. HENRY MILCH. EARL C., Kansas City. Free fuIIthickness skin transpIantation. J. Kansas Med. Sot., May, 1927, xxvii, 145.
PADGETT,
The main advantages of the fuI1 thickness graft are: (I) Contraction is much Iess than foIIowing a Thiersch graft (a Thiersch graft does not give a satisfactory resuIt in cases of marked deformity after burns); (2) in the paIm of the hand, and other areas subjected to considerabIe trauma, fuI1 thickness grafts wiI1 give a good functiona resuIt if there is any soft tissue between graft and bone; (3) in certain congenita1 anomaIies as in web fingers it offers a method giving a good resuIt in one operation; (4) in certain disfiguring facia1 bIemishes it has possibiIities not possessed by other types of skin transplants. If the bone is nearIy bare or thickness is desired a ffap transpIant offers advantages not otherwise obtainabIe. The disadvantage of a flap is, first, that its thickness in certain areas gives a cIumsy resuIt Iess pIeasing from the esthetic standpoint, and second, that severa operations are required. The WoIfe graft can be transpIanted usuaIIy in one or two operations. The fIap transpIant has its distinct indications and probabIy is more usefu1 in the various phases of pIastic surgery than the fuI1 thickness graft. The Thiersch graft has the advantage that it wiI1 grow in an uncIean fieId. From the standpoint of appearance a fuII-thickness graft in successfu1 cases is far superior to the Thiersch graft which is generaIIy paIe and white. The WoIfe graft in good “takes” appears, eventuaIIy, as norma skin.
NEW SERIES VOL. III, No. I
and ending at the base. BIaustein the term “incIine bIadder” for this He uses a 2 per cent or 2.3 per cent sodium iodide instead of the 12.5 cent strength commonIy used for
proposes condition. soIution of or 15 per this work.
BALLENGER, EDGAR G., and ELDER, OMAR F., AtIanta, Ga. Post-operative cystitis. South. iU. J., ApriI, 1927, xx, 321. Concerning the cause or causes of the cystitis which fohows operations, when the bIadder has become overdistended and urethra1 catheterization is required, the genera1 assumption seems to be that an infection has been carried by the catheter. AIthough this may at times be a factor, it is not the primary factor in the majority of instances. The actua1 cause of the cystitis more frequentIy is trauma in the form of smaII Iacerations of the mucosa from sudden overdistention of the bIadder. These minute injuries afford an entrance for organisms passing down from the kidneys or up through the urethra. When the distention of the bIadder is graduaI in onset, as in prostatic obstructions or tabes, the pavement epithehum grows as the residua1 urine increases and the minute Iacerations do not deveIop as they apparentiy do in rapidIy distended bIadders. Danger of prompt or repeated catherizations is trivia1 compared with danger of injury to the bIadder mucosa by overdistention. This view is strongIy supported by the rarity of cystitis after operations when the bIadder has not become overfiIIed and by the infrequency of cystitis from urethral instrumentation. Overdistention of the bIadder aIways precedes this type of cystitis. The mucous membrane when damaged by overdistention or trauma from chemica1 agents becomes a Iess efficient barrier against infection, just as does the injured epidermis. Surgeons shouId Ieave a standing order after operations for carefur observation of the patient’s hIadder in order that it may be emptied before harmfuI distention occurs. Furthermore, it may be of vaIue, when catheterization becomes necessary, to inject a miId germicide into the bIadder after it has been emptied to contro1 or Iimit the infection if damage has been done to the mucosa by the overdistention. MOORE, THOMAS D., Memphis. The diagnosis of bIadder atony. J. Tennessee M. A., Feb., 1927, xix, 286. Diagnosis
of
bIadder
atony
is
important
in
Surgery
American Journal of Surgery
97
because of the evident tendency to ascribe the patient’s symptoms to some obstructive condition, resuIting in futiIe surgica1 interference. Two of the cases reported had been subjected to prostatectomy without reIief, due to such erroneous diagnoses. The outstanding features of the disease are five in number: (I) Marked urinary diffrcuIty; (2) residua1 urine, usuaIIy a Iarge amount; (3) the absence of any discoverabIe obstruction to the urinary stream; (4) poor detrusor tonus as noted by the sIow dribbIing from an inserted catheter or manometer reading, and (3) diminished sensory responses. Three patients, two men and one woman, having atony of the bIadder, were subjected to careful examination of the centra1 nervous system, incIuding study of the spina fluid. In a11 of them the resu1t.s were negative. Studies of the intravesica1 tension with a water manometer reveaIed a curve somewhat typical of the disease. BIadder sensory tests discIosed varying degrees of anesthesia for tactiIe, thermaI, and pain stimuli. These findings favor the opinion that atony of the bIadder is dependent upon some disturbance in the IocaI nerve supply, probabIy a degenerative process invoIving the hypogastric pIexus or interference with the refIex tract through the vesica1 center in the Iumbar cord. TURNER, B. WEEMS, Houston, Texas. Syphilis of the urinary bIadder with report of six cases. South. M. J., ApriI, 1927, xx, 289. Primary and secondary syphilitic manifestations in the bIadder are as a ruIe comparativeIy insignificant. They vary from a generaIized reddening of the mucosa to a discrete, macuIar or petechia1 reddening which readiIy cIears under treatment of the disease. VesicaI gummata are among the rare syphiIitic manifestations, and as a rule are probabIy not recognized unIess uIceration with secondary infection and hemorrhage directs attention to the bIadder. The characteristic pathoIogica1 finding of syphiIis of the bIadder in its tertiary manifestations is a true cystitis, with thickening of the entire waI1 of the bladder and resuItant contracture and reduction in its capacity. The Iesions more frequentIy appear at the base, usuahy some portion of the trigone, and it is beIieved that this predilection possibIy arises from the Iocation of the Iymph gIands and gIanduIar tissue in that region. Given a Iesion in the bIadder, the differentia1 diagnosis is to be
98
AmericanJournaIof Surgery
Progress
made between eIusive uIcer, papiIIomata, carcinoma, tubercuIosis and sarcoma. It is not possibIe to make an absoIute diagnosis with cystoscope aIone, but certain characteristics are fairIy significant and warrant seeking other evidences. Among these are generaIized thickened, reddened mucosa with macuIes distributed at the base, pearIy, opaIescent papuIes occurring as buIIae adjacent to the uIcer or papiIIomata, with an absence of the typica eIevation and infiItration seen in maIignancy. It seems that syphiIis is not a factor in production of papiIIomata, although two of Turner’s cases showed definite papiIIomata, with papiIIary vegetations coexisting with the bIadder Iesion. It is aIso quite evident that maIignancy can be engrafted upon a syphiIitic Iesion of the bIadder. J. T., MeIbourne. Prostatectomy and its after-resuIts. Med. J. Australia, ApriI 16, I9271 Pa 571.
TAIT,
Of eighty patients admitted 82 per cent were operated upon in one stage and 18 per cent required the two-stage method. The two groups were distinguished by genera1 cIinica1 examination rather than by the renaI function test. The operative mortaIity for suprapubic prostatectomy in one stage was 4.6 per cent, the mortaIity for a11 cases being 8,75 per cent. In 85 per cent of one-stage operations for prostatic disease of innocent nature the Iate resuIts were satisfactory, though IO per cent of the patients had an attack of epididymitis after discharge from hospita1. In the remaining IO per cent there was persistent cystitis. In 12 per cent of cases histoIogica1 examination showed that maIignant change was present in the prostate and of these patients onIy 50 per cent were we11 two years after operation. A reIativeIy frequent seque1 of two-stage prostatectomy was postoperative hernia, otherwise the Iate results were comparabIe to those of the operation in one stage. J., Paris. ResuIts of suprarenaIectomy in spontaneous gangrene of the extremities. (ResuItats de Ia surrenaIectomie dans Ies gang&es spontankes des membres). Presse mid., ApriI_g, 1927, No. 29, 454.
S~N~QUE,
SCnitque reviews the”Iiterature on the treatment of gangrene and especiaIIy thromboangitis obIiterans by means of excision of the
in Surgery Ieft suprarena1 gIand. He quotes the statistics of Herzberg in I IO cases, of which 8 were Herzberg’s. Of this series, 14 were reported to have been cured. In a11 but three, results are too recent to be of much vaIue. It has been cIaimed that there is definite ameIioration of the symptoms, disappearance of pain, cure of the uIcers and in some cases even reappearance of the peripheral circulation. %n&que observes with justice that this operation is faIIing into disrepute even among those who were its most staunch protagonists. He beIieves that the operation is not founded on firm anatomopathoIogica1 grounds and that it finds no warrant in cIinica1 experience. HENRY MILCH. EARL C., Kansas City. Free fuIIthickness skin transpIantation. J. Kansas Med. Sot., May, 1927, xxvii, 145.
PADGETT,
The main advantages of the fuI1 thickness graft are: (I) Contraction is much Iess than foIIowing a Thiersch graft (a Thiersch graft does not give a satisfactory resuIt in cases of marked deformity after burns); (2) in the paIm of the hand, and other areas subjected to considerabIe trauma, fuI1 thickness grafts wiI1 give a good functiona resuIt if there is any soft tissue between graft and bone; (3) in certain congenita1 anomaIies as in web fingers it offers a method giving a good resuIt in one operation; (4) in certain disfiguring facia1 bIemishes it has possibiIities not possessed by other types of skin transplants. If the bone is nearIy bare or thickness is desired a ffap transpIant offers advantages not otherwise obtainabIe. The disadvantage of a flap is, first, that its thickness in certain areas gives a cIumsy resuIt Iess pIeasing from the esthetic standpoint, and second, that severa operations are required. The WoIfe graft can be transpIanted usuaIIy in one or two operations. The fIap transpIant has its distinct indications and probabIy is more usefu1 in the various phases of pIastic surgery than the fuI1 thickness graft. The Thiersch graft has the advantage that it wiI1 grow in an uncIean fieId. From the standpoint of appearance a fuII-thickness graft in successfu1 cases is far superior to the Thiersch graft which is generaIIy paIe and white. The WoIfe graft in good “takes” appears, eventuaIIy, as norma skin.